. Directorentralntelligence
a nil
1
Africa's
AIDS Crisis
.
Special National Intelligence Estimate
Spoa'ot National IntelligenceBsiimata represents the views of the Director of Central Intelligence with tho advice and assistance of the US Intelligence Community.
Sub-Saharan Africa's Worsening AIDS Crisis
Intonation available as of0 was..
m the preparation ol ffus Special National mt&bgonce Estimate
The heowing intetogwix organizations particjpatod
tho preparation ol this Bsnmate:
The Central Intelligence Agency
The Defense InteUigonco Agency
The Natonal Socuniv Agency
Th* Bureau of Intelligence and Research.
Department of Siato
aeso parvcipat'ng-
Thei ot Staff for intei^gence. Department ol the Army The Director of Naval Intelligence. Departrrcm ol tha Navy
This Estimate was approved for publication by tlie National Foreign Intelligence Board.
0
sub-saharan africa's worsening aids crisis'!
Shortureaccine, which are unlikely by the, there appears to be little opportunity to slow the African AIDS epidemic. It engulfs all countries of Sub-Saharan Africa and is spreading at such an alarming rate that weillion Africans will be infected by tbe i
The economic and social consequences for countries that lose significant portions of their urban adult populations to AIDS will be debilitating. In some countries, economic productivity will probably beownturnnd severe stress on the extended family network will be evident.
Crowing international concern wilh the epidemic may complicate Western tics to Africa. Africans will expect tbe United States and the West to provide increased assistance lo cope with the disease, and failure lo do so may result in harsh criticism and charges of racism.
C*lobal Human Immunodeficiency Vims (HIV) Estimales: Rales of Infectionersons
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Key Judgments
Shorture or vaccine, which arc unlikely by Ihe, there appears to be little opportunity to slow the African AIDS epidemic. Africans are not changing sexual behavior patterns enough to affect the course of the disease, even though most know more about AIDS/HIV (human immunodeficiency vims) transmissionesult of education campaigns.!
The epidemic engulfs all countries of Sub-Saharan Africa and is spreading at an alarming rate through the central and southern regions. Wc estimate thatillion Africans are alreadyigure we expect to increaseillion by the. The combination of AIDS with the myriad of natural and manmade adversities couldchange African societies and their relationships with others during this decade. Humanitarian and health issues wilt becomeimportant to international and regional leaders struggling to save future generations from illness and premature death.
African Response
All African countries participate in the anti-AIDS program of the World Health Organization (WHO) and eagerly accept bilateral aid; nevertheless, few African political leaders now put the full force of government into the fight and fewer still share the medical professionals' sense of urgency. The relatively low political priority accorded the crisis has meant that the creation of national AIDS committees and the startup of education campaigns has been excessively bureaucratic and only slowly implemented, even though external funding has been generous. In South Africa, for instance, onlyerccnt infection rate was found among the adult black population did the government appeal for international assistance in
Increasing illness and death among elites during theay prompt more aggressive action, but, in view of hard economic limesack of resources, frustrated leaders are likely to seek scapegoats among unpopular ethnic or regional groups or blame the West for inadequate assistance. Costs of upgrading health systems lo even minimal standards, however, are beyond the reach of stretched assistance budgets of Western donors. P
Consequences
The economic and social consequences for countries that lose significant portions of their urban adult populations to AIDS will be debilitating. Infection rates in African cities rangendercent or more, and are rising. Of particular importance for future stability will be the depletion of the small number of political, military, and economic elites, ofisproportionate share arc prone to high-risk sexual behavior. Unless Africans overcome cultural antipathies to the only means of prevention currently available- abstinence from casual sexual encounters and condomresources uf governments and economics will be sapped:
Although wc cannot as yet document AlDS-induced economic change, wc believe that the first indicator willeduction in the size of some labor forces because of increased morbidity and mortality. Preliminary results from an epidemiological-dcmographic model suggest that such declines in the working-age population will be noticeable5 in
for instance. But given data shortcomings, wc can only speculate inai5 workers will be younger, less experienced, and less well trained and that productivity will probably beownturn.
The rising incidence of infection among children and mothers is setting the stageew set of problems, including severe stress on the extended family network in some countries. International health officials predict conservatively that2frican children will have AIDS or be infected. African governments rely on the extended family to care for orphans, sick and dying AIDS patients, and the elderly whose adult children succumb to the disease. But many families are too poor to assume these multiple burdens, and, coupled with the fear and prejudice still surrounding the disease, many victims arc shunned by family, expelled by villagers, and left to fend for themselves. )
The disease has made inroads into rural areas, and it is probable, although undocumented, that current low HIV infection rates there are increasing. Much of the increase is fueled by urban migrants who, during returns to the countryside, infect rural residents. There are high rales of infection in populations along major transportation routes, because of transmission from truckdrivcrs and Ihc prostitutes who haunt the irucksiops. Regions beset by warfare are particularly at |
Datu Shortcomings
Despite an increase in information on AIDS in Sub-Saharan Africa over the last several years, data remain fragmented, inconsistent, and. in many casts, unreliable. Health care systems remain both rudimentary ond inaccessible to the majority itl people. Diagnostic ability in most countries is still inadequate, survey taking to assess behaviorals.lust begun, and some governments remain defensive and unwilling to release data that do become available. Modest improvement* in testing and Informationhowever, have enabled some refinement if infection and disease estimates and allowed preliminary projections of the potential spread of AIDS. We believe that further improvements In data collection will probablyrisis of even greater magnitude than is portrayed in this Estimate. i
High prevalence of other endemic diseases,imitless demand for AIDS care and control programs will overwhelm already weak health systems. The cost of upgrading health systems will probably be prohibitive for governments as well as for foreign donors who fool much of the bill even now. I
External Involvement
The USSR, Easiern Europe, and Cuba will probably play minor roles in Africa's anti-AIDS campaigns. The Soviet Union's AIDS disinformation campaign ha* wound down under pressures from tbc United Stales and iis own desire lo be seen as more cooperalivc internationally. East European countries will most likely remain preoccupied with internal changes and newly recogni/ed AIDS epidemics within Iheir own borders. Although Cuban doctors and technicians arc acceptable lo African counlries, no African government has been willing to embarkolicy of lifelong quarantine of infected persons similar io lhat in Cuba. Requirements denying entry to infected African students arc likely lo remain in effect as Ihey have noi disrupted bilateral relationships between Africa andcounlries!
Growing international concern with Ihe epidemic may complicate Western tics to Africa. Africans will expect the United States and the West to provide greatly increased assistance lo cope with the disease. African disappointment may result in harsh criticism and charges of racism The withdrawal of Western business asset* or investments because of AIDS would add to tensions and African frustrations. Finally, ethical questions raised by any drug or vaccine testing on African populations by Western researchers may also strain relations,
Contents
The AIDS Virus ia Africa
Origins. The origins of the viruses that cause AIDSailer of probably unprovable hypotheses. Those who propose African origins of the AIDS epidemic presumeutant variant of one or more of simian retroviruses was accident-ly passed to humaiu. where it underwent further spontaneous adaption before emerging as Human Immunodeficiency Vinaore recent hypothesis is lhal human retroviruses have long existed and may have mutated repeatedly,emerging as HIV. In any case, Africans remain extremely resentful of any implication that Ihey were responsible for the emergence of AIDSlobal disease, ft;/
Virus Variants. HIV is highly mutable. HIV-I. the first virus recognized in the epidemic, has been found in retrospective examination <tf samples from both the Untied States and Africa that had
been collected and preserved inecond major variant.as recognized in
West Africat Is also prevalent in .Angola and Mozambique. Other variants may emerge in Africa during the span covered by this Estimate, but so far none have been recognized. The abiluy ofo produce human disease seems similar to HIV-I, but further study will be needed to determine if there are maior differences in the incubation period or lethality of the two strains.
ft)
Modes of Transmission. Heterosexual andtransmission dominate the African epidemic. No matter how effective preventive education and condoms may come to be, the number oflready infected will result in rapidly risingof deaths of adults and children for the next decade. (V,
The rate of infection through blood or blood products is falling as ihe technology jarlood has been successfully exported to Africa, lood-borne transmission will be significantly cur-tailed in the coming decade provided the external ssistance for screening continues to be available, v. Homosex ual transmission and transmission by needles shared for drug abuse are probably of inimal significance in the African epidemic^ept among whites in South Africa, fvf ;
mm
Cofacton. Probably there are multiple cofactors either facilitate infection or accelerateto AIDS- Especially significant Inare other sexually transmitted diseases. 'particularly those that cause ulcerationor genital mucosal surfaces. Also, 'men.uneircumcised have greater risk of Infectionthose who are circumcised, {ii}Y
Discussion1
, Suh-Saharan Africa: Implications of the AIDS Pandemic, published inroperly warned of ihe spread of AIDS io all Sub-Saharan countries and correctly called attention to anurban epidemic thatisproportionate number of Africans in the modern scClur, including the military, at high risk. The Estimate also correctly earned of ihe possibility of increasing AIDS in rural areas, especially along major transportationise in AIDS cases among mothers and infants, and of the inability of the health systems to cope with large numbers of the terminally ill.
The Estimate underestimated the degree ofby most African countries of internationally backed campaigns for public education efforts to change high-risk sexual behavior. Itacklash against the West, East European countries, and the USSR resulting from mandatory testing and expulsion of HIV-infected civilian and militaryas wellacklash against Africaninability to combat the disease. On the other hand, although few of the adverse economic and political trends forecast have occurred, it is probably too early in the course of the epidemic to measure such cffccts.l
Despite an increase in informationhe scope and intensity of the epidemic are still difficult to precisely assess because data remain fragmented, inconsistent, and unreliable. The vast majority of Africans do not come under the care of public health systems, diagnostic ability in most countries is still inadequate, survey taking to assess behavioral change has just begun, and some governments remainand unwilling to release data lhat do become available Nevertheless, some modest improvements in testing and information collection over the past
1 This FMimnlc wai imliiird by Ihr National Intelligent ODicCf far Adici in liahl or Eiming concern abnit tlx AIDS cpidsmic in Africa. Il ratintnta iheand imnnci nf the dlic&ic thrcutli ihe I
three years have enabled some refinement of infection and disease estimates and allowed preliminaryof the potential spread of the epidemic' (u)
ApMrmk'
A rapid increase in reported AIDS and HIV carriersndisputed. The World Health(WHO) estimates that bytillion Sub-Saharan Africans (one or everydult men and women) were infected, more lhan half (he global total. Our own estimate is even higherillion Africansigure we expect to increaseillion by the. The epidemic nil) is predominantly urban (abouterceni ol Sub-Saharanillion people are urban! and hits hardest among the economically productive0ge group. Although infection rales ore usually lower in rural Africa, ihe epidemic is beginning lo make inroads there as well, and, because io many women carry the virus, Ihe number of infants born infected is risingj
Geographic Scope
The epidemic is spreading unabated throughoutsouthern, and eastern Africa. HIV infection rales are sure lo rise ia most counlries during. Virtually ill of those no* infected will develop the clinical symptoms of AIDS and die within five toears and will be capable of infecting others.infection rates arc rising almost everywhere, ihey are particularly high in certain countries and cities:
On the basis9ercent of the population of Bangui, Central African Republic, were estimated to be infected, a* many aseople. Smaller towns in ibe aorta and east are experiencing rates nearly as high.
1 St* annn to dcuihiwuMoa ot out am(O
officials in Rwanda estimated thai the number of infected people in the country nearly doubled in four years, up toerceniyear-olds In Kigali were infected, and rural rales wereercent and increasing.
Survey resultserceni of the Kinshasa. Zaire, population are infected.
8 survey showed urban infection rates ofercent in the central region andercent in Kampala. On lhc basis of thedults0 children arc estimated to be infected
Researclieis estimate thaioercent of Zambia's adult population arc infected, andercent in Zimbabwe)
As few as three years ago. West African countries had hoped ioevere epidemic, but by0 the disease was recognizedhreat lo them as well. Infection ralesew countries, such as Ivory Coast and Guinea-Bissau, approximate those elsewhere in Africa:
Ivory Coast, excluding Abidjan, surveys showed infection ratesercent in urbanercent in rural areas,ersons infected8 survey in Iwopercent infection rates among patients.
WHO estimates infection rates in Guinea-Bissauoerceni.
countries have lower rates: Gambiaercent, doubling yearlyhana,erceni;ercent of the urban adult population In Mali.
ajor variant of the AIDSmuch of the disease in West Africa,the course of the epidemic there may differ from that in other parts of Ihc continent. I-
AIDS Among Selected Population Croups Rural-Urban Differencet. Data show urban infection rales higher than rural in nearly every country. Rather than rural people being somehow at lower risk, the spread of the disease there may simply be several years behind the cities, or poor documentation of rural prevalence may be hiding the extent ofack of medical care, personnel, and health resources in the countrysideidespread ability lo diagnose AIDS or test for HIV, and few rural populations have been systematically screened to determine the levels of infection, in8 survey, the onlystudy to include both urban and rural IIIV screening to date, rural rates rangehan urban rates, but still very high.
(L)
Some researchers suggest thai traditional mores in rural communities limit casual sexual activity and hold HIV transmission in check. This hypothesis is supportedtudyew rural Zairianwhere infection rates haveercent or less forears. It is questionable, however, whether these limited findings should be extrapolated to applyhe whole of rural Zaire or lo any other country's rural population.
War and civil unrest increase the disease risk for some rural populations. Hard hit by such turmoil and now suffering an intense AIDS epidemic are the civilians living on the western shore of Lake Victoria in Uganda and in Ihc northern border villages ofthe route of9 Tanzanian incursion in Uganda, (u)
Rapid urbanization and urban lifestyle factors are at least partially responsible for high urban infection rales. Urbanization in Sub-Saharan Africa hasfromercent0 to an estimatedercentost African cities have demograph-ically unbalanced populations because of theof males in migration flows. Researchers haveelationship between sex ratios and high
Secret
into: the higher the ratio of men to women, the more likely there willarge commercial sex trade, an increase in high-risk sexual behavior on the part of young males, and rapidly rising levels of sexually transmitted diseases and AIDS.opulation imbalance is one factor likely to accelerate epidemics in Abidjan and Nairobi. (t|
Infected urban migrants who return lo rural homes may hasten the spread of ihe virus among rural populations, but AIDS control officials are more concerned with the high-risk behavior of trackers and pros limits in small trading centers along major roads through the counlryside.urveys showedercent of the truckers on the Uganda-Kenya route were infected and nearlyercent of prostitutes al Iruckslops were infected. More recent surveys found that, at the first stop in Zimbabwe on ihe route to Zambia, all ofrostitutes were infected, as wereercent of drivers operating between Zambia and South Africa. Truckers In Niger. Uganda,South Africa. Nigeria. Malawi, Ethiopia, and many other count nc* have been targeted forcampaigns and some, such as Ihe Iruckers union in Niger, have requested prevention programs.|
Elites. Although data vary from study to study, urban-based economic and political elites seem to be infected at levels at least as high as the general urban population or higher if they indulgt in high-risk sexual behavior made possible by their privileged positions and better salaries. Anecdotal evidenceAIDS deaths of government officials and high-ranking military personnel in many counlries and some small survey*rowing HIV epidemic among the skilled work force and upper-income groups:
percent of health workersissau obstetric clinic were found io be infected.
mililary students have been expelled from other Third World countries, the West, the USSR, and Eastern Europe when found infected.
Militaries. African security forces are al particularly high risk because most of them arc stationed in urban areas and high-risk sexual behavior is common. Many soldiers arc far from their families andcansexual partners. Insurgent groups in Africa arc also vulnerable; particularly in southern Africa, guerrilla organizations have initiated anti-AIDS education programs- Information on infection levels and AIDS cases is sketchy, however, because data are not collected assiduously, testing is sporadic, and test results are closely held for security
Wc expect combat support and technical fields lo be severely affected in many African militaries. I roblem in lhc military is likely to grow. In addition, the policy of rotating brigades in country means the armed forces could spread AIDS to tumI areas |
il mm Approximately half of all AIDS/HIV casesAfrica are female. The number of infected mothers is highstill vastly uadcrrcported because mostdo not a'.lcad clitics or get tested *hcn there Approiinuiclyoercent of children born to infected mothers will themselves be infected, (f)
Groups that engage regularly in high-risk behavior, such is prostitutes, have been known to have high rates of infection for several years,pcrccni
Infection rates among prostitutes in Kinshasa and theercent or higher rates in Nairobi arc no longer surprising. What is alarming to researchers andhowever, is the discovery of increasing rates among these groups in countries considered to have low or moderate levels of infection, such as Niamey, Niger,erceni of prostitutes were infected5 percent were infected one year later.
Education and Pretention Campaigns
African efforts to tackle AIDS problems soaredthe creation7 of the World Health Organization's Global Program on AIDS (WHO/GPAk Before then,andful of Sub-Saharan countries were casting about for ways to combat the disease, and fewer still were willing to openly recognize or explain to their citizens the scope of the epidemic or the sexual nature of the disease (see foldout,oday, with the technical andassistance of WIIO/GPA and donors, newly created national AIDS committees in most countries have adopted National AIDS Programs to protect the blood supply, stimulate public education activities to urge sexual behavior change, plan for care of the infected and ill, and create surveillance and reporting schemes. WHO/GPA is funded by0 million per year, and in turn fundsoercent of the National Program in individual countries, with bilateral and multilateral donorsthe rest.0 National AIDS Program budget for Africa is projected3 million from all sources, someercent of National Program spending in Third World countries. (U)
Although strides have been made in devising anti-AIDS strategics, key decisionmakers often do not share the sense of urgency shown by the medical professionals who direct national programs, and Health Ministries seldom have political power. Lack of participation at the top rungs of government has resulted in faltering projects and slow approval of new activities, andew governments have dedicated their own fundsomplement to international AIDS assistance.
ess thin wholehearted commitment by political leaders, WHO hasove away from official defensiveness and denial and the will, by some governments, lo back sensitive projects. For instance, Zaire, which barely acknowledged AIDSew years ago.ass media campaign in Kinshasa to promote condom use8 survey showed lhat onlyercent of women andercent of men knew condomseans of prevention, and onlyerceni had everondom. After the media campaign, the number of condom sales in Kinshasa increasedegligible levelillion per month during tbe first halfhere i* little evidence, however, thai such charges in knowledge and attitude have as yetin sexual behavior changes on the scale needed to slow the spread of the
The credibility gap between many centraland major sectors of the populationajor constraint on such educational efforts and leads some groups to reject Ihe prevention message as yet another tactic of those in power lo tighten government control. This is especially true of rural people who discount the advice of urban-based officials whom ihey accuse of delivering only words and not needed basic services such as health cart or schooU-f
Cultural and technical barrier* lo countrywide AIDS education arc formidable. Poor communicationsmean that the more conccnirated and belter educated urbanjust those in the capitalreached more often by printed materials and radio and television programs lhan arc farftung, less literate rural populations. liven in small countries where distances between urban and rural populations
/
are nol great, educational outreach faces manyIn the Gambia, where nearlyercent areecent survey found that most Gambians knew AIDSiller disease, but few knew of any prevention measures. Media design isearth of African communications experts needed to design posters and presentations often results in the use of foreign consultants who sometimes miss the nuances necessary for cultural acceptance of the message, and the multitude of languages in any one country present translation problems and expense.
Health Infrastructure*
AIDS patients have already overwhelmed the grossly inadequate health system* in most highly infected countries, and similar problems are likely in those countries only now beginning lo experience aain AIDS patients Public health networks across (be continent sutlerack ofcapita health spending averagesershortage* of drugs and equipment, poor facilities, and inadequate training of the loo few medical personnel andospitals in central and southern Africa arc grappling with the leading edge of tbe epidemic and already losing the resource battle:
In Lusaka the University Hospital hasoercent of it* beds occupied with AIDS patients and only6 arc needed.
Mama Yemo Hospital in Kinshasa, one of the largest in Africaedsdaily, is woefully underfunded, under-equipped, and understaffed Inalf the patients on internal medicine wards andercent on pediatric wards had AIDS
IDS patients were treated in tbc main hospital io Kigali, comprising about one-half of all patients Special drugs arc seldom used; tbe cost of treatment with AZT -the most effective drug in thefor one month wouldop civil servant's entire monthly salary.
The physical strains on health systems will be difficult lo overcome, but financial strains may well beTo illustrate the added burdenby the AIDS epidemic- the World Bank has projected that inaverage treatment costs for AIDS are0 pernational health budget would need to be increasedercent3 just to accommodate AIDS palients.
AIDS has been superimposed on Africa's overtaxed health systems. Malaria, measles, diarrhea,illnesses, schistosomiasis, sexually transmitted diseases (STDsX and malnutrition currently affect more people than AIDS-someercent of Sub-Saharan Africa's total population, according lo WHO. These problems receive higher priority from most health professionals because most arcor treatable, in contrast lo AIDS. :i
Adding lo the grim health picture is the role the HIV virus is playing in outbreaks of tuberculosis, which bad been in decline for over two decades. Although infection with tuberculosis is common inrates of nearlyercent occur in somedisease remains latent in most healthy people. When immune Systems are compromised by HIV. however, those with latent tuberculosis develop the disease and are then capable of spreading tuberculosis as well as HIV.month period,ercent of new tuberculosis patients in Abidjan were also HIVas wereoercent in Zaire andercent in the Central African Republic, (u)
Cultural Changes
There is no evidence that risk-reducing behavior changes arc occurring ai levels sufficient to slow (he epidemic in Sub-Saharan Africa. Mass mediahave succeeded in convincing audiences lhat AIDSatal disease, but followup surveys findombination of traditional behavior patterns,perception of information, and fatalism have thwarted the adoption of unpopular preventiveuse, prohibition on casual sexualor abstinence, (u)
Research Progress on AIDS in Africa
'TAe tfwr is conducing major research efforts on
molecular virology. anti-HIV drug development, and Hiy vaccines, while African research ison documenting the epidemic,the natural history of the disease, and studying the social and cultural context of the African epidemic. In many instances, African.scientists have collaborated with Western counterparts, most notably in multinational centers such as Project SIDA in Zaire. There have been, however, two exclusively African efforts to develop drugt^ Egyptian and Zairian doctors developed the drugnd7 announced iture, at' though9 they said its benefits had.been: overstated. The ingredients of MM-I, and of the follow-on versionave never been revealed nor made available to other scientists fortesting and evaluation. On the other hand, the drug Kb'MRON, developed by Kenyanis undergoing evaluation tests sponsored by WHO. {uj
Available drug therapies only temporarily slow the progression to AIDS. Each eventually losesand none is curative. The drugs have
proved too costly for use in African medical settings Success in vaccine development remains uncertain and any practical results art at leatlears Into the future. Severtheless, in anticipation that ultimately both drugs and vaccines of tuffi-cltnl promise to Justify testing in humam will be found. who and governmental agencies have done adwtnce planning as to where such testing can be done mosl efficiently, Medically, jests itf African populations wilh their very high rates nf new infections could provide clear answers yearsthan tests of Western populations with much lower rales of infections. So mailer how welt lustified scientifically or carried out with informed consent of governments and participants under who protocols, however, such testing could be viewed by some Africans as exploitation ijblocks for the benefit of wealthy whites, evenaccine that prevents infection Is developed and used, thercwould beoears of wind down while the disease ran its course in those already j
of most countries, interviews of civilian and mililary personnel in Congo showed lhai llie majority of people knew AIDS was fatal and that it was transmitted sexually and through blood products but still characterized multipartner sexual liaisons asdemonstrations of male virility; they said condoms were too expensive, culturally undesirable, and rarely used. Fvcn in hard-hit Uganda, President Museveni condemns condom use for AIDS prevention as leading lo moral degeneracy and prohibitscalling insteadeturn to traditionalmarriage. Moreover, in most countries, women who insist on condom use are often accused by husbands and family of ignoring traditional values in an effort to limit fertility and are at added risk of beatings, divorce, or expulsion from the extended
family. Finally, the status of motherhood farthe risk of HIV infection, and women typically assess the risk of bearing infected children who will soon die as no greater than the risk of infant death from oneyriad of childhood diseases. I
Unable to care for the burgeoning caseload of pa-tienls, authorities rdy on the extended family to take over the burden. Many families accept the financial and psychological obligation, bul Olhers expel the sick from family and village because of economic hardship and the fear and prejudice lhat surrounds the disease.
M
bi2.
A study nf the urea around Rakai in Uganda ofrecognized outcome of the epidemic-ofthe breakdown ofcoping mechanisms. The area is nearly bereftmen and women, and about half of thoseare infected.0 childreo arein tbe town of Rakai0 inNearly half of the surviving caretakerstoo young or loo old to provide both childfarm labor, resultingood shortage in aarea. Un the basis of data from Rakai andrapid spread of AIDS throughout theresearchers estimate that Uganda will bewith the needso more than Iorphans in coming years. Problemsthis magnitude can be expected inas well as Burundi, Malawi. Rwanda,
Wilh little help coming from modem medicine, many Africans turn to traditional healers. While some healers do little more than squeeze money from the poor and credulous, others arc seriously confronting the disease. The leaders oflrong Pan-African Traditional Healers' Association recently consulted with Western medkal practitioners and then issued guidelines for AIDS protection. They directed members lo urge Africans to followsexual behavior, ideatined as abstinence before marriageonogamous marriage relationship, and included permission for condom use. Many AIDS experts believe thai more interaction betweenhealers and AIDS educators could help in control efforts, <l)
To help fill Ihe gap left by overburdened health services and traditional structures, community based self-help and support groups are springing up in many countries, although they so far reachinuscule portion of those in need, arc grossly uno>rfundod, and occasionally meet strong local opposition.organi/atium are beginning to lend their expertise to these struggling gioups, but few local or national governments have as yet offered assistance to such private-sector initiatives, (u)
Outlook for
Social, economic, and political repercussionsoaring AIDS epidemic will confront all Sub-Saharan African governments and populations before theof the decade- Tbe upward spiral of AIDS cases and deaths are but the leading edge of (hesoon to follow win be hundreds of thousands more victims, most already on the brink of death. As grim as the situation is, Ihc epidemic is probablyby available data because of Ibe lack of expertise and resources lo conduct systematic evaluations. We believe that improvements in data collection willrisis of even greater magnitude than is now appreciated by mosl African Icaders.f-
The impact of the epidemic in populous Wesleginning to be felt. Mosl governments ideally arcelter position to stem the rapid spread of infection than were countries hit several years ago as theelter understood and WHOsstrategies arc already defined. Nevertheless. West Africa's leadersense of urgency, aod ihe pattern of lackluster response seen in other regions is likely to be repealed. Thus, the number of carriers and victims in West Africa's large population and teeming cities could become enormous]
Urban youlh. military personnel, and the moreclasses have shown little inclination lo change Ihe high-risk sexual behavior lhal fuels the epidemic. Such elite groups arc as culturally opposed lo strict monogamy or condom use as arc powerless and less well-educated citizens. As tbe epidemic spreads,and depletion of their numbers increases, the elite are likely to insist on government attention to their personal and class crises |
Although we have not yet observed important political effects of AIDS in Africa, wc believe they will be evident in tbe hardest hit countries by tbc:
Increasingorsening AIDS crisis will add yet another burden on already fragilestruggling wilh intractable problems such as
dclH, economic stagnation, populaiion growth,degradation, and sharpening conflictsange of domestic issues stimulated bypluralist expression.
Scapegoating. Under pressure to do mure on AIDS despite scarce resources, African leaders arc likely to search for scapegoats. This may lead to repressive or discriminatory policies toward unpopular ethnic or regional groups, or AIDS victims themselves, and fuel anti-Western sentiment.
Manpower lasses. Death rates among politicalwill probably reach levels that begin to impair capabilities to govern. In addition to sheer loss of trained manpower, rulers and civil servants may come torowing fatalism within their societies about AIDS that overwhelmingly favors short-term goals and satisfactions over long-term solutions.
The effects of AIDS on African militaries andsecurity forces in the next few years will have important security implications. Although wc have not yet observed degradation of military capabilities from AIDS, serious problems will impair readiness and effectiveness in the future:
performance and loss of trainedexperienced officers, and technicians.
Restrictions on military students going abroad for iraining; foreign military advisers in country; and training and exercises wilh foreign forces.
Aggravation of morale and discipline problems.
Strains on military medical systems.
Poor civil-military relations if the armed forces are perceived by the populace as contributing to the spread of
The growing epidemic could also lead to heightened tensions within and between African states. Iflevels arc high or AIDS cases numerousarticular area, travel restrictions that might becould result in tense political relations,isolation, the disruption of key trade andlinks, border closings, and expulsion of for-cigncrs,| " |
It is not yet possible to document an AlDS-induced economic decline, but analysis of populations most affected byyear-old urban dwellers- strongly implies that the economic and political elites, and ihe youths who are training to enter their ranks, arc likely to fall victim to the disease in large numbers. The possible lossignificant portion of Ihe already small cadre of skilled workers and professionals could result inproductivity and less capable management within five or six years. Replacements will, of neccssi-ly. be less well trained and experienced, which could further aggravate economic difficulties.|
High prevalence of other endemic discuses, und an limitless demand for AIDS care and control programs will overwhelm already weak health systems. Tbe overall quality of health care is poor and has declined under the hard economic conditions of. Governments are unlikely to recover the ground lost and will falter badly as AIDS cases skyrocket The cost of upgrading health systems will probably be prohibitive for governments as well as for foreign donors who fool much of the bill even now.esult. AIDS paiients will remain untreated und Ihe myriad of other diseases could gain new strength.
No African populaiion is likely to slop growing altogether, although in some countries growth will slow by ihe end of the decade as rates declineercentage point or more. Ihe populations of cities and heavily infected rural provinces, however, could well experience outright declines. (i|
Slowed population growth will not case social or economic problems in the short term. The highest disease rates and greatest number of deaths are already occurring in ihe productive, economically activeoge group, with maximum rales in theo iO-years-old. The result of losses In this group could be fewer icachers for even reduced
student numbers; surviving health professionalsby increased patient loads;lowing of business activityurther reduction of economic
resources
The costs of shoring up institutions to meet thewill deplete tbc already shrinking pool ofand money for economic and socialcompeting needs arc sorted out, politicalbe threatened if those pans of society that loseresource struggle become disaffected enough tothe locus of serious political
External lntohcment
The USSR, Eastern Europe, and Cuba
The initial flurry of anger and resentment shown by African countries over the testing and deportation of infected African students from the USSR, Eastcountries, and Cuba has died down and resulted in only negligible political fallout; similar policies incountries arc abo not contentious. New student groups arc arriving in Cuba on schedule, and any reductions in African training slots in the USSR or East European countries will have more to do with political changes in those countries than with the AIDS epidemic in Africa. The Soviets, besieged with domestic problemsise in its own epidemic, have recently begun to seek cooperative research efforts with the United States, but have so far made no dramatic overtures to aid Africa's anti-AIDS campaigns. East European countries are also struggling wiih changed domestic situations and newly recognised epidemics in some, such as inand are unlikely in ihe near term lo be significant players in Africa's AIDS struggle.)
Over thewo years, Moscow has backed away from iis allegations in Ihe Soviet and international media lhat the United Slates is responsible for inwntlng ond spreading AIDS. Since the endhere have been onlyalf dozen replays of AIDSin the Soviet press. US protests and exposure of Soviet involwment stent to have convinced the Soviets that such operations may harm their new. more cooperalixr international image In an7 mews conference, representatives of the Soviet Academy nfdiscredited the AIDS stories, stating tha; "no seriouselieved the allegations. Furthermore,adio Moscow broadcast in early8 claimed that AIDS was manufactured in the United States and tVestern Europe. Moscowtrong US'pro-the official Soviet position that AIDS was not munmadc. Radio Moscowblamed the broadcastslon-level 'nut" and bureaucratic
he AIDScampaign was always est in Africa, where Soviet placements'.
Hird
, ivend.aUhough tnue to receive some.attention in World media for many years to come, we believe that Moscow will refrain from providing any new stories or replaying old ones]
continues its decades-long policy of using medical assistance to maintain involvement in Africa. But we expect Cuba to beinor actor in the AIDS struggle. Although countries eagerly accept Cuban medical experts. Cuba's stringent policy of lifelong quarantine for its infected population has not been copied in Africa. p
The tailed Stales and the West Growing international concern with the epidemic may-complicate Western tics to Africa. Western countries will continue to consider ways of limiting ihe exposure
of their military personnel lo the disease without offending host governments. US and Westerninterests could curtail or suspend operations in fear of health risks lo their personnel or because of highly infected indigenous labor forces and further depress African economies. Pushed to respond to an increasingly difficult domestic situation and aloss of prestige internationally, African leaders
may in frustration lash out at the United Slates and the West, even though the major hopeureaccine appears to lie with Western research.I-
The cooperative relationships forged between the West and Africa over the past three to four years to combat the disease may begin to falter. The value of internalionally assisted prevention programs, bilateral aid for condom distribution and technical training, and cooperative research efforts may come to seem insignificant in the eyes of Africans as the rising toll of illness and deathense of isolation and panic. Africans will expect the United States and the West to underwrite broader and more costlyprograms to cope with the disease. However, the massive assistance needed to raise health careto even minimum standards are probably out of the question in days of stretched assistance budgets. African disappointment may result in bitter criticisms and charges of racism. Moreover, the ethicalraised by any drug or vaccine testing on African populations by Western researchers may also strain relations. I
Annex
Country Profiles
profiles give on overview of AIDS cases, HIV infections, and information on Ibe institutionalof Sub-Saharan couniriea to the epidemic, (u)
AIDS cast* reported to WHO arc the cumulative cases mosl recently reported by the countries to the World Health Organization (WHO) and entered0 in WHO'* monthly compilation of eases worldwide. These numbers grossly undcrrcprcscntAIDS coses in Africa because of rudimentary health systems and their inaccessibility Iu theof people, the inadequacy of health surveillance and reporting systems, and political sensitivities about the intensity of the epidemic- (u)
HIV prevalence is estimated from the results of the testing of blood samples from selected population groups such as blood donors and those considered at high risk of HIV infection. The reliability of these screenings us the basis for estimating infection rates for similar larger populations or countrywide isthef the tested population is usually small or nonrcpresentalive of larger populations, testingare sometimes medically inadequate, andand recordkeeping is often methodologically flawed amd incomplete. Test results cited here are illustrative of the accumulating body of HIVdata, but they areefinitive compilation of screening results,
AIDS program components within the Plnnsby the World Health Organization/Globalon AIDS (WIIO/GPA) include education and information campaigns, protection of the bloodand care for the infected and ill. Nearly all Sub-Saharan countriesnort-Term Plan (STP) that institutionalized AIDSNational AIDS Committees, identified health, communtcalions, and research resources and then advancededium-Term Plan (MTP) strategy for
mulliyear prevention and care programs. Bilateral and multilateral donors and the WHO/GPA provide the bulk of funding. There are also AIDS activities outside the WHO/GPA umbrella, such as bilateral technical and commodity assistance, national and international medical and behavioral research, and counseling and education initialed by privateorganizations, (u)
Health budget gives the amounts allocated to general health care by theare country funds addedhe WHO/GPA and donor AIDS projects. Budget figures are often unreliableauge of health care spending; actual expenditures or monies misdirected or wasted are unknown; and projects funded outside of Health Ministries such as military medical care for civilians are nol included, nor are foreign donor projects lhal often comprise ashare of delivered health care. Health careercentage of the national budget and per capita spending arc also suspect but are provided asof the government's priorities and its ability to deliver health services, (U)
Angola
AIDS cases reported to2 per hundred thousand population) as ofu)
AIDS program: MTP adopted. (u>
AIDS cases reported to WHO:er hundred thousand population) as ofu)
HIV prevalence: no data available, (u)
AIDS program: MTP adopted in June
Bolswana
AIDS cases reported to WHO:er hundred thousand population) as ofu)
Burundi
AIDS cases reported to6 per hundred thousand population) as oft')
AIDS program: MTP adopted
Burkina Paso
AIDS cases reported to6er hundred thousand population) as ofu)
AIDS program: MTP adopted, (u) Cameroon
AIDS cases reported to WHO:er hundred thousand population) as ofu)
AIDS program MTP adopted in
MTP adoptedu) Cape Verde
AIDS cases reported to WHO:er hundred thousand population) as oful
AIDS program SIP adopted, iu)
Central African Republic
AIDS cases reported to9 perthousand population) as ofU)
AIDS program: MTP adopted, (u) Djibouti
AIDS cases reported to If/YOerthousand population) as ofu)
AIDS program: MTP adopted in8
AIDS cases reported to WHO:er hundred thousand population) as ofu)
program: STP completed; work ongoing for MTP. (u)
program MTP adopted in November
AIDS cases reported to WHO:er hundred thousand population) as ofu>
Guinea
AIDS cases reported to WHO:erthousand population) as ofu)
program: STP adopted, (u)
Congo
AIDS cases reported toprogram: STP adopted. <u)
hundred thousand population) as of
. AIDS cases reported toer hundred
thousand population) as ofu)
(.liana
AIDS cases repotted to8 perthousand population) as ofu)
AIDS program: MTP adopted, (u)
AIDS program: MTP adopted9
Gabon
AIDS cases reported to WHO:er hundred thousand population) as ofu)
Gulaea
AIDS cases reported to WHO:er hundred thousand population) as ofi: j
AIDS program: MTP being formulated, (u)
Guinea-Bissau
Thecases reported to WHO:8 per hundred
AIDS cases reported to WHO:erpopulation) as ofu>
thousand population) as ofu)
AIDS program: MTP adopted in
Ivory Cowl
AIDS cases reported to9 per hundred thousand population) as of
Lesotho
AIDS cases reported to WHO:erthousand population) as ofv)
AIDS cases reported to6 per hundred thousand population) as ofu)
Mudagascar
AIDS cases reported to WHO: none as ofU)
AIDS program: MTP adopted, funding pledges for9 through December
Malawi
AIDS cases reported loerthousand population) as ofl)
AIDS cases reported lo WHOer hundred thousand population) as oful
AIDS program: MTP adopted in
AIDS cases reported to WHO. Namibia Rained the right to membership in WHO after its independence in0 but has not yet officially reported cases. The Department of Health andumulative cases by
Niger
AIDS cases reported to WHO:er hundred thousand population) as ofu)
AIDS cases reported to WHO: none as ofu)
program: MTP formulated. <U) Mauritius
AIDS cases reported to WHO:er hundred thousand population) as ofu)
AIDS program: MTP adopted. (U)
AIDS program: MTP adopted in0
Nigeria
AIDS cases reported to WHO:er hundred thousand population) as ofu)
Somali*
AIDS easts reported lo WHO.hundred thousand population, as of February(U)
program; MTP is ncuring)
program: STP adopted- M
South
ases reported toer hundred
^ulauon as o,U>
W
rogram. MTP adopted. (u)
Sao i'otnc and Prl-dpe
aAfporred to WHOer hundred thousand population) as ofU)
program: STP adopted, (u)
AIDS program: Ihc South African Government
TTt docs not participate inf
AIDS cases reported toer hundred thousand population) as ofL)
er hundred thousand population} as ofu)
AIDS program: MTP adopted, (u)
Seycbelkrs
,lf0SrsawnW ro Kv#/ft none as of January
u)
XS program MTP adopted. (u>
Sierra
AIDS cases reported to WHO:0er hundred thousand population) as oful
AIDS program: STP in effect, but Ihc MTP, although formulated, has nol been officially adopted.
cast, reported lo WHO.er hundred thousand population) as ofi}
Zaire
AIDS cases reported lo2 per hundred thousand population) as ofi
aids i'm.aii,.' Wd ini.it>
Original document.
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