What are the main causes of and most effective strategies to reduce

HIV infection in Sub-Saharan Africa?

Desirae Merrill

Senior Project Advisor: Julian Springer

Abstract

In total there are a total of 25.7 million people living with HIV/AIDS in the Sub-Saharan Africa
population. As more people in the SSA region become infected with HIV/AIDS and die from the
infection every year, the need to address root causes in regards to HIV/AIDS through preventive
and treatment services is increasing. The purpose of this paper is to research the root causes of
HIV/AIDS and which effective strategies will decrease the infection in SSA. The research
encompasses medical journals and studies on not only how healthcare affects HIV/AIDS but,
also how other factors such as culture affects it as well. It was found that the major root causes
and spread of HIV/AIDS in SSA can be boiled down to lack of education, lack of quality
healthcare, and restrictive cultural norms. From this services geared towards educating,
providing quality healthcare, and reducing restrictive cultural norms need to be implemented in
SSA that are easy to access. However, further research on the politics in regards to HIV is
recommended.

12th Grade Humanities

Animas High School
February 20, 2020
 Part I: Introduction

Currently, the continent of Africa has the highest incidence of Human

Immunodeficiency Virus (HIV) in the world, with 25.7 million people living with the disease as

of 2018. “Sub-Saharan Africa is home to only 12% of the global population, yet accounts for

71% of the global burden of HIV infection.” (Kharnasy et.al) Additionally, only 70% of people

in Africa are aware of their HIV status. The incidence of HIV has decreased since the 1960s, yet

multiple barriers primarily related to poverty have made it problematic for people to find

transportation to clinics and afford quality care. HIV is commonly transmitted through unsafe

sexual practices (lack of condom use, anal sex, and having multiple partners), contact with

infected blood, intravenous drug use, and mother-to-child transmission through breastfeeding.

Currently, there are 1.6 million adolescents between the ages of 10 and 19 who are HIV

positive worldwide; the majority of that population lives in Sub-Saharan Africa (SSA) with 1.5

million adolescents currently infected in the region. Most adolescents acquire HIV through

mother-to-child transmission via breastfeeding and are undiagnosed during infancy, while others

are infected through sharing needles when injecting drugs, unprotected sexual contact, and

unsanitary health practices. Finding solutions to the root problems around lack of education, lack

of quality healthcare, and restrictive cultural norms is important for the future of HIV in SSA

HIV destroys the immune system and affects an individual's CD4 cell count, increasing

the chances of obtaining a secondary infection or other Sexually Transmitted Disease (STD).

When infected with the disease, HIV slowly reduces the CD4 immune cells by infecting the CD4

white cells that play an important role in responding to infections within the body. Once the CD4

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cell count decreases below 200cells/mm3, a person is diagnosed with AIDS. While HIV can lead

to deterioration of the immune system, AIDS, which is short for autoimmune deficiency

syndrome, is a condition caused by damage to the immune system from HIV. Unfortunately,

HIV/AIDS can not be cured, but it can be treated. viral suppression is considered treatment for

HIV. Treating someone HIV positive with antiretrovirals decreases the viral load in the blood

and in other parts of the body to very low levels, keeping the immune system working, as well as

preventing further illness. If HIV is not treated opportunistic infections such as tuberculosis and

pneumonia occur because of the weakened immune system's inability to fight off HIV-related

infections. If viral suppression is done correctly and effectively, then people may never show

signs of AIDS and can live a long and normal life.

If not contained, through education providing quality healthcare, and addressing cultural

norms, the infection will continue to spread from individual to individual increasing the

prevalence in SSA. In 2016, there were close to 6,000 new cases of HIV each day. The chances

of becoming infected with HIV are high, due to limited access to education, treatment, and

restrictive cultural norms. Therefore, implementing solutions to this problem is crucial due to the

negative effects this disease has on communities, families, and the economy. The Joint United

Nations Programme on HIV and AIDS (UNAIDS) set the goal to increase testing of HIV to 90%

globally, put 90% of those infected with HIV/AIDS on viral suppression therapy, and increase

rates of viral suppression to 90%. This is also referred to as the 90-90-90 goal. Rather than

relying on outdated methods like preaching abstinence, the most effective way to decrease HIV

infection in Sub-Saharan Africa is to educate, provide quality healthcare, and reduce restrictive

cultural norms.

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 ​Part II: Historical Context

In 1999 a few years after HIV first occurred, researches traced the origin of HIV back to

chimpanzees from a strain of SIV (Simian Immunodeficiency Virus), an HIV-like

immunodeficiency virus that was found to be nearly identical to HIV. Conducting more research,

scientists found that when the chimps hunted and ate two smaller species of monkeys, the

smaller monkeys infected the chimps with two different strains of SIV. The two strains

combined and formed into a third SIV virus, the new third virus ended up being able to infect

humans. Scientists believed the chimpanzees spread the third virus to humans due to

chimpanzees being killed and eaten, or the infected blood of the chimps got into the wounds of

the hunters. The virus adapted within the hunter’s body and formed a new strain called HIV,

leading to the spread of HIV. With the first early cases of HIV starting the year of 1960 with an

estimate of about 2,000 cases. At the time it was unknown how HIV was spreading in

Sub-Saharan Africa.

Similar to SSA, India experienced confusion surrounding the initial spread of HIV. India

is also one of the many countries like Sub-Saharan Africa that has a large number of people

infected with HIV. Authorities in India were unsure of why HIV appeared in their country,

carrying the third largest HIV epidemic in the world. Later India found that “sex work has been

the key driver of the epidemic in the region and the burden of HIV remains disproportionately

high amongst female sex workers.” (Tanwar et.al) Along with India, the epidemic in

Sub-Saharan Africa grew due to sexual transmissions and unclean drug use practices, in addition

to truck drivers carrying the infection and spreading to casual partners. Little did they know this

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new unknown virus was going to infect millions and start the HIV epidemic. HIV/AIDS in the

gay community, ​what used to be called GRID (Gay-Related Immuno Deficiency), was originally

beleived to be transmitted via gay sex. However, once it started to spread, other forms of

transmission became apparent. In the western world HIV/AIDS was believed to be isolated to the

gay community, and stigmatized. For gay men, espically for men who have sex with men

experienced increased social homophobia and everyday discrimmination preventing people in

the LGTBQ community from accessing treatment and testing services for HIV/AIDS. Through

research on the disease, people learned that it was not isolated to the gay community and

treatment began to emerge so doctors were not simply sending people home to die. Once the

western world began researching and acknowledged this disease, aid involving treatment and

prevention resources from the western world for HIV spread into the developing world including

SSA

Part III: Research and Analysis

The root causes of the spread of HIV in Sub-Saharan Africa are multifaceted but can be

boiled down to ineffective education strategies, cultural norms around gender roles,

communication in relationships, and limited access to quality health care. These root causes can

be addressed by education, effective treatment, and reducing stigma. These methods will

ultimately decrease the number of new HIV/AIDS infections every day.

Education:

Education around HIV/AIDS in Sub-Saharan Africa is critically important. Knowing how

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to prevent and how to seek treatment can benefit the SSA region but, with a lack of education in

youth, parents, teachers, and adults, becoming infected with HIV can become a risk

A large percentage of those infected with HIV are adolescents between the ages of 10 and

19, and a lack of sex education among youth is strongly correlated with HIV prevalence. “​Young

people are particularly vulnerable to HIV infection because of the risky sexual behaviours they

engage in. These behaviours are influenced by lack of access to accurate and personalised HIV

information and prevention services, socio-economic reasons, lack of parental control, peer

pressure and lack of youth-friendly recreational facilities” (Tarkang et.al).​ I​ n the U.S., once

adolescents reach a particular age, between grades five and twelve, many schools will

incorporate sex education as part of the curriculum. By high school age, every student is

expected to be educated on subjects such as consent, safe sex, and how to prevent contracting an

STD. Sex education in SSA is rarely introduced into schools, which leads to an increased rate of

HIV and other STDs in students. “​Often, teachers do not feel confident about delving into topics

they may find embarrassing and do not allow their students the space to explore these issues in a

frank and open way” (“Education and HIV”). Specifically in SSA talking about sex can be

considered taboo or uncomfortable for teachers, community members, and parents.

Parents have a large influence on the sexual behavior of their children due to the fact that

they are an authority and children tend to conform to the standards set by their parents. Research

has shown that most children who have had a conversation with their parents about safe sex,

specifically using condoms as contraception, were more likely to use condoms during sex and

continue to use them throughout their adult life. Even though parents have a large influence on

their children, sex education is rarely discussed between parents and their children. Some

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“adults, for instance, fear that informing young people about sex and teaching them how to

protect themselves will make them sexually active.” This way of thinking results in a lack of sex

education that is needed to inform adolscents on how HIV and other STDs are caused.

Additionally, parents are unlikely to talk about HIV/AIDS and sex education because they feel

“uncomfortable doing so, or lack the knowledge themselves” (Tarkang et.al).

Considering the fact that adolscents are one of the many populations that lack education around

safe sex and HIV prevention, many adults are also uneducated on this subject and do not feel

adequately prepared to educate their younger family members. Most education programs are

geared toward youth because there is a high prevalence rate of HIV among children and by

educating the youth of a community it is more likely that the knowledge/information will be

passed on to generations to come, allowing old patterns to be reversed. From this it is evident

that the general population needs to be educated on safe sex and HIV because there is also a lack

of knowledge within adults. The reasons why children don’t receive education are the same

reasons why adults are not educated. There is a lack of educational resources as well as a large

stigma surrounding sex. General information on how HIV/AIDS spreads through breastfeeding,

sharing needles when injecting drugs, sexual contact, blood coming in contact with infected

blood, and even what HIV/AIDS is, must be taught to those living in Sub-Saharan Africa to

reduce the incidence and spread of HIV/AIDS. 65

Cultural Norms:

Africa is home to many tribes and ethnic groups with widespread beliefs and practices.

Even though society in Sub-Saharan Africa is evolving, cultural norms encompassing polygamy,

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gender inequality, and Stigma around HIV/AIDS continue to exist within the region.

Polygamy, a practice where an individual has one or more partners has been part of

African culture for centuries and still exists within many communities. Specifically, nothing

about having a polygamist life and having multiple partners has led to the cause of many HIV

cases. The risk of being infected with HIV in a monogamous relationship is equal to the risk for

a man or woman with multiple partners. Unsafe sexual practices within those multiple partner

relationships are leading to new HIV infections. Engaging with multiple partners increases the

risk of spreading HIV/AIDS because of the increased number of people that individual is having

sexual contact with. There is a lack of faithfulness with people living with HIV/AIDS by not

respecting uninfected people by infecting them with HIV. A common saying used in the

infectious disease field is if you are sleeping with one person you are sleeping with all of their

previous partners. Meaning that if an individual slept with one person with an STD, they are

likely to spread it to any other sexual partners that individual may have. These unsafe behaviors

allow HIV/AIDS to spread at a more rapid rate by infecting multiple partners within those

relationships.

In an article titled “HIV Infection and AIDS in Sub-Saharan Africa: Current Status,

Challenges and Opportunities”, the author points out that “​not only do young women aged 15-24

years have higher rates of HIV than males in the same age group, they acquire HIV infection 5-7

years earlier than men”(Kharnasy et.al). Unequal gender roles in these communities are a

common social norm, especially in more rural settings. For years, many African cultures, as well

as other cultures around the world, have functioned as patricharcial cultures and societies.

Women stay home and do the housework and care for the children while the men do the labor

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work and hunting. To this day, a pataricharcial culture provokes women's inability to protect

themselves from contracting HIV due to the need to please their spouse or other men in their

community.

Women’s dependency upon men and conforming to the needs of their husbands leads to a

higher risk of women becoming infected with HIV, and may decrease the ability of women to

obtain care for HIV due to fear. In a medical article titled “Cultural practices, gender inequality

and inconsistent condom use increase vulnerability to HIV infection: narratives from married and

cohabiting women in rural communities in Mpumalanga province, South Africa​,”​ the author

explains why women are more vulnerable to HIV infection. “In most patriarchal societies, the

needs and desires of women are not considered and often they play no part in sexual decision

making, nor are they allowed to express their sexuality.”(Madiba et.al). For example one African

tradition performed is known as the Bride Rice where an amount of money or property is paid by

the groom and his family to the family of the bride. This type of tradition can lead to unequal

gender roles within the relationship in terms of sexual decisions. Men make all the sexual

decisions in the relationship for the reason that men believe that since they paid the bride's rice

for the women, and not anything else like condoms, they can do anything they desire. From this

information women often fear recommending condoms or seeking HIV treatment due to men

possibly resulting in violence or even to the extent of unconstentual sexual intercouse because it

questions male authority.

HIV stigma is one of the many factors that has limited people living with HIV/AIDS to

seek proper medical care. This stigma manifests as fear of being shamed and rejected within

one's community. ​In a study with 40 in-depth interviews of men and women around personal

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experiences of stigma, a 27-year-old man in a seroconcordant couple where both partners are

either HIV positive or negative stated.​“​The community disrespects people with HIV. Even if you

are alive, they believe that you are half dead.” The study found that the majority of interviewees

expressed hesitation to seek medical treatment out of fear of being recognized (Spangler et.al)

There is a stigma around HIV because “it carries many symbolic associations with danger.

Attribution of contagion, incurability, immorality and punishment for sinful acts is common in

many societies.” (Mbonu)​ ​Due to stigma many people are scared of going to get medical

treatment, increasing the number of people that aren’t treated, as well as increasing the number

of deaths from AIDS. There is a mass of people living in SSA that are religious and attend

church regularly. Many religious leaders in churches link sexual transgressions with HIV/AIDS,

viewing HIV as impure or a sin. Other religious groups and churches implement mandatory HIV

testing before marriage as a way to ensure purity of the couple (Mbonu). However many other

religious groups have been effective in helping people living with HIV to cope with negative

feelings and help to reduce the stigma surrounding an HIV diagnosis.

Lack of quality healthcare

With a large population of People living with HIV (PLHIV) as well as undetected cases,

quality healthcare is critical when addressing this disease. Having access not only to healthcare

but to quality healthcare, meaning providing care to the patients needs when it is needed in an

effective manner, is crucial to maintaining health through prevention, managing disease, and

reducing mortality rates. Since Africa has one of the largest disease burdens in the world,

healthcare is very important. The article “​Taking on the Challenges of HealthCare in Africa”

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explains that ​less than 50% of the African population beaer access to up to date health facilities.

Most countries in Africa spend under 10% of their GDP on health care (Clausen), compared to

the U.S. spending 18% of their GDP towards healthcare in 2017. Many groups are impacted by

this lack of access, and those without regular access to quality healthcare are more susceptible to

disease and other medical problems, and may not seek out care for these conditions. These

factors each play a role in leading to fatality from a lack of medical care. However, those who

live in rural regions, a population of ​645,077,217,​ are dealing with little to no access to

healthcare to address their health needs. This is due to the fact that there may not be a clinic or

other medical facility close enough to travel to on foot. Many people in Sub-Saharan Africa

either travel by foot or by a bus. Unfortunately, financial burden makes travel out of reach for

many.

While there are many factors contributing to lack of healthcare affecting the SSA

population, the most impactful in the modern age is a shortage of healthcare workers. This crisis

affects many communities within the SSA region specifically in regards to the treatment of

disease and infection, leading to high child and adult mortality. In the comprehensive review

“​The Critical Shortage of Healthcare Workers in Sub-Saharan Africa”, researchers found that ​46

out of the 47 countries in the African region have fewer than 2.28 physicians or nurses per 1,000

people, which is considered the minimum needed to provide basic health services​. Putting more

of an emphasis on addressing the uneven distribution of healthcare workers in urban and rural

areas, o​nly 25% of the doctors and 40% of nurses are stationed in rural areas, while 45% of the

population dwells there (Haseeb).

The shortages in health care workers can be attributed to disease and infection outbreaks

10
such as HIV, lack of graduating medical students, and moving of healthcare workers. To have a

higher number of quality healthcare professionals, individuals must undergo vigorous schooling

and skills practice in order to deliver quality healthcare. There must also be a push to send

community members to school with the purpose of becoming a healthcare provider. ​It is

estimated that, on a yearly basis, only “10,000 to 11,000 medical students graduate from the

region. This substantially low number is directly tied to the shortage of medical

schools.”Another factor impacting the shortage of healthcare workers is large outbreaks of

diseases and infections such as HIV, ebola, and other harmful diseases. “HIV/AIDS has caused

the healthcare workforce of sub-Saharan Africa to decrease by as much as 20%” (Haseeb). Due

to the fact that healthcare workers are more vulnerable to contracting these diseases without

proper equipment. Antiretroviral treatment coverage has a strong correlation to the density of

healthcare workers. Many countries with a low population of healthcare workers have attempted

to implement HIV treatment programs for more people to access antiretroviral therapy, however

undergoing a lack of resources and workers these programs were unsuccessful. In a thorough

study the author explains that “many sub-Saharan African countries, like Rwanda, would require

an increase in their healthcare workforce by as much as 50% to administer antiretroviral therapy

on a national scale” (Haseeb).

In addition to increasing the number of healthcare providers in hard-to-reach populations,

it is also important when providing quality care to obtain the proper high-quality instruments

along with an appropriate supply of medication and other medical technology. The lack of such

resources makes it challenging to properly supply medication to treat people when they come

into the clinic. In the article “Dying from Lack of Medicines​” ​a member of the United Nations

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gives context, saying “less than 2% of drugs consumed in Africa are produced on the continent.

This means that many sick patients do not have access to locally produced drugs and cannot

afford to buy expensive imported medication.” Most people in low-income sectors of SSA rely

on public health clinics to treat their health needs. With the limited amount of medications that

healthcare workers in clinics have access to, the most available options are to treat symptoms

using painkillers as a treat all drug or turn to cheap medications. These cheaper, less effective

drugs are often ineffective in treating certain conditions like HIV/AIDS, and ultimately lead to

more fatalities from minor diseases. Access to high-quality drugs is oftentimes out of the clinics’

hands. “Africa’s inefficient and bureaucratic public sector supply system is often plagued by

poor procurement practices that make drugs very costly or unavailable. Added to these are the

poor transportation system, a lack of storage facilities for pharmaceutical products and a weak

manufacturing capacity” (Pheage). Through increasing the number of healthcare providers as

well as access to resources throughout communities in Sub-Saharan Africa,quality care can be

provided for those who are suffering from HIV/AIDS

Since public health clinics have a shortage of supplies, the only option is to reuse needles

and syringes. In some cases, nurses go from patient to patient giving injections reusing the same

needle because it is the only way to care for the high volume of patients. As a result of these

unhygienic practices, patients can come into contact with potentially infected blood or other

bodily fluids, which leads to infection of HIV. Additionally, the absence of funding around

public health clinics forces unsanitary clinics with poor infrastructure to conduct sterile

procedures. In a journal article “Taking on the Challenges of HealthCare in Africa”the

challenges in the healthcare system are discussed. The article states that “shopping malls are

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provided with air-conditioning, while medical clinics without air-conditioning; much-needed

medical equipment such as MRI machines get caught up in the gridlock of international

customs”(Clausen). There are many factors surrounding healthcare such as healthcare staffing,

medical supplies, supply of medicine, and international support that need adjusting to support

needs to accomplish such goals around HIV.

Solutions to the Lack of Quality Healthcare

Throughout the HIV epidemic there have been many medical advancements around HIV

programs to address challenges regarding the lack of healthcare around HIV/AIDS. Even though

there have been statistically proven improvements in decreasing the mortality rate from AIDS

and new infections, there is still a gap that needs to be filled. There are many programs that have

been tested throughout the years, in fact it is a very richly studied topic with several routes

available to provide improvement. two to three solution programs are offered that correlate with

solving these problems.

The main concern about lack of access to healthcare is the inability to increase access to

treatment services for people in SSA. When proposing solutions they must be effective in

addressing certain challenges. It is important to consider that because a large population is living

in impoverished areas solutions must be implemented that are cost-effective, easy to access, and

are effective. Many of these programs have both benefits and drawbacks. There is a large variety

of medications that manage and prevent HIV from spreading. However, there must be programs

with the goal of getting certain medications out into rural and impoverished communities that

have little to no access to quality, affordable medications/preventative services for their

HIV/AIDS needs.

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 Many of the programs in place are tailored towards either prevention, treatment, or

treatment as prevention to decrease HIV infections. Starting ​in 1991, in Kampala the AIDS

Information Center for anonymous VCT first opened. VCT (Voluntary Counseling and Testing)

is viewed as a form of a prevention service Most VCT groups access communities through

mobile clinics so quality services can be given in hard to reach populations. VCT offers a

multitude of things, such as pre-test counselling, HIV testing with same day results, referral for

treatment medicines, and post-test counselling services.

HIV/AIDS cannot be cured, only treated through suppressing the viral load of the

infection by taking antiretroviral therapy drugs (ART), a daily regimen of a combination of

medicines for people living with HIV that mobile clinics provide referrals to get at clinics. This

form of medication acts as treatment as prevention by managing HIV and preventing individuals

from spreading it. Through the many years since ART was started there have been many

advancements and changes that increased coverage of HIV/AIDS treatment and have overall

benefited a lot of people. In 2010 the way public health addressed the HIV epidemic was

recommended to treat only those that have an advanced HIV disease and immunodeficiency who

were at a high risk of fatality. Because of the low ART initiations due to the guidelines of the

programme there were no improvements in treatment coverage in SSA. Later in 2015 the WHO

modified the guidelines to treat all patients with HIV regardless of the patient’s CD4 cell count

and disease stage. In a study with 3,405 people accessing HIV care in Eswatini, from 2014 to

2017, to evaluate the effectiveness of the ‘treat all’ guideline on timely ART initiation in 14

service delivery cities, it was discovered that, “Six months after enrolling in HIV care, patients

enrolling under the intervention condition were seven times more likely to be retained in care

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with viral suppression than those enrolling under the standard-of-care condition (i.e. the national

guidelines in place at the time). At 12 months after enrolment, retention remained 60% higher in

the ‘treat all’ compared to the control group.” (Nash et.al)

More coverage of ART a combination of drugs and ARV single tablet drugs has

benefited SSA substantially. To this day ART and ARV medications are proven to be effective.

These are the only medicines available that can let people living with HIV/AIDS live a full life

with HIV without spreading it to others in an affordable way. Currently the cost of a year supply

of ART is less than $100 per person, compared to $10,000 in the year 2000. People are becoming

more aware of ART medicines through programmes like VCT. While VCT is a great route to get

tested and directed to treatment, it is also an efficient way to educate on HIV. The procedure

VCT utilizes is pre- and post-test counselling. Pre-test counselling is focused on assessing

behaviors and educating people on how those behaviors can increase risk. Depending on the

results, there will be a post-test counselling session educating patients on next steps and the

individual will be encouraged to go to a club to help with mental health and issues patients are

facing. The UNICEF supports VCT saying

“to know their own status and to evaluate their behaviour and its consequences. A

negative test result offers a key opportunity to reinforce the importance of safe and risk-reducing

behaviours. A positive test result should allow adolescents to receive referrals for counselling,

care and support, including opportunities to talk to knowledgeable people who can help them

understand what their HIV status means and what responsibilities they have to themselves and

others as a result.” (“Voluntary Counselling for HIV”)

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 In terms of addressing lack of quality of healthcare VCT is becoming more widespread,

and expanding access to proper medications, testing services, and support all while promoting a

sanitary environment. Humanitarian aid plays a large role in the importation of medical care, and

without this aid, obtaining treatment and prevention of disease would be more of a challenge.

Most of SSA’s medications are not produced on the continent of Africa, instead, most

medications are imported from other regions by not for profit organizations and religious groups.

By providing medical supplies, finances, and other resources, outreach into communities across

Africa can be more far-reaching. There is a fair amount of humanitarian aid encompassing

distribution of preventative resources that, for some people, are inaccessible due to lack of

awareness, education, or assets. Preventative care includes resources such as condom promotion,

needle exchange programs, and other medications.

Most of these services are provided by local and foreign Non-Governmental

Organizations (NGOs). For example, in Uganda, “beginning in the early to mid-1990s, millions

of condoms have been distributed by the Ministry of Health through health centers and NGO

projects, purchased mainly with external donor funding.” Before the implementation of several

projects with the purpose of promoting safe sex, condom use was reported at 6%, however after

the implementation of these programs, condom use rose to 11% of sexually active Ugandans

(Green et.al). It became clear that encouraging safe sex is obtainable by increasing access to

condoms. ​A change in sexual behavior is needed to limit the spread of HIV in populations of

people with multiple partners. However, an alternative for people that want to continue to have

multiple partners is to use condoms and safe sexual practices during sexual intercourse. The use

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of condoms is effective in preventing STDs and is becoming more culturally accepted and easy

to access in Sub-Saharan Africa.

When the HIV epidemic was at an all time high there was an included preventive

program provided by many local NGOs as well as foreign aid. Needle exchange programmes

were very common in areas in Nepal, it has been implemented in SSA and expanded in the year

of 2012. Needle and syringe programmes are tailored to addressing the people who inject drugs

and are thus more at risk for HIV by using unsterile needles and sharing needles with others.

Needle and syringe services mission is to provide sterile needles for those who inject drugs

without the heavy cost. “As of 2018, approximately 135 needles and syringes were being

distributed per person who inject drugs per year” (“Needle and Syringe Programmes”).

Many of these programs are supported by NGOs and foreign travelers providing aid.

While SSA is very impoverished the most beneficial form of Aid has been through donating

money so organizations and public health clinics can obtain supplies that they need. There are

many ways finances can be used to help stop the spread of, and treat HIV/AIDS in SSA. It can

be utilized to fix the infrastructure of clinics, provide quality medicine and tools, and pay for

individual’s medical bills. Many organizations such as the Gates Foundation donate funds to

support medical care of HIV/AIDS in Sub-Saharan Africa. The Gates Foundation stated ​“​to date,

we have committed more than US$3 billion in HIV grants to organizations around the world and

more than US$1.6 billion to the Global Fund to Fight AIDS, Tuberculosis and Malaria” (Gates

Foundation). with a focus of reaching regions that don’t get as efficient funding, While other

organizations accept donations on their website but, also work on the forefront of these issues.

This is used for example in the World Health Organization, UNAIDS organization, and other

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NGOs. With a mission to increase ART initiation as well as increase preventive treatments.

While on the other hand being largely advocated within these communities. With a goal to boost

leadership and accountability, forming more political investment into the issue and make sure

communities are on track with working towards decreasing HIV infections and increasing viral

suppression rates.

Regarding NGOs, ​The Global Gag Rule was first implemented by Ronald Reagan in

1984, and in 2017 President Trump expanded the Gag Rule with the implementation of the

Protecting Life In Global Health Assistance policy. The Global Gag Rule prohibits NGOs that

recieve U.S. global health assistance to perform legal abortion services. If it is done anyway by

NGOs the funding they get from the U.S. will be cut off. This has a tremendous effect on

programs around HIV/AIDS because the availability services provided for HIV/AIDS such as

treatment, testing, and prevention services are suffering. (“What is the Gag Rule”) The expansion

of the global gag rule is making resources needed to improve HIV/AIDS in Sub-Saharan Africa,

but without funding NGOs it will be hard to afford resources to prevent and treat HIV. ​ Although

there are limitations when it comes to placement of NGOs across SSA, the benefits of these

organizations far outweigh any limitations in regards to funding

Solutions to Restrictive Cultural Norms:

Sub-Saharan Africa’s cultural norms and gender roles have played a large role in fueling

the HIV epidemic.The large stigma formed around HIV/AIDS, the little say women have in

sexual practices, and people with multiple partners have all made it difficult for people to get

tested and seek care before HIV turns into full-blown AIDS. Many programs that are emplaced

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are addressing the stigma specifically around HIV/AIDS by meeting people in a way that keeps

patients information confidential as well as breaking people's silence. Through time we also can

learn from other countries' successes in implementing programs to build self-sufficiency,

behavioral changes, female empowerment, all achievable goals that will help the SSA

population.

The majority of the SSA population has a large stigma around HIV/AIDS making it fairly

challenging to get tested and treated.. This can be caused by two different forms of stigma, the

typical one being the feeling of stigma from others in the community who are against HIV/AIDS.

The other form of stigma being internalized stigma where individuals absorb negative messages

and stereotypes about HIV/AIDS and begin to believe those stereotypes about themselves. One

way of dealing with this stigma is to ensure confidentiality of HIV status. Voluntary counseling

and testing services are not only a way of addressing the lack of healthcare, but are effective in

reducing stigma as well. To ensure confidentiality, and to provide education surrounding HIV,

mobile VCT works to meet patients in a private setting to prevent being noticed within the

community.

While ensuring medical privacy is essential, guaranteeing confidentiality will not play a

role towards decreasing stigma. Instead, encouraging self-disclosure within people living with

HIV by looking past stigma has been relatively successful. In a study with 38 in-depth interviews

among a mix of HIV-positive pregnant and postpartum women and their male partners, 10 of the

couples were both HIV positive or negative and the other 9 couples had one partner who is HIV

positive and the other is negative. The purpose of the study was to explore issues around stigma

preventing people from seeking care among self-disclosed couples in Southwest Kenya. As a

19
result, researchers found that, “disclosure to spouses was usually the first and most important

source of support, followed by family members, friends and sometimes the voice, action or

example of a stranger. Health workers, peer mentors and HIV educators also provided

meaningful support, especially in promoting the normalization of HIV and motivating

participants to initiate and continue treatment” (Spangler et. al). From that information

normalizing HIV is a crucial step in limiting stigma, as it allows for HIV negative individuals to

view people with HIV the same as everyone else, taking away all the assumptions about that

person’s history and morals. Along with helping HIV positive individuals to disclose their HIV

status without fear. Services such as VCT have worked to normalize HIV and HIV testing within

communities where stigma exists. The more tests done by VCT services the more people are

aware of their HIV status resulting in increased normalization of HIV. In the guide book

“Integrating HIV Voluntary Counselling and Testing Services into Reproductive Health

Settings” the authors point out that “making VCT more accessible to enable people to know their

status can help break the cycle of silence and the myths and misconceptions that fuel the

epidemic.” (IPPF and UNFPA) When individuals break silence about their status, things that

were considered scary to people can be easy to access. The amount of people treated will

increase due to timely ART initiation and patients will be more willing to take their daily

regimen so the HIV is managed.

To prevent the spread and amount of new infections of HIV, especially when there is a

high rate of heterosexual transmission within the HIV epidemic, unsafe sexual behavior must be

addressed. Changing a large population's sexual behavior is a difficult task, and complete

educational reform is hard to obtain. Yet programs implementing behavior change in an effective

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way can fix challenges around unsafe casual multiple sexual partnerships and the little say

women have in their own sexual decisions. Learning from past successes and important

moments within history can be beneficial in other countries through echoing programs

implemented that lead to that history-making successes. For instance, Uganda is considered by

the UNAIDS organization in 2004 to be one of the world's most compelling national successes in

fighting the spread of HIV thanks to programs that caused a change in sexual behavior. Author

Edward C. Green et.al and other authors found that data suggests that,

“behavior change programs, particularly involving the extensive promotion of “zero

grazing” (faithfulness and partner reduction), largely developed by the Ugandan government and

local NGOs including faith-based, women’s, people-living-with-AIDS and other

community-based groups, contributed to the early declines in casual/multiple sexual partnerships

and HIV incidence and, along with other factors including condom use, to the subsequent sharp

decline in HIV prevalence.” (“Uganda’s HIV Prevention Successes”)

The first step in addressing the HIV epidemic in Uganda was to bring awareness around

HIV/AIDS so action could occur and a multi-sectoral response. All programs developed and

provided by NGOs utilize the ABC approach. A stands for abstinence or delay in sexual activity.

B stands for being faithful, which includes partner reduction. C stands for promoting condom use

for high-risk sex. In 1986, a few years after HIV in Uganda peaked the president at the time

made it his patriotic duty to fight against AIDS. Openness and leadership from villages to the

statehouse was required, with an emphasis on large national media coverage of education on the

HIV epidemic. Due to early, high-level support, a multi-sectoral response attracted a large

variety of national participants. Awareness began to spread to urban and rural areas within the

21
Uganda region in many forms, from billboards and faith-based organizations, to people in

communities raising awareness around HIV/AIDS pushing to change risky behaviors. For

communities in Uganda spreading the word was not just “information and education but rather a

fundamental behavior change-based approach to communicating and motivating.” This strong

community involvement drove “creative and culturally appropriate interventions that helped

facilitate individual behavior change, as well as changes in community norms.”(Green et. al)

Implementation of interpersonal communication reached not only the general population but also

groups with a large number of people being infected with HIV/AIDS such as sex workers, truck

drivers, and soldiers. Therefore, in terms of limiting multiple casual sexual partners in other

countries, replicating the widespread community interpersonal communication and community

involvement used in Uganda would decrease the number of people partaking in multiple partner

sex and risky sexual behaviors. Considering the number of people who are unwilling to change

risky sexual behaviors, promotion of condom use is essential.

Not only does behavior change in partner reduction play a crucial role in decreasing the

spread of HIV but, addressing the lack of power women have in society will improve prevention

of HIV in Sub-Saharan Africa. During the time the president of Uganda and the political party

empowered women through giving them more political voice, “including in parliament where

women must take up at least one-third of the members by law” (Green et. al). After this policy

change, women gained a substantial amount of power within their community. Allowing women

to make big decisions in communities shifted the role women have in society and allowed

women to be taken more seriously.

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 Since women face the risk of acquiring HIV earlier than men due to unequal gender roles

surrounding sexual practices, specifically the lack of power women have in their sexual

decisions, accommodating for the population of women can decrease new infections. One

solution to empower women is providing them with more political voice, and creating

organizations that are geared towards empowering women. Again other countries strongly

affected by HIV can learn from Uganda. There is a large population of women in SSA, and

unfortunately, not every woman is going to be given the opportunity to be a part of the

legislation. For the rest of the women facing gender inequality, many women-led NGOs exist

with a mission to empower women on multiple fronts. In terms of HIV/AIDS women-led NGO

“​campaigns have resulted in legal reforms pertinent to the fight against AIDS, including

strengthening of rape and defilement laws and laws governing property rights for women”

(Green et.al). Regarding behavioral changes, many women-led organizations supported partner

reduction and condom promotion in order to change behavior within men that don’t use

condoms, have multiple partners, and don’t allow women to make sexual decisions. There is

always going to be unequal gender roles in SSA in many scenarios however, since women are

more likely to recommend condoms and HIV treatment they should be allowed to make those

important decisions because it is something to be taken seriously. When women are allowed to

make decisions in terms of the HIV epidemic, they could end up preventing themselves, young

girls, other women, and pregnant women from being infected with HIV. For those who were not

able to access treatment in the past, now are able to due to the empowerment of women through

these positions in leadership.

23
Solutions to Lack of Education:

For some individuals in the Sub-Saharan Africa region, the cause of becoming infected

with HIV, or not seeking treatment is due to the fact that most individuals have not been

educated on the virus. Obviously, one solution to address the lack of education is to provide

teaching in a way that is efficient and bears in mind the cultural and financial issues surrounding

reasons for lack of education. These gaps in knowledge can be bridged through providing

education to parents and teachers, who would then provide further education to the younger

generations. Every generation of youth brings hope and change in the future; they have the

potential and knowledge to change history. There is great importance in educating youth on

HIV/AIDS for the reason that there is hope for the next generation to flip the status of HIV in

Sub-Saharan Africa. It encourages change in practice and social stigma so that the younger

generations will not become infected like other youth in their country. Working towards

educating parents and teachers can offer more opportunities to educate children so that they

know how to prevent further spread of HIV.

Parents are in a unique position to prepare their children for future sexual experiences,

yet it is taboo for parents to begin these conversations with children. The Ottawa Charter for

Health Promotion came out of the first International Conference on Health Promotion organised

by the World Health Organization. The five stages of the Ottawa Charter for Health Promotion

“provide strategies from which governments and health promoters in SSA can support parents to

promote health and encourage safe sexual practices among young people.” (Tarkang et.al) The

first stage is building healthy public policies where governments should include in their action

plans for HIV/AIDs is to commit to teaching parents about the pandemic as well as creating a

24
supportive environment to have parent-youth communication around HIV. Creating a supportive

environment for safe sexual practices is the second stage. Goverments need to intisitute laws

against sexual violence and rape to ensure that youth avoid getting HIV. The next stage is

strengthening community action, where parents are encouraged to create self-help groups with

parents and youth to support and learn from one another to build community and help parents

who may be HIV positive. The fourth stage is developing personal skills, where strategies are

provided to empower parents that consist of leadership training and learning opportunities for

health. Developing these skills can help parents so they can identify the needs and concerns of

their children. The final stage is reorienting health services, so that instead of trying to cure

infections within children healthcare givers should prioritize teaching parents about HIV, so that

they have the ability to help their children avoid infection. The five steps outlined in the Ottawa

Charter for Health Promotion used in programs can enhance the knowledge of parents in SSA to

feel empowered to have beneficial conversations with their children regarding sexual behavior

(qtd. In Tarkang et.al)

School is another opportunity to reach adolescents through teachers incorporating

HIV/AIDS education into their curriculum. But, similarly to parents, talking about sexuality can

be taboo for even teachers and they can even be uneducated themselves. The five stages used to

educate parents can also be used in educating teachers on HIV so they can have meaningful

conversation about sexuality to children. In a study designed to identify factors that support or

block the role of secondary school teachers in HIV/AIDS activities around prevention in South

East Asia and the Pacific, that had similar issues to SSA regarding HIV/AIDS. Few of the

teachers received training on HIV. Regarding the training researchers found a difference between

25
the two groups, 85% of the teachers that acquired training were proven to be more likely to teach

about HIV in the classroom in comparison to the 43% of teachers that did not receive training on

HIV. The teachers were less likely to teach about HIV/AIDS to students in the lower grades

(Sarma et.al). Considering this outcome, teachers who received training were more likely to

teach HIV in their classroom because teachers felt more confident to teach correct information

on HIV.

The study also assessed what teaching methods would be beneficial in assuring students

retained the information taught. Given the freedom for teachers to choose a teaching style for this

curriculum some teachers chose to use traditional teaching and the remaining few chose to do

interactive style of teaching that encompassed group discussions and case studies. The study

showed a positive correlation between interactive teaching methods and students asking

questions during the lesson (Sarma et.al). This was most likely because students were engaged.

From all of this information it can be said that teaching teachers accurate information by having

them take part in training is beneficial in teaching students effectively. Having interactive lessons

so students are able to retain the information being taught so they can apply it to their lives.

When children are able to apply it to their lives it ensures that students will be safe in sexual

intercourse to avoid the potential of becoming infected, if a child was to become infected they

would know what services are available to seek treatment. Without the proper education initiated

when children are young, the chances of that child contracting HIV and potentially spreading to

others can become a risk.

Solutions around the lack of education in the adult population in Sub-Saharan Africa are

different than the ones provided to children. Obviously adults don’t attend school to access

26
correct, effective education on all the risks of HIV. On the other hand adults aren’t left with

nothing. It is easier to access education services as an adult because it is provided commonly in

communities. Organizations that do prevention and treatment services like testing, ART

initiation, and condom promotion also incorporate education during their services. For example

voluntary counseling and testing services educate through counselling sessions and other

non-governmental organizations bring awareness around HIV and educate communities both in

rural and urban areas. Along with those services many faith based organizations actively

participate in education on HIV/AIDS. Implementing HIV/AIDS education in faith based

organizations was one of the services that lead to Uganda’s well-known success. The Anglican

Church in Uganda implemented a HIV/AIDS prevention service using a peer education

approach. Messages around HIV/AIDS were delivered from the pulpit in sermons, funerals, and

even weddings (Green et.al). Due to the information provided to adults through religious

organizations and churches, there are not as many additional services geared towards adults in

Uganda.

The many solutions to the root causes of HIV/AIDS are excellent, but they have some

set-backs. Approaches taken to initiate behavior change can have their limitations. Behavior

change success in Uganda was very specific to Uganda and their HIV status. Replicating that in

another country may lead to success as well, however there is no proof supporting behavior

change can be successful to the extent it was in Uganda. Not every country is going to be the

same as Uganda when it comes to beliefs, politics, and community involvement. Although it is

unknown if these solutions will take effect across the developing world as a whole, it is probable

that they will be effective based on the success seen in Uganda. Considering the cultural and

27
economic similarities of Uganda to the rest of Sub-Saharan Africa, it can be expected that the

solutions that are so effective across Uganda will also have an immense impact across the rest of

the region.

Part IV: Conclusion

The most effective way of decreasing HIV/AIDS in Sub-Saharan Africa is through

Voluntary Counselling and Testing (VCT) services, as well as treating HIV/AIDS with

antiretrovirals. Doing something to either help prevent or treat HIV is more effective than doing

nothing at all, so any kind of prevention and treatment services provided can affect HIV in

Sub-Saharan Africa positively. There is a huge emphasis on spreading access to HIV testing

since it can detect people infected that are unaware of it. What we can learn for many other

pandemics and epidemics is testing is a necessity to fully grasp the amount of people infected, as

well as catching HIV in its early stages so ART can be initiated as soon as possible. VCT is a

service that provides what is needed and that is testing plus the additional services. VCT is

proven to be very effective in terms of addressing most of the root causes of HIV. Many studies

conducted found that VCT had a statistically significant impact on reducing the number of sexual

partners one has. People who recived VCT were more likely to reduce the amount of sexual

partners and unprotected sex compared to those who didnt recieve VCT. Additionally VCT

offers next steps for patients so they can access ART so they can live a long life and prevent

others from getting infected. Effective ART is the most important intervention in terms of

longevity and preventing infections in patients with HIV infection. The research suggests that

ART initiation is highly effective in terms of achieving viral suppression. The study found that at

12 months after enrollment, retention remained 60% higher in the ‘treat all’ compared to the

28
control group (Nash et.al). From this information when ART is easy to access, more HIV/AIDS

cases will be treated.

Going forward, information suggests that we know what we need to do to decrease

HIV/AIDS in SSA but still need to figure out how to actually do it. Voluntary counseling and

testing along with antiretroviral therapy is already existing in Sub-Saharan Africa and is already

helping to treat HIV. Moving forward bringing awareness around these programs, catching

people's attention in rural and urban areas will motivate them to seek HIV services. Uganda

brought awareness of HIV through billboards, the media, influential people spreading the word,

NGO’s, and community members to spread the word. Also normalizing HIV in these

communities by eliminating stigma will empower people to face the fear brought by society and

seek care. By following these actions Sub-Saharan Africa has the potential to work towards

meeting the global UNAIDS goal to end AIDS by 2030.

Limitations:

With HIV being around the world for years, there is tons of studies and rich information

around HIV/AIDS in Sub-Saharan Africa. Obviously this thesis is not going to address every

single moment in history involving HIV/AIDS. There are other factors that could play into

decreasing HIV/AIDS in Sub-Saharan Africa. This topic requires lots of research, it takes years

for even people with PHDs to come to a conclusion. Through tons of research and from what I

learned I came to a conclusion based on what the research showed.

29
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