Table Of ContentAIDS in Africa
Second Edition
AIDS in Africa
Second Edition
Edited by
Max Essex, DVM, PhD
Chairman, Harvard AIDS Institute
Mary Woodard Lasker Professor of Health Sciences
Harvard University, Boston, Massachusetts, USA
Souleymane Mboup, PharmD, PhD
Professor of Microbiology, Laboratory of Bacteriology and Virology
CHU Le Dantec, Université Cheikh Anta Diop, Dakar, Senegal
Phyllis J. Kanki, DVM, DSc
Professor of Immunology and Infectious Diseases, Department of Immunology and Infectious Diseases
and the Harvard AIDS Institute, Harvard School of Public Health, Boston, Massachusetts, USA
Richard G. Marlink, MD
Senior Research and Executive Director
Harvard AIDS Institute, Boston, Massachusetts, USA
and
Sheila D. Tlou, PhD
Associate Professor, Department of Nursing Education
University of Botswana, Gaborone, Botswana
Managing Editor
Molly Holme
Department of Immunology and Infectious Diseases and the Harvard AIDS Institute
Harvard School of Public Health, Boston, Massachusetts, USA
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To Elizabeth, Marie, Pascal, Kim, Tom, and Carel
Contributors
Quarraisha Abdool Karim, PhD, Univer- Health, Population Council, Johannesburg,
sity of Natal Medical School, Durban, South Africa
South Africa
Elisabeth Bouvet, MD, Infectious Disease
Iain W. Aitken, MB BChir, DCMT, MPH, Physician and Professor, Bichat Hospital,
Lecturer on Maternal and Child Health, University and GERES, Paris, France
Harvard School of Public Health, Boston,
Bluma G. Brenner, PhD, McGill
Massachusetts, USA
University AIDS Centre, Montréal,Québec,
Anthony Amoroso, MD, Assistant
Canada
Professor of Medicine, Institute of Human
Virology, Baltimore, Maryland, USA Carl H. Campbell, Jr., MPA, Senior Public
Health Advisor, Global AIDS Program,
Gabriel M. Anabwani, MBChB, MMed,
Centers for Disease Control and Prevention,
MSc, Professor of Pediatrics, Senior
Atlanta, Georgia, USA
Consultant Pediatrician, Princess Marina
Hospital, Gaborone, Botswana Robert Colebunders, MD, PhD, Professor
of Infectious Diseases, Institute of Tropical
Ahidjo Ayouba, PhD, Centre Pasteur,
Medicine and University of Antwerp,
Yaoundé, Cameroon
Antwerp, Belgium
Francis R. Barin, PhD, Professor,
Université François Rabelais, Tours, France Sylvie Corbet, PhD, Serum Statens
Institute, Copenhagen, Denmark
Augustine Barnaba, Queen Elizabeth
Central Hospital, Blantyre, Malawi Brian Coulter, MD, Senior Lecturer in
Tropical Child Health, Liverpool School of
Françoise Barré-Sinoussi, PhD, Professor,
Tropical Medicine, Liverpool, United
and Head, Retroviral Biology Unit, Institut
Kingdom
Pasteur, Paris, France
Charles E. Davis, MD, Assistant Professor
Michael Bartos, MEd, Senior Policy
of Medicine, Institute of Human Virology,
Advisor, Joint United Nations Programme
Baltimore, Maryland, USA
on HIV/AIDS, Geneva, Switzerland
Seth Berkley, MD, President and CEO, Martin Dedicoat, Liverpool School of
International AIDS Vaccine Initiative, New Tropical Medicine and the Africa Centre,
York, New York, USA Hlabisa Hospital, Hlabisa, KwaZulu Natal,
South Africa
Gunnel Biberfeld, MD, PhD, Professor,
Department of Immunology, Karolinska Beth A. Dillon, MSW, MPH, Centers for
Institute, Stockholm, Sweden Disease Control, Atlanta, Georgia, USA
Kelly Blanchard, MSc, Robert H. Ebert Ousmane M. Diop, PhD, Institut Pasteur,
Program on Critical Issues in Reproductive Dakar, Sénégal
viii CONTRIBUTORS
José Esparza, MD, PhD, WHO-UNAIDS Phyllis J. Kanki, DVM, DSc, Professor of
HIV Vaccine Initiative, World Health Immunology and Infectious Diseases,
Organization, Geneva, Switzerland Harvard School of Public Health, Boston,
Massachusetts, USA
Max Essex, DVM, PhD, Chairman, Harvard
AIDS Institute, and Mary Woodard Lasker Saidi H. Kapiga, MD, MPH, ScD, Assistant
Professor of Health Sciences, Harvard Professor of Reproductive Health, Harvard
University, Boston, Massachusetts, USA School of Public Health, Boston,
Massachusetts, USA
Eka Esu-Williams, PhD, Population
Elly T. Katabira, MD, World Health
Council, Horizons Program, Johannesburg,
Organization, Harare, Zimbabwe
South Africa
David A. Katzenstein, MD, Associate
Wafaie W. Fawzi, MD, DrPH, Associate
Professor of Medicine, Stanford University
Professor of International Nutrition and
School of Medicine, Stanford, California,
Epidemiology, Harvard School of Public
USA
Health, Boston, Massachusetts, USA
Patrick K. Kayembe, MD, DrPH, Associate
Geoff Foster, MBBS, DCH, MRCP,
Professor of Medicine and Public Health,
Consultant Pediatrician, Mutare Provincial
University of Kinshasa, Kinshasa,
Hospital, Mutare, Zimbabwe,
Democratic Republic of Congo
Stefan Germann, Masiye Camp, Bulawayo, Poloko Kebaabetswe, RN, RM, MPH,
Zimbabwe CHES, Botswana-Harvard AIDS Institute
Partnership, Gaborone, Botswana
Peter B. Gilbert, MS, PhD, Assistant
Research Professor, Department of Annamaria K. Kiure, MD,SM, Harvard
Biostatistics, University of Washington, School of Public Health, Boston,
Seattle, Washington, USA Massachusetts, USA
Sofia Gruskin, JD, MIA, Assistant Mark W. Kline, MD, Professor of Pediatrics,
Professor of Health and Human Rights, Baylor College of Medicine, Houston, Texas,
Harvard School of Public Health, Boston, USA
Massachusetts, USA
Sibylle Kristensen, MPH, MSPH, Co-
Aïssatou Guèye, Institut Pasteur, Paris, director, AIDS International Training and
France Research Program, University of Alabama at
Birmingham,Birmingham, Alabama, USA
Aissatou Guèye-Ndiaye, PharmD,
Marc Lallemant, MD, Perinatal HIV
Assistant Professor of Microbiology, Centre
Prevention Trial, Thailand, Institut de
Hospitalier Universitaire, Dakar, Senegal
Recherche pour le Développement, Chiang
Amar A. Hamoudi, Center for International Mai, Thailand
Development, Harvard University,
Anne Laporte, MD, Institut de Veille
Cambridge, Massachusetts, USA
Sanitaire, Saint-Maurice, France
Keith E. Hansen, MPA, JD, Deputy Sophie Le Coeur, MD, PhD, Institut
Manager, AIDS Campaign Team for Africa, National d’Études Démographiques, Paris,
The World Bank, Washington, DC, USA
France
Samuel Kalibala, MD, Horizons Project, Tun-Hou Lee,SD, Professor of Virology,
East and Southern Africa, Population Harvard School of Public Health, Boston,
Council, Nairobi, Kenya Massachusetts, USA
CONTRIBUTORS ix
Shahin Lockman, MD, Harvard School of Gernard I. Msamanga, MD, ScD, Associate
Public Health, Boston, Massachusetts, USA Professor, Department of Community
Health, Muhimbili University College of
Chewe Luo, MBChB, MMED, PhD,
Health Sciences, Dar es Salaam, Tanzania
HIV/AIDS Officer, UNICEF, Gaborone,
Botswana Katawa Msowoya, MSc, Malawi AIDS
Counseling and Resource Organization,
Eligius Lyamuya, MD, PhD, Senior
Blantyre, Malawi
Lecturer and Head, Department of
Microbiology and Immunology, Muhimbili Michaela C. Müller-Trutwin, PhD, Institut
University College of Health Sciences, Dar Pasteur, Paris, France
es Salaam, Tanzania Ruth Nduati, MBChB, MMed, MPH,
Senior Lecturer, Department of Pediatrics,
Miriam Maluwa, LLB, LLM, The Joint
University of Nairobi College of Health
United Nations Programme on HIV/AIDS,
Sciences, Nairobi, Kenya
Geneva, Switzerland
Ann Marie Nelson, MD, Chief, AIDS
Indu Mani, DVM, Harvard School of Public
Pathology Branch, Armed Forces Institute of
Health, Boston, Massachusetts, USA
Pathology, Washington, DC, USA
Richard G. Marlink, MD, Senior Research
Eric Nerrienet, PhD, Head, Virology
and Executive Director, Harvard AIDS
Laboratory, Centre Pasteur, Yaounde,
Institute, Boston, Massachusetts, USA
Cameroon
Elizabeth Marum, PhD, Centers for Disease
Robert Newton, MBBS, DPhil, MFPHM,
Control and Prevention, Nairobi, Kenya
Radcliffe Infirmary, Oxford, United
Philippe Mauclère, MD, PhD, Director, Kingdom,
Institut Pasteur de Madagascar, Kathleen F. Norr, PhD, Associate Professor,
Antananarivo, Madagascar University of Illinois at Chicago, College of
Harriet Mayanja-Kizza, MBChB, MMed, Nursing, Chicago, Illinois, USA
MSc, Senior Lecturer and Head, Department Vlad Novitsky, MD, PhD, Harvard School of
of Medicine, Makerere University Medical Public Health, Boston, Massachusetts, USA
School, Kampala, Uganda
Stephen J. O’Brien, PhD, Chief, Laboratory
Dorothy Mbori-Ngacha, MBChB, MMed, of Viral Carcinogenesis, National Cancer
MPH, Senior Lecturer, Department of Institute-Frederick, Frederick, Maryland,
Pediatrics, University of Nairobi College of USA
Health Sciences, Nairobi, Kenya
Churchill L. Onen, MBChB, MMed,
Souleymane Mboup, PharmD, PhD, Senior Consultant Physician and Head of
Professor of Microbiology, CHU Le Department of Medicine, Princess Marina
Dantec/Université Cheikh Anta Diop, Dakar, Hospital, Gaborone, Botswana
Senegal
Martine Peeters, PhD, Institut de Recherche
Kenneth McIntosh, MD, Professor of pour le Développement, Montpelier, France
Pediatrics, Children’s Hospital/Harvard Peter Piot, MD, PhD, Executive Director,
Medical School, Boston, Massachusetts, Joint United Nations Programme on
USA HIV/AIDS, Geneva, Switzerland
Monty Montano, PhD, Assistant Professor Jean-Christophe Plantier, PhD, Assistant
of Medicine, Boston University School of Professor, Laboratoire de Virologie, Hôpital
Medicine, Boston, Massachusetts, USA Bretonneau, Tours, France
x CONTRIBUTORS
Kirthana Ramanathan, MD, MPH, Daniel Tarantola, MD, Senior Policy
Harvard AIDS Institute, Boston, Advisor, Director General’s Office, World
Massachusetts, USA Health Organization, Geneva, Switzerland
Robert R. Redfield, MD, Professor of Sheila D. Tlou, PhD, Associate Professor,
Medicine and Director of Clinical Care and Department of Nursing Education,
Research, Institute of Human Virology, University of Botswana, Gaborone,
Baltimore, Maryland, USA Botswana
Boris Renjifo, MD, MS, PhD, Harvard Coumba Toure-Kane, PharmD, MD,
School of Public Health, Boston, Assistant Professor, Laboratoire de
Massachusetts, USA Virologie, Hôpital Le Dantec, Dakar,
Senegal
Renée Ridzon, MD, Centers for Disease
Control and Prevention, Atlanta, Georgia, Sten H. Vermund, MD, PhD, Professor and
USA Director, Division of Geographic Medicine,
University of Alabama at Birmingham,
Jeffrey Sachs, PhD, Galen L. Stone
Birmingham, Alabama, USA
Professor of International Trade, and
Director, Center for International Mark A.Wainberg, PhD, Professor, McGill
Development, Harvard University, University AIDS Centre, Montréal, Québec,
Cambridge, Massachusetts, USA Canada
Jean-Louis Sankalé, PharmD, DSc, Neff Walker, AB, MA, PhD, Senior Advisor
Harvard School of Public Health, Boston, for Statistics and Modeling, United Nations
Massachusetts, USA Joint Programme on HIV/AIDS, Geneva,
Switzerland
Roger L. Shapiro, MD, Harvard School of
Public Health, Boston, Massachusetts, USA Carolyn Williamson, Associate Professor,
François Simon, MD, PhD, Head, Faculty of Health Sciences, University of
Retrovirology Laboratory, Centre Capetown, Capetown, South Africa
International de Recherche Médicales de Anne Willoughby, MD, MPH, Director,
Franceville, Franceville, Gabon Center for Research for Mothers and
Moses Sinkala, MD, MPH, Director, Children, National Institute of Child Health
Lusaka Urban District Health Management and Human Development, Rockville,
Board, Lusaka, Zambia Maryland, USA
Freddy Sitas, PhD, Head, Cancer Cheryl A. Winkler, PhD, National Cancer
Epidemiology Research Group, National Institute-Frederick, Frederick, Maryland,
Cancer Registry, South African Institute for USA
Medical Research, Johannesburg, South
Debrework Zewdie, PhD, Manager, AIDS
Africa
Campaign Team for Africa, The World Bank,
Karen A. Stanecki, MPH, Chief, Health Washington, DC, USA
Studies Branch, International Programs
John L. Ziegler, MD, MSc, Professor of
Center, U.S. Census Bureau, Washington,
Medicine, Emeritus, and Director, Cancer
DC, USA
Risk Program, University of California at
Zena A. Stein, MA, MB BCh, Professor of San Francisco Comprehensive Cancer
Public Health and Psychiatry Emeritus, Center, San Francisco,California, USA
Mailman School of Public Health, Columbia
Lynn S. Zijenah, PhD, Senior Lecturer,
University, New York, New York, USA
Department of Immunology, University of
Arnaud Tarantola, MD, GERES, Faculté Zimbabwe Medical School, Harare,
Xavier Bichat, Paris, France Zimbabwe
Foreword
The way we deal with AIDS in Africa will All of them take account of the local cultural
determine Africa’s future. The devastation context. But they all have something else in
wrought by HIV/AIDS on the continent is so common; they stem from a political will to
acute that it has become one of the main fight AIDS, and a recognition that facing up
obstacles to development itself. AIDS to the problem is the first step towards con-
threatens to unravel whole societies, com- quering it. I am convinced that, given that
munities, and economies. In this way, AIDS will, every society can do the same.
is not only taking away Africa’s present—it We have seen a growing understanding
is taking away Africa’s future. of the inextricable link between prevention
This crisis requires an unprecedented and treatment, and a conviction that treat-
response. It requires communities, nations, ment can work even in the poorest societies.
and regions, the public and the private sector, We have seen AIDS drugs become more
international organizations and nongovern- available and affordable in poor countries,
mental groups to come together in concerted, and scientific progress promises simplified
coordinated action. Only when all these treatment regimes. Above all, we have seen a
forces join in a common effort will we be able growing understanding that the key is politi-
to expand our fight against the epidemic to cal commitment to providing treatment,
decrease risk, vulnerability, and impact. All backed up by community involvement.
of us must be open about HIV, and raise our Our challenge now is to build on the
voices against stigma and discrimination. All momentum that has been achieved. Practical
of us must rise above turf battles and doctri- medical education is a vital pillar in that
nal disputes. The only acceptable result is that process, and this book promises to be an
we replace suffering with hope. invaluable tool. I am especially heartened that
This is indeed a time of hope, for after so many of its chapters are written by
years of slow and inadequate responses, we Africans—for the solutions to this crisis must
have seen a turning point in the fight against come primarily from Africa itself, with sup-
HIV/AIDS. For much of the international port from the wider internationalcommunity.
community, the magnitude of the crisis is Whether you are a practitioner, a policymaker,
finally beginning to sink in. At no time in a public health expert, a person living with
dealing with this catastrophe has there been AIDS, or a concerned member of the public, I
such a sense of common resolve and collec- hope you will use this authoritative work to
tive possibility. At no time have we seen advance our fight against AIDS in Africa.
such strength of purpose shown by African
leaders themselves.
We have seen examples of effective pre- Kofi A. Annan
vention efforts across the continent. All of Secretary-General of the United Nations
them were developed by actors inside the and Winner of the 2001 Nobel Peace
country; they were not imposed from outside. Prize
Preface
Eight years ago the first edition of AIDS Over the last eight years, there has been
in Africa was published. Since then, many a massive expansion of the AIDS epidemic
millions of Africans have died of AIDS in Africa. During the same period there have
and huge numbers of children have become also been major milestones of progress.
orphans. In some countries, life expectancy Perhaps the most dramatic of these has been
has been reduced by more than a third, and the recognition that the lives of most AIDS
more than a third of young women are patients can be saved with the use of combi-
HIV-infected. nations of antiretroviral drugs. However,
The worldwide AIDS epidemic has with very few exceptions, Africans have not
now surpassed the former benchmark of yet benefited from the fruits of research on
infectious disease epidemics—the bubonic AIDS treatment.
plague—in total deaths. That epidemic of For more than 15 years, there have been
the 14th century eliminated entire civiliza- statements of intent to develop a vaccine.
tions and changed the course of history. Yet, such statementshave never been backed
Numbers of annual deaths from AIDS also by resource allocation for vaccine research
recently surged past those representing the that has matched the allocations for drug
burden of death from malaria. While the research. Preventive medicine has never
numbers for AIDS morbidity and mortality been as popular as therapy to save the lives
worldwide may seem astounding, they of those who are already ill, even when it is
should be even more astounding when we much more cost-effective. Those who can-
consider that more than 70% of the world’s not pay the cost of treatment are often left
burden is concentrated in sub–Saharan to die.
Africa, home to just 10% of the world’s There is some good news. Some of the
population. drugs designed for treatment have been
During the 1980s most of the attention shown to be remarkably effective and also
given to AIDS issues focused on the United cost-effective for preventing the transmis-
States and Europe. Africa was largely sion of HIV from mother to child. Some
ignored by the rest of the world and many countries within Africa, such as Senegal and
African governments were in denial. Few Uganda, have made impressive progress in
political leaders remain in denial, but the controlling HIV epidemics. A few interna-
devastation of AIDS in Africa is still largely tional agencies, especially the Bill and
ignored by governments of the affluent Melinda Gates Foundation, have made
nations of the North. Even some countries important commitments to the problem of
that were previously considered models of AIDS in Africa. The United Nations has
success in Africa—those with expanding established the Global Fund.
economies, lack of violence, and good gov- The new edition ofAIDS in Africa has
ernments—have been devastated by HIV been completely reorganized and revised to
and AIDS. reflect the current and future epidemics of
