African Refugees and HIV/AIDS

            The entire world is consumed by news and discussion of COVID-19.  It has killed millions of people and made many more millions sick, some critically so.  However, COVID has crowded out discussion and action on many other deadly diseases, not the least of which is the human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS).  Because it is not discussed as much as in the past, some may think it is completely under control.  Unfortunately, it is not, and the millions of refugee situations worldwide make it even more problematic, nowhere more so than in Africa.

Last year, Africa saw the most new internal displacements as conflict and violence flared in several countries across the continent. Millions of new displacements were recorded in the Democratic Republic of the Congo, Ethiopia, Central African Republic, South Sudan and Nigeria, triggered by increasing insecurity and human rights violations. 

More than 2.2 million South Sudanese refugees have been hosted in the Democratic Republic of the Congo, Ethiopia, Kenya, Sudan and Uganda, making it the largest refugee crisis in Africa as South Sudan replaced Eritrea as the fastest-emptying country in Africa. 

The world is now focused on the refugees in Ukraine fleeing the Russian invasion, as we should be, but that means less attention is on the many refugees in other areas of the world, such as Africa.

HIV/AIDS is most prevalent in Sub-Saharan Africa, where the disease accounts for more than 70% of the global burden of infection. Exacerbated by the presence of other common conditions such as malnutrition and what are called opportunistic infections, it is devastating families, communities and nations. Conflict, displacement, food insecurity and poverty make affected populations more vulnerable to HIV transmission. The common assumption is that this vulnerability necessarily translates into more HIV infections and consequently fuels the HIV/AIDS epidemic, but is not supported adequately by available data. How conflict and displacement affect HIV transmission depends upon numerous competing and interacting factors and depends on accurate data, which is usually not reliably available. 

Nutritional and micronutrient deficiencies play an important additive role in immune degradation and impaired development in children. Careful implementation of antiretroviral drugs, complemented by simultaneous efforts to ensure proper nutrition among HIV-infected children and adults are essential components of an effective response to the HIV/AIDS pandemic in Africa and elsewhere.  Yet poor nutrition exists widely even in successful African  countries.

Just as epidemics vary by country, so do national responses to this complex emergency. This is illustrated by the cases of Botswana, South Africa, and Uganda, all of whom handle HIV/AIDS differently.  

When Uganda announced its prevention strategy of abstinence, behavior change and condoms, the government’s strategy was criticized as being dangerously naïve.  In South Africa, former President Thabo Mbeki organized a Presidential advisory panel regarding HIV/AIDS in 2000, including several scientists who denied that HIV caused AIDS. Over the next eight years of his presidency, Mbeki continued to express sympathy for HIV/AIDS denialism and instituted policies denying antiretroviral drugs to AIDS patients.  Botswana, with the second highest rate of (HIV) in the world, was the first country in sub-Saharan Africa to offer universal access to HIV care and remains among a handful of countries investing in care at this level in the world

It is especially the social aspects of the disease that make HIV/AIDS in sub-Saharan Africa different—and worse—than HIV/AIDS in the United States or Europe. By making Africans more vulnerable to economic and sexual exploitation, poverty increases the likelihood that they will be infected. By making them too often unreachable customers for pharmaceutical companies, poverty also puts therapies out of the reach of most of the Africans who need them.

According to the Joint United Nations Program on HIV/AIDS (UNAIDS), at the end of June 2021, just 1% of people in low-income countries and 11% in lower-middle-income countries had received at least one dose of a potentially life-saving COVID-19 vaccine, compared to 46% in high-income countries.    In a 2021 report, UNAIDS reported that low-income and lower-middle-income countries are home to a majority of the world’s people living with HIV, and an increasing body of evidence indicates that people living with HIV who
acquire SARS-CoV-2 infection are at heightened risk of severe COVID-19 illness and death. In sub-Saharan Africa, where two thirds (67%) of people living with HIV resided in 2020, the highest rates of one-dose COVID-19 vaccination coverage in June 2021 were in Equatorial Guinea (19%), Botswana and Zimbabwe (9% each) and Namibia (6%). No other countries in the region exceeded 5%.

            Even when AIDS victims in Africa are on antiretrovirals, their treatment can be interrupted, which is exceedingly problematic for them and for the people to whom they can spread the disease.  I visited Zimbabwe with a Congressional staff delegation in 2005, and the country was in the midst of dislocating people on what the government considered illegal settlements.    It was called Murambastsvina, “Move the rubbish” in the Shona language.

One such settlement we visited was completely torn down, including its clinic that was catering to the health needs of HIV patients.  Many of the refugees from these settlements fled to South Africa, but after being off their medication for a prolonged period, that medicine would no longer work as desired.  Many may not have known that and thought they would be protected once they resumed their treatment, but they were not.

Government action against refugees or settlers is not the only reason why antiretrovirals are not adequately used in Africa.  AIDS victims who are poor have been known to sell some of their drugs to make enough money to support themselves.  Partial doses don’t effectively treat AIDS; in fact, using antiretrovirals incorrectly can cause the disease to mutate into a version that the drugs they possess won’t work anymore.  Now you have a new strain that may infect others that is not yet accounted for in the effort to develop drugs to treat it.

Culture and traditions are seen as factors in the spread of HIV/AIDS.  We have seen in the reaction to Ebola in Africa and even in the few victims here in the United States that the way people think about how to deal with a deadly disease such as this can determine whether they react in ways that diminish its danger.  During the Ebola outbreak in West Africa several years ago, a Liberian-American visited his Ebola-stricken sister in Liberia to care for her.  Despite all warnings, he followed traditions in her care and in her burial, catching the disease himself.  He was on his way home to the United States when symptoms broke out at the Lagos, Nigeria, airport.  Had it not been for quick action by Nigerian medical personnel, the disease would have spread widely and perhaps reached the United States.  As it was, the first doctor to treat him died from the virus he passed onto her, and there were cases of Ebola contracted from this man elsewhere in Nigeria, but medical officials were able to do successful contract tracing and identify potential Ebola carriers before it became an epidemic.

A nurse in a U.S. hospital dealt with Ebola victims, but instead of altering her behavior, she went to a fitting for the dress she was to wear at an upcoming wedding.  This error in judgement fortunately didn’t lead to sickness and death, but it does demonstrate how people sometimes don’t take necessary precautions when they conflict with their plans.

Intravenous drug users and prostitutes also are transmission vectors for HIV/AIDS, and both segments of society either feel that they can’t change their behavior or that they just don’t want to.  As both segments engage in illegal acts, changing their behavior is difficult to impossible to enforce with certainty.  Perhaps the cruelest vector for HIV/AIDS is mother-to-child transmission.  A mother who unknowingly becomes infected can easily pass the disease on to her child without adequate treatment.

HIV/AIDS is a serious enough challenge in peacetime.  In the chaos of conflict or disasters, it is even more challenging to get a handle on how to prevent or treat transmission of this virus.  Funding from donor countries and international organizations will be critical – not only for the logistics of distributing drugs, so that victims of the virus are tracked to allow for the kind of data gathering necessary for meta decision on care.  We cannot continue to operate largely in the dark on this virus.  We need solid facts so that strategies will be effective in addressing this still-deadly disease.

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