Ethics and AIDS in Africa

The Challenge to Our Thinking

Anton A Van Niekerk, Loretta M Kopelman, Anton A Van Niekerk, Loretta M Kopelman

• Publisher: Routledge
• Year: 2020
• Print ISBN:
  9781598740707
  9781598740707
• Edition: 1
• eBook ISBN:
  9781315429038
• Topic: Social Sciences
• Subtopic: Anthropology
• Index: Social Sciences

Africa poses daunting medical, social, and economic challenges, placing local, regional, national, and international communities at a moral crossroads. This book, the first to systematically examine the ethical implications of the AIDS pandemic for Africa, examines such pressing questions as: How do we deal with the uncertainties surrounding AIDS statistics? Is it really too costly to provide people highly active antiretroviral therapies in Africa? What is the relationship between AIDS and poverty? Is the political leadership in South Africa doing what is right and prudent to meet the challenge of AIDS? Is the developed world responding responsibly and justly to this crisis in the developing world? Is it moral for companies to make profits from AIDS drugs? Given the scope of the crisis, ought First World ethical standards for doing research on AIDS drugs and vaccines to apply unchanged to Africa? Ought we to include children in research for AIDS vaccines, and if so, how? Why do people persist in regarding AIDS as punishment for sin?

Chapter 1

AIDS in Africa: facts, figures and the extent of the problem

Although there are some discrepancies in statistics, the figures given here by Alan Whiteside¹ prove that Africa has been hardest hit by the AIDS epidemic. The impact is, and will be, devastating across many sectors, and an immediate and appropriate response is necessary.

Every year UNAIDS releases new data on the extent of the epidemic across the world. The trend is inexorably upwards. At the end of 2004 there were an estimated 39.4 million [35.9 million–44.3 million] people living with the virus. Of these, 4.9 million [4.3 million-5.4 million] people were infected in 2004. An estimated 3.1 million [2.8 million–3.5 million] people died of the disease in the past year (UNAIDS and WHO 2004).

Sub-Saharan Africa is the worst affected continent, with 25.4 million [23.4 million–28.4 million] people living with HIV at the end of 2004, an increase of one million since 2002. About two thirds (64 percent) of all people living with HIV are in sub-Saharan Africa, as are more than three quarters (76 percent) of all women living with HIV. There is not ‘one’ epidemic in Africa. There are differences in the size and trajectory of the disease – Southern Africa has by far the worst epidemic, while in North Africa there is no significant HIV infection.

This chapter will:

look at the recent debate on how data are collected;

discuss the African epidemics;

examine the figures to understand future impact, especially with regard to demographic, development and economic consequences;

point to the moral issues.

Data debates: an update

Where do data come from? How can UNAIDS say that there are between 23.4 and 28.4 million people infected in Africa – how certain are they about this? As with so many other fields, we need to understand the limitations of data and data collection. This is well described in the chapter ‘Through a glass darkly, data and uncertainty in the AIDS debate’, an article first published in Developing World Bioethics, 3(1), May 2003: 49–76 by Alan Whiteside, Tony Barnett, Gavin George and Anton A van Niekerk and included in this collection as Chapter 2. This chapter does not revisit that discussion, but rather updates it.

Scientists (and social scientists) recognise the imperfections of the data we have. However, this is not the case for others. Indeed for South Africans, one of the depressing features of 2004 was the renewed questioning of data by ill-informed people who ‘discovered’ the fact that we do not ‘know’ and therefore assume that all data must be wrong.

The 18 December 2003 issue of the British magazine The Spectator ran an article by South African journalist Rian Malan under the headline ‘Africa isn’t dying of AIDS’ (Malan 2003). This article was picked up by the British and South African press and read widely. Malan was given additional credibility by being quoted extensively – although not on the issue of AIDS – by President Thabo Mbeki in his state of the nation address on 6 February 2004. Two days later Mbeki used Malan’s arguments in a TV interview to argue that AIDS is not as serious a problem as we think.

Malan made two key arguments: the first, that while AIDS is a serious issue for Africa, the size of the problem and its long-term effects on society and the economy have been exaggerated; the second suggested that there is something of a cover-up of the true (and more limited) extent of the epidemic as it would not suit the AIDS industry for whom this disease provides employment. There were a number of responses to Malan, one co-authored by myself (Barnett, Prins & Whiteside 2004). Rather than rehash the debates, in the next section this chapter will review the latest data and assess what it means for Africa, and will return to the data issue in the last section.

Before we do this, let us spend a few minutes looking at where data come from. When ‘Through a glass darkly’ (Chapter 2) was written, almost all of the information on HIV prevalence came from antenatal clinics (ANC). The reason was that this is a sexually active, convenient population from whom blood was drawn anyway. Sampling an entire population is expensive and difficult, especially when the test requires blood. It had been done in a few locations and the results of these surveys suggested that ANC data over-estimated prevalence in younger women and underestimated it in older women. It was also believed that although more women would be infected at younger ages, the increased prevalence among older men would even this out.

It has become apparent that in sub-Saharan Africa HIV/AIDS is affecting women and girls in increasing numbers.

With time it has become apparent that in sub-Saharan Africa HIV/AIDS is affecting women and girls in increasing numbers. While globally, just under half of all people living with HIV are female, women and girls make up almost 57 percent of all people infected with HIV in sub-Saharan Africa. In the younger age groups (15 to 24 years), 76 percent of those infected are female.

But there are also new data sources. There have been a number of population-based surveys. In South Africa we have two new surveys – the Nelson Mandela/HSRC population study in 2002 (Nelson Mandela/Human Sciences Research Council 2002) and the 2004 Reproductive Health Research Unit (RHRU) survey of 15- to 24-year-olds (Pettifor et al. 2004). In countries to the north, HIV prevalence is being surveyed as part of some of the Demographic and Health Surveys. This has been done in Kenya and Ghana (where preliminary results are available), and Burkina Faso. There are a number of other studies ongoing and these will report in 2005.²

What these studies show varies. In South Africa, the HSRC survey found a prevalence rate of 17.7 percent among women aged 15 to 49, while the 2001 antenatal survey figure for the same age group was 24.8 percent. However, among pregnant women the prevalence was 24 percent in the HSRC survey – albeit in a very small population. The South African ANC survey shows the prevalence rising steadily. HIV prevalence amongst pregnant women in 2002 was 26.5 percent rising to 27.9 percent in the 2003 – and most recent – survey. According to the RHRU survey HIV prevalence among 15- to 24-year-old South Africans was 10.2 percent. This was 15.5 percent among women and 4.8 percent among men. Prevalence among 21-year-old women was over 30 percent.

Are these differences in South African prevalence levels significant? According to the RHRU report: ‘The HIV findings from this study are similar to those found in the 2002 Nelson Mandela/HSRC survey and the 2002 Antenatal Clinic Survey. Differences are most likely the result of sampling from different populations. Given the paucity of comparative data it is not possible to ...

Table of contents

• Cover
• Title Page
• Dedication
• Copyright Page
• Foreword
• Table of Contents
• LIST OF CONTRIBUTORS
• INTRODUCTION
• CHAPTER 1 AIDS in Africa: facts, figures and the extent of the problem
• CHAPTER 2 Through a glass, darkly: data and uncertainty in the AIDS debate
• CHAPTER 3 Rolling out antiretroviral treatment in South Africa: economic and ethical challenges
• CHAPTER 4 Moral and social complexities of AIDS in Africa
• CHAPTER 5 The HIV/AIDS pandemic: a sign of instability in a complex global system
• CHAPTER 6 Principles of global distributive justice and the HIV/AIDS pandemic: moving beyond Rawls and Buchanan
• CHAPTER 7 Access to affordable medication in the developing world: social responsibility vs. profit
• CHAPTER 8 Affordable access to essential medication in developing countries: conflicts between ethical and economic imperatives
• CHAPTER 9 Mother-to-child transmission of HIV/AIDS in Africa: ethical problems and perspectives
• CHAPTER 10 HIV vaccine trial participation in South Africa: an ethical assessment
• CHAPTER 11 The HIV/AIDS pandemic, African traditional values and the search for a vaccine in Africa
• CHAPTER 12 The dilemma of enrolling children in HIV vaccine research in South Africa: what is in ‘the child’s best interest’?
• CHAPTER 13 If HIV/AIDS is punishment, who is bad?
• INDEX