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From Awareness, to action plan, to program implementation.   ABUJA- NIGERIA REGIONAL CONFERENCE ON STRATEGIES FOR COMBATING THE SPREAD OF HIV/AIDS IN West Africa.   http://democracy-africa.org/articles/hivc.htm Epidemiology of HIV/AIDS in the West African Region By Dr. Aderemi Desalu I have been asked to discuss the epidemiology of HIV/AIDS in the sub-region under the following topics: 1. The epidemiology of HIV/AIDS and types 2. Factors driving the epidemic 3. HIV/AIDS surveillance These will be addressed in the context of Sub-Saharan Africa with focus on the West African sub-region, and in particular, Nigeria. Epidemiology refers to the study of the distribution of disease in human population against the background of their total environment. It includes a study of the patterns of disease as well as a search for the determinants of diseases. As regards the distribution of disease, three major questions are usually asked: 1. What is the distribution in terms of persons? - Who? 2. What is the distribution in terms of place? - Where? 3. What is the distribution in terms of time? - When? The first case of HIV/AIDS discovered in Nigeria was in Lagos in 1986. The individual was a Ghanaian prostitute practicing in the Ivory Coast. The finding was interpreted to mean that the infection was already in the country. The very low prevalence rates recorded in other parts of the country at the time was also an indication that we were at the beginning of the epidemic and that we had an opportunity to avoid the havoc the disease had caused in other countries we seem not to have taken prompt appropriate action as was done in Senegal, which was at the time in a similar position to Nigeria. Due to Senegal's prompt and appropriate action, it now has a prevalence rate of below 3%. The likelihood of adults in SSA to be infected is ten times greater than for an adult in North America and twenty times greater than an adult in Western Europe. The West African sub region is in Sub-Saharan Africa. Today 22.5 million persons living with HIV are in Sub-Saharan representing 80% of the world's total amount; an alarming situation. Within the West African sub-region (and I will explain later on) the prevalence rate ranges from between 2% and 8%, with the exception of Cote d'Ivoire and Togo which range between 8% and 32%. Senegal on the other hand, as mentioned earlier, is below 3%. None of these percentages are acceptable and we must all, very seriously, join hands to bring under control this grave threat to your sub region, to our children, to our future. The prevalence rate in Nigeria going by the HIV Sentinel Survey, 1999 is 5.4%, as mentioned earlier this was not always the case. We have seen a steady rise, as most of our sister nations in the West African region. Nigerian statistics tell is that in: 1992 - The prevalence rate was 1.8% 1994 - The prevalence rate was 3.8% 1996 - The prevalence rate was 4.5% 1999 - The prevalence rate was 5.4% Fortunately now we have a very serious and committed response by the government with the most important multi-sectoral approach. One hopes that all parts of this jigsaw fit together and at the right time in order to bring about the outcome we are all working so hard to achieve. Adult prevalence rates for West African sub-region indicate that in 1982 no country in our sub region had over 0.5% prevalence. Indeed the statistics tell us the whole West African sub-region was between 0% and 0.5%. In 1987 we had begun to see a few countries with a prevalence of 0.5% to 2.0%. These were Ghana, Sierra Leone and Senegal. A few had also in 1987 a prevalence rate of 2.0% to 8.0%. These were Togo and Burkina Faso. In 1992, the picture was looking significantly worse. The adult prevalence rates were: 0.5% to 2.0% for: Nigeria Benin Republic Liberia Guinea Guinea Bissau Gambia Senegal 2.0% to 8.0% for: Ghana Togo Burkina Faso Sierra Leone With the range of 8% to 16% being seen in the Cote d'Ivoire. By 1997 we were all between 2% to 8% with the exception of Togo which joined Cote d'Ivoire in the 8% to 16% adult prevalence rate group and rising. Some of the indicators for geographic areas of affinity in Sub-Saharan Africa, which includes the West African sub-region are: 1. Year of HIV spread 1977-1978 2. Year of first AIDS case diagnosed 1985 3. Availability of data High in the sub-region As regards major modes of transmission, transmission in the sub-region via: · Blood/Blood products Medium./Low · Homosexuality Low · I.D.U. Low · Heterosexuality High Urban/Rural ratio - 3.6-1 Male/Female ratio - 1-1.3 As we all know, HIV is transmitted from one person to the other by: · Unprotected sexual intercourse 80% · Blood/Blood products 10% · M.T.C.T./Needles/sharps, etc. 10% The groups of people most at risk cut across the West African sub-region and include: · Commercial Sex Workers - Statistics show that the rate of HIV infections among this group is very high - 55% in Abidjan, Cote d'Ivoire - 34.2% in Nigeria (1996) · STD patients - In Nigeria, going by the 1996 average, a prevalence rate of 15.1% was seen in these groups. There is scientific evidence that a person with untreated STDs is up to 6-10 times more likely to pass or acquire HIV during sex. · M.T.C.T.(Vertical transmission from mother to child) - The child of any HIV positive mother has a 30-40% chance of being infected. Going by the national average in Nigeria, 4.5% of antenatal cases were found to be HIV positive. Higher figures are seen in Burundi - 20%; in Abidjan the figure is between 10-15%; in South Africa, 11-18% are seen. Around 90% of children who become infected under 15 years of age acquire the virus form their HIV infected mothers, whether before or during breast-feeding. As women of childbearing age themselves become infected in ever-greater numbers, a trend reflecting their own vulnerability to HIV, the number of babies infected through mother to child transmission rises correspondingly. Since the beginning of the HIV/AIDS epidemic in the late 70s and early 80s, the WHO and UNAIDS estimate that more than 5 million children under the age of 15 years have been infected. In 1998 alone, 1400 children died of AIDS daily and an even larger number become newly infected with every passing day. At the end of 1998, it was estimated that 1.2 million children under 15 years of age were living with the virus, and well over 90% of these children live in developing countries like ours. If our children, our future, continue to be born with a death sentence on their heads, because ladies and gentlemen that is what it is, we have no future. · Long distance lorry drivers, migrant workers and drifting across ECOWAS borders in search of greener pastures is another risk group that cuts across the whole of the West African sub-region. Let us hope that the newly introduced ECOWAS passports do not make an already difficult task even more so. · The youth, between ages 15 and 24 years are the most affected age group. In Nigeria, the youths between the ages of 20 and 24 have an HIV prevalence rate of almost 10%. · The military and paramilitary forces throughout our region are a high-risk group. Recent test results in Nigeria of soldiers returning from duties in Sierra Leone and Liberia show a high percentage of HIV positive results. Ladies and Gentlemen, the simple truth is we are all at risk. This scourge touches every one of us and will in one way or another knock on our personal doors. The time to act is now; later may be too late. The types of HIV we have are Type 1, Type 2, and Type 1-2. In Nigeria, HIV-1 was the predominant virus found, accounting for 89% of all the infections. HIV-2 accounted for 4% while HIV 1-2 accounted for 7%. UNAIDS statistics tell us that HIV-1 is the dominant type worldwide, and HIV-2 is found principally in Africa. There are at least 10 different genetic subtypes of HIV-1, but their biological and epidemiological significance is unclear at the present time. Both HIV-1 and HIV-2 are transmitted in the same ways, but while this sis the case HIV-2 appears to be less easily transmitted than HIV-1. The progression from HIV-2 infection to AIDS appears to be slower than in the case of HIV-1. AIDS seems clinically identical whether it results from HIV-1 or HIV-2. It is expected that the vast majority of HIV infected individuals will eventually develop AIDS although no long-term cohort studies have been completed. Progression from initial HIV infection to onset on AIDS might be more rapid in developing countries. We need not be reminded that we are in our sub-region, third world developing countries. Having briefly discussed the first topic, I will now move on to discuss the factors driving the epidemic in our sub-region. I need to quickly point out that though I will be concentrating on factors driving the epidemic, it does not mean that we have no factors that could help us slow down the epidemic that may be discussed at another time. Man's total environment includes all living and nonliving elements in his surroundings. It consists basically of 3 major components. Physical Biological Social I will discuss the social component a bit further. This represents the part of the environment that is entirely manmade. In essence it represents the situation of man as a member of society, his family group, his village, or urban community. His culture including beliefs and attitudes, the organization of society, politics and government, laws and the judicial system, the educational system, transport and communications and social services including health services. Many of our societies in our sub-region are still held tightly in the vicious cycle of: Poverty Ignorance Disease Having mentioned the above, I will now proceed to look at the very many factors that drive the HIV/AIDS epidemic in our sub-region. 1. Poverty of our people, which I believe is mainly a function of poor leadership, political instability and destruction of institutions among many others. Poverty is also inclusive of poverty of education, social sciences, infrastructure, hope and a future. 2. Lack of safe sexual behavior. From the detailed work already done by NACA one can list the following factors within and accounting for this main factor: a) Continued denial of the existence of AIDS b) Educational limitations, such as - limited information in local languages - absence/limitation of sexual education in schools - general low enrollment of children in schools - low girl attendance c) Cultural limitations to S.S.B. These include - negative cultural factors - the youth cannot speak about sexuality with parents publicly - male sex behavior dominance d) Contributory social behavior to the lack of S.S.B. - Prostitution - Indifference to HIV/AIDS by people - crime e) Lack of S.S.B. as concerns the use of condoms are due in part to - lack of appropriate information on use/benefits - non-acceptance of condoms - low availability of condoms - cost of the condom - condoms should be free and of good quality 3. The epidemic is also driven by inadequate STD prevention, diagnosis and management. In this regard the following are contributory factors a) The prevention, diagnosis and management of STDs are not sufficiently integrated into P.H.C. b) Lack of information about where to go for diagnosis c) Lack of information about STDs among the population d) Fear of stigmatization e) Non/poor availability of laboratory facilities for diagnosis f) Competition with alternative medical practitioners g) Insufficient number of health workers h) Poor availability of drugs i) Poor management of information system in STDs j) Poor management of staff k) Financial cost 4. Stigmatization of HIV/AIDS is also a major driving force of the epidemic 5. Blood safety inadequacies. These are contributed to in part by: a) Lack of national policy and implementation of b) No national blood transfusion services c) Inadequate number of trained personnel d) Lack of voluntary non-remunerative blood donor system e) Non-sustainable supply of consumables and reagents f) High cost of processing blood for transfusion g) Lack of blood substitute and components h) Poor political and financial commitment 6. Inadequate targeting of youth is another epidemic-driving force and this is caused by many factors, some of which are: a) Lack of integration of necessary information into school curriculum b) Many youth are not in school c) Negative attitude of parents to sexual education d) Poor role models e) Lack of youth friendly health services and counseling facilities f) Declining moral standards g) Paucity of channel of information targeted at youth h) Poor recreational facilities for the youth i) Non-implementation of the laws and rights of children/youth j) Increasing unemployment k) Lack of social welfare package l) Inadequate funding of youth-related STD/HIV/AIDS programs 7. Another major driving force of the epidemic is the inadequate care and support, and this in turn is brought about by the following factors: a) Not enough facilities for V.C.T. b) High cost of diagnosis and inadequate diagnostic facilities c) Inadequate number of social workers d) Inadequate guidelines on counseling e) Inadequate home-based care structures and support f) Inadequate supply and high cost of drugs g) Stigmatization 8. The medical, social and related factors driving the epidemic include a) Ignorance of both the health care workers and the patients b) Poor health-seeking behavior c) Inadequate and misdistribution of health facilities d) Poor infection control e) Poor access to A.R.V. drugs and drugs for opportunistic infections f) Inadequate number of trained counselors at all levels g) Inadequate psycho-social help h) Lack of confidentiality i) Poor referral systems and lack of continuum of care j) Competition with spiritual healers k) Religious and cultural barriers 9. Epidemic driving factors related to human rights and justice, which I will take Professor Soyinka's permission to list. Some of them include: a) Non-sensitization of legal staff to HIV/AIDS b) Non-formulation of new laws and abundance of existing laws as it relates to HIV/AIDS c) Lack of information to PLWHAs regarding their rights d) Not enough political drive e) Strong religious and traditional laws which may be contrary to HIV/AIDS f) Protection of prisoners and people in detention 10. Other factors which drive the epidemic in our sub-region include: a) A lack of focus on women's needs b) Lack of research and facilities for research c) Ineffective management of skills d) Bureaucracy e) Lack of the bottom up approach and involvement of and capacity building of grass root organizations and structures f) Maximally effective IEC g) Proper monitoring and evaluation of programs and adequate data collection h) Lack of multisectorality i) And finally, lack of funds. The best-laid plans may collapse without appropriate funding. This factor needs to be concentrated on. The third and final topic which I will be addressing is HIV/AIDS surveillance. Accurate HIV/AIDS surveillance is a beacon for action against the epidemic, and the need for quality surveillance cannot be overstated, in order to map the epidemic, region-by-region and country-by-country. Surveillance succinctly means monitoring the trend of a disease, in this case HIV/AIDS surveillance is to monitor the trend of HIV/AIDS over a period of time as it affects the risk groups, the age ranges, the prevalence, is the epidemic getting better or worse, the gender disparities, etc. Tracking the HIV/AIDS trend can serve as an early warning system, allowing countries to anticipate and counteract new waves of infection, and at the same time it focuses world attention on the epidemic and its dramatic impact in many countries. For surveillance to be effective, the system and structure to be used need to be well conceived and workable. This will lead to accurate and relevant data being collected, as it relates to the various markers and groups decided on. The data that is then collected needs to be professionally analyzed to give us an accurate up to date situation of the disease. By monitoring the situation of the disease, we are then in a better position to plan our various meaningful interventions, in order to better control the spread of HIV, and to. As mentioned earlier, anticipate and counteract changes in the epidemic. HIV/AIDS surveillance has been carried out in the countries of our sub-region, hence the availability of he statistics mentioned earlier. For example, we know that between 1982 and now the sub-region has gone from 0 - 0.5% to 16% in some countries. Surveillance has told us that a country like Senegal is achieving a lot more in the control of HIV/AIDS than the Cote d'Ivoire or Sierra Leone. It has raised questions. It has made us explore further why this is so. It has given us answers as to why this is so, and now it now puts us in a better position to effectively tackle the HIV/AIDS scourge. A task we cannot and must not fail in. I thank you all very much for listening and wish us all a successful conference. Back to top HIV/AIDS Prevention Strategies for West African Region By Dr. Tony Elioke Introduction In spite of developments in drug therapy for people living with HIV/AIDS (PLWHA) and vaccine against HIV, prevention of HIV infection still remains the priority objective for HIV/AIDS control globally, more so in developing and underdeveloped regions, like West Africa. It will be quite some time before currently in use HIV anti-retroviral drugs become readily available, accessible and affordable generally, in the countries of West Africa. And within the interval, HIV/AIDS will have caused so much devastation of the socio-economic systems of the countries that little may be redeemable. The cost of managing an AIDS epidemic is enormous and so it makes every economic sense to apply the scarce resources of the West African countries to prevention of HIV infection in the populations against the option of paying more attention to drug management of AIDS cases. Past and present experiences with syphilis and gonorrhea teach us that not all epidemics can be controlled effectively through and emphasized strategy of chemotherapy. Prevention Strategies that have worked and those that have not worked. Strategies for HIV prevention have developed along the line of transmission. In Africa, the sexual role of HIV transmission has remained overwhelmingly predominant; it is the same for West Africa. Thus, Nigeria's Medium Term Plan II (1993-1997) emphasized the strategy of prevention of sexual transmission, with such interventions as: · Promotion of safer sexual behavior · Early diagnosis and proper management of STD Another strategy is the prevention of HIV transmission through blood and blood products, with: · Promotion of appropriate use of blood and blood products · Safe blood for transfusion, etc. Prevention of peri-natal transmission is a third strategy. All these strategies have largely worked where the interventions have been appropriately packaged and delivered. Unfortunately, in the mid-80s to mid-90s, interventions were largely packaged from the experts' perspective above and literary imposed on target sub-populations. (Many interventions did not even target populations.) The none involvement of the beneficiary population made projects alien, failed to utilize the vast potentials of the sub-population, could not be integrated into existing programmed of the groups and therefore could not be sustained. Many projects did not have proper evaluation as they had no base line and so success or failure could not be objectively stated. · Political commitment at leadership level has remained very vital and much has gone into advocacy in the sub-region but political commitment is only beginning to be secured in many West African countries. Only a few have addressed the Agenda for Action of the African Heads of State and Government of 1991/92/ · The strategy of preventing sexual transmission through the adoption of safer sexual behaviours is an uphill task in practice. Most activists believe that providing information regularly to people would make them adopt safer behaviours as prescribed, confronted with deadly scourge like AIDS. That has not worked. Condom promotion and condom use appear to be succeeding more, in practical terms, than the doctrine of abstinence and fidelity. The controversy over the age of entry into sexuality education has worked negatively against postponement of age at first sex for young people. · Power of negotiation of safer sex by woman is still elusive and because most of sexual encounters outside marriage have strong element of sexual exchange in the sub-region, he who pays the piper dictates the tune and men want to get full satisfaction for the material favours to their sex partners. · Behavioural Sentinel Surveillance just beginning in the sub-region, will give better insight into the successes and failures in sexual behaviour interventions. · With prevention through appropriate use of blood, those countries with Blood Transfusion Services have achieved almost complete safe blood transfusion. But in countries where private laboratories, using commercial blood donors, provide most of the blood banking services, transmission through blood, especially in children, remains largely uncontrolled. Further, consistent use of sterile instruments and disposable syringes and needles is yet to be achieved in some of the West African countries, especially where 'quacks' abound in the health service provision. Pre-marital HIV testing for intending couples is being practiced in some of the countries to reduce the incidence of peri-natal transmission and ante-natal clinic attenders are being routinely screened for HIV in some services. HIV positive mothers are not encouraged to breastfeed. Anti-retroviral therapy to block vertical transmission is largely for studies. Again, evaluation of the impact of this strategy is not common. Role of Parents and Schoolteachers in HIV/AIDS Prevention. · Parents and teachers have enormous roles to play in HIV/AIDS prevention. Particularly among young people. AIDS and sexuality education is vital for this prevention and at the age when this education will be most effective and fruitful, the young persons are totally under the control and guide of parents and teachers. Unfortunately, communication between children, adolescents and youths, on the one hand, and their parents and teachers on the other hand, is often poor in this part of the world. Culture and tradition is largely responsible. Further, on sexuality issues, parents and teachers are not equipped with the knowledge and skill to effectively educate the young ones. · Communication between spouses on sexuality is equally poor, making prevention of HIV infection among couples poor. Extra-marital relationship is high in most communities encouraged by some cultural practices and many clients of female sex workers are parents who thus sustain the "importation" of HIV into families. · Polygamy aids this importation. D. Role of Religious and Community Leaders in HIV/AIDS Prevention · Religious and Community Leaders wield a lot of influence over vast majority of the people. They can be invaluable assets to HIV/AIDS prevention, if properly mobilized, sensitized and have capacity built. But they can be equally very obtrusive if their professional biases are allowed to hold sway. Many are also highly conservative and resist changes. Religious organizations often have reliable operational structures and services that can readily integrate HIV prevention and control strategies. Their leaders are highly regarded, looked up to as representing God and exercise largely unquestioned powers with their flock. · It is similar with Community leaders. · They are equally good at mobilizing resources and implementing programmes successfully, with cost effectiveness. · They can accomplish the informational aspect of AIDS education but may often have problem with the methods of behaviour change know to produce better results. · Over the years of the AIDS fight in the sub-region, AIDS activists have been on a running battle with religious leaders over the issue of condom promotion for HIV prevention. E. Prevention of Mother-to-Baby Transmission As mentioned earlier, the ideal for this strategy is to have all couples intending to make babies HIV-free. This free state is easier to achieve at entry into marital relationship, excluding extra-marital motherhood. Intra-marital HIV testing will hardly ever become popular in this part. · Having children to survive a man, in this sub-region, is so vital that the pre-occupation of many young men who tested HIV positive is often how to get a child, preferably male, to survive them. They, therefore, rush marriage and gamble for an HIV negative child, often with success, but at great risk to their spouse. Use of anti-retrovirals to protect a baby from an infected mother may even encourage this practice. Artificial insemination with donor sperm is a healthy option. · Many of the pregnant women testing HIV positive at ANC never have their spouses tested. · Uncontrolled vertical transmission will raise both infant mortality and AIDS orphans. F. Role of the Mass Media in HIV/AIDS Prevention. · Raising public awareness and providing accurate information on which people can act is most vital in HIV prevention. · The fastest way to reach large populations is through the mass media, especially the electronic media, in West African Region. Most surveys in Nigeria give this indication. The electronic media can use diverse methods, which appeal to diverse sub-populations most and target populations with air time. · A good number of the populations hold mass media information as credible. The programmers need proper training and orientation for this role. G. Ensuring the Safety of Blood Supply. · There must exist a national policy on blood supply. (e.g. the NBTS) · Such policy must be religiously implemented across the country · For this to happen in a country like Nigeria, there must exist effective supervision of the operators of any system that is in use. · Donor selection must be practiced to compliment donor screening for HIV. · HIV testing kits must be in regular supply, especially to all blood supply facilities. Interrupted supply of kits and therefore screening of blood is unacceptable. · Commercially supplied blood must be re-screened in the health facility before transfusion. · Blood screening should include for the routine pathogens, like Hepatitis B. CONCLUSION HIV is still spreading in the various countries of West Africa, at varied rates, but through common modes the most important of which is heterosexual. Unsafe blood transfusion is still going on in some of the countries and puts many children at risk. · Prevention still remains the cornerstone of the fight against the HIV/AIDS epidemic and strategies for prevention have evolved in line with international guidelines, namely for sexual, blood and blood products and vertical transmissions. · The multi-sectoral approach, involving all stakeholders and service providers, particularly parents, teachers, political, religious and community leaders, is most effective. · Realistic methods and interventions based more on what works that what is ideal are to be preferred for achieving the goal. · Practical political commitment of the leaders is a sine qua non for efforts to yield the desired results. · The window of hope is West African Sub-region is gradually closing and actions must be hastened. · With joint realistic efforts, we can and should be able to have a hold on the prevention of further HIV transmission in West Africa. Back to top ROLES OF RELIGIOUS LEADERS, NEWS MEDIA PRACTITIONERS AND PARENTS IN COMBATING HIV/AIDS IN WEST AFRICA. A PAPER PRESENTATION AT THE FDA REGIONAL CONFERENCE ON STRATEGIES FOR COMBATING THE SPREAD OF HIV/AIDS IN WEST AFRICA HELD AT ABUJA FCT, NIGERIA, JUNE 5-8, 2000. BY CHINASA ORJI NIGERIA YOUTH AIDS PROGRAMME 9, ADEBOLA STREET, SURULERE, LAGOS 01-5455268, email: nyap@home.panafrica.com INTRODUCTION The HIV/AIDS Pandemic has remained a major reproductive health problem all over the world with catastrophic effects in many countries, especially the developing countries. In Nigeria, according to the statistics released by the Ministry of Health between 1987 and April 1999. Over the years various efforts have been made by the international, national and local organization in related fields to fight the spread of HIV/AIDS by increasing awareness on its modes of transmission and prevention but the number of infected persons have been on a steady increase especially among the youth. This can be attributed to the fact that pre-marital sexual activities are a common, but disturbing phenomenon in the sub-region. The Issue The whole issue of HIV/AIDS prevention is viewed viz. a viz. the health, cultural, economic, religious and social dimensions and this is applicable to the entire sub-region. With the increase in the number of those affected with the AIDS virus in Africa on a daily basis, there is an urgent need for us to look inwards to identify better strategies that can most effectively address the problem of HIV/AIDS. HIV/AIDS Prevention Programmes in Africa are prone to a lot of problems which affect the receptivity and sustainability of the programmes. Issues such as cultural diversity and belief in harmful traditional practices have direct impact on the health of members of the communities where they are practiced. Such practices include: female genital mutilation, wife inheritance, tribal marking, polygamy and early marriage. These practices do not make room for promotion of positive health seeking behavior among community members. For instance in a culture that permits wife inheritance, the transmission of HIV through this process is quite common. Polygamous settings also make it conducive for the transmission of STIs from one person to the other. Religion has a great influence in the behavior and code of ethics of those practicing it. Over the ages, it has been used to contribute to human development by structuring the lives of men and women along particular codes. Also, over time, traditional practices have intermixed with religion and has led to difficulty in separating one from the other. Some aspects of religion have failed to ensure continuity with the changing environment or reflect the significant changes that the lifestyles of people are undergoing and have undergone. Issues bordering on condom use, sexuality, family planning and care and support of persons living with HIV/AIDS are often considered controversial subjects. However, it is important that we identify the aspects of religion that are likely to affect the health of its followers and at the same time promote those that affect health positively. The common ground in HIV/AIDS prevention is abstinence and mutual fidelity between couples. This should be fostered by religious leaders. Socio-economic problems faced by a majority of Africans have led to the weakening of our codes of ethics. As a result, practices which were hitherto taboos are being condoned because of the economic benefits they afford the people involved. The perception of the maleness and femaleness has direct implications for behavior and health. For instance a girl that is under the illusion that she is meant to submit to the opposite sex would naturally find it difficult to say no to sex or even negotiate for safer sex practice. On the other hand, a boy may feel obliged to go any length to demonstrate his virility even at the risk of contracting STIs. From the foregoing therefore, the leaders of the society are the influential tools that can be used to positively redirect the downward trend in the AIDS pandemic in the sub-region. At home, parents should begin to internalize in their children positive values and behavior that will reduce the risk of contracting AIDS. Positive health seeking behavior must start fro the home to become deeply rooted in our communities. In view of frightening trends on its spread, there is an urgent need for effective responses to the HIV/AIDS pandemic by seeking ways of curbing its spread. Most HIV/AIDS prevention strategies in the region now involve community empowerment which can be simply described as the provision of necessary skill, information, and education to community people, to enable them to function effectively in their various localities and take control of their lives and make decisions for themselves. This empowerment could be economic, social or political for HIV/AIDS prevention. Community empowerment could be measured by the use of policymakers, i.e. community and religious leaders, parents and news media practitioners, as health educators. Peer education approach is now being used extensively in HIV/AIDS/STI intervention programmes in various countries including Senegal, Egypt, Colombia, Sierra Leone, USA and Jamaica because of its advantages which include cost effectiveness, effective influence on behavioral changes, and its snowballing effect. Peers usually feel more comfortable to discuss their health concerns with their peers. ROLES OF POLICY MAKERS IN COMBATING THE SPREAD IF HIV/AIDS Roles of Religious Leaders Religion is one of the most important social institutions with pervasive effects on various aspects of people's lives, attitude and behavior. The importance of religion in understanding the behavior of individuals, groups and communities can be illustrated with Email Durkheim's (1991:47) definition of religion as: A unified system of belief and practices relative to sacred things, that is to say things set apart and forbidden - beliefs and practices which into one single moral community… all those who adhere to them. There are three main religions in Africa - Christianity, Islam and traditional religion. This definition indicates that religion is a set of beliefs and practices that are shared by a group of people. One inference that can be made from this is that religion affects not only the group's behaviors, but also individual's behavior. The religious institutions have been identified as important agencies for the dissemination of information. The importance of religious groups as effective educational and enlightenment agencies can be attributed to their sacred, dogmatic and awe inspiring powers. Many believers hold information of religion on reproductive health behavior and sexuality of young people in particular and the society in general, especially in terms of sexual morality, fidelity and chastity before marriage. Since the religious institutions have this advantage, coupled with the fact that they often command a captive audience, they could be effective tools in combating the spread of HIV/AIDS in the sub-region. Also, in the care and support of Person infected and affected with HIV/AIDS, religious leaders and the institutions are able to provide the necessary spiritual and emotional support which would enable individuals and families cope with the question of life, death and ill health. The effectiveness in carrying out this role is largely dependent on the level of awareness of the HIV/AIDS pandemic. Roles of Parents and Community Leaders These two groups of people play fundamental roles in combating HIV/AIDS because African societies are changing even with the opening up to the world is still seen and interpreted according to our culture, as such individuals are firstly part of their societies before they are part of their world. With this, the parents and community leaders who head the family which is the primary social group in Africa, and who traditionally performs important socialization functions often do not recognize sex education for children/wards as part of their duties, or when they do, they often shy away from discussing the issues with their children/wards, for the fear of encouraging them to have sex. Furthermore, sexual and reproductive health matters are regarded in Africa especially in many homes as very private and sensitive issues, which should not be discussed even between parents and their children, community leaders and their community, teachers and students. This lack of knowledge usually leads many young people to engage in sex, ignorant of the consequences of their behavior and end up being blamed, chided or abandoned to their fate when they get into trouble. So it is the role of parents and community leaders to make the home and environment the first place for HIV/AIDS education and information as "Charity they say begins from home". The family should consciously care and support their members who are faced with the consequences of the HIV/AIDS pandemic rather than rejecting and stigmatizing them. Having established the point that the role of parents in HIV/AIDS Prevention cannot be overemphasized. The next question would be, how can parents communicate with their children/wards? Parents need to communicate to their wards using four basic skills that are being suggested; they are interaction, inquiry, directive influence, and strategic influence. Interaction: involves openness, accessibility, friendliness and being approachable and sympathetic to each other. Inquiry: involves listening, asking questions, clarifying received information and conceptualizing possible solutions of actions. Directive influence: involves pulling together various opinions and ideas into a plan, providing specific recommendations, setting standards, fulfilling and eliciting promises, challenging poor performance, commendation of good performance, setting priorities and guides for implementing activities. Strategic influence: involves getting things done. This is achieved through stimulating others behavior by honestly showing feelings, motives, and concern, convincing others, shaping their behavior through constructive criticisms and providing a favorable atmosphere and support to achieve results. Roles of News Media Practitioners: This group plays an information role by bringing to light information relevant in HIV/AIDS prevention because the media reaches wide ranges of people with information, entertainment, advertisement, etc. This groups is also equipped with materials to do justice to media blitz required in HIV/AIDS campaign prevention It is worthy of note that a group of media practitioners in Nigeria has set up a network of media people working in the areas of HIV/AIDS prevention campaign (Medianet). This group is mandated to cover any workshop, conference, and forums relating to HIV/AIDS within and outside Nigeria. The media is also a role model, by shaping attitudes, setting trends, setting agenda for public debates and discussions as a result of their programming which may be controversial, like the recent discussion on vaccine for cure of HIV/AIDS by Dr. Jeremiah Abalaka. The assistance of the media on such topical issues also increases the public awareness. Recommendations/Suggested Solutions 1. Level of communication and counseling services provided in religious institutions should be improved. More information should be provided for youth about causes and consequences of various types of RH problems as well as preventative measures. This can be done by integrating Reproductive Health, HIV/AIDS and sexuality information in the activities and programmes of religious institutions. There is urgent need to break the culture of silence on the discussion of the above issues within the religious institutions, integrate HIV/AIDS counseling in already existing counseling services in churches and mosques. 2. Organise training programmes for ministers, parents and youth workers in order to enhance their capacity to cope with need for counseling on RH, HIV/AIDS, etc. It is only when parents, religious and community leaders are well informed about the HIV/AIDS issues that they can at their level, combat the problem. 3. Beyond the lip service, concrete avenues should be provided for members also to discuss RH, emotional issues with trained counselors in religious institutions without inhibition or fear of moral reproach or lack of confidentiality. 4. There is a need for more enlightenment programmes for both young people and adults. This will help to reduce the misconception and prejudices that both parties have which may inhibit discussion on HIV/AIDS. For adults, this will also help to increase their knowledge and build their capacity to responding effectively and appropriately to the RH information needs of their wards and the wider community. Advocacy for the inclusion of RH and HIV/AIDS education should be in the curriculum of trainee pastors. 5. More media programmes should be organized including the government on RH and HIV/AIDS for young people, children and adults. Information material creating awareness on HIV/AIDS should be highly simplified and translated into local dialects and circulated to the rural areas. 6. There should be stakeholder needs assessment and stakeholder participation in the design, plan of programmes, development policies and implementation of programmes addressing the HIV/AIDS pandemic. 7. When a thorough needs assessment is done, target specific curricula should be developed to meet specific training needs of all groups/religious leaders, community leaders, media practitioners and parents. 8. Encouraging Intergenerational Communication (Parent-child communication) on sexuality and Reproductive health at the home level, community, religious environment and schools have been identified as a viable strategy n HIV/AIDS prevention. 9. There should be a systematic plan for education of all the various categories of people being discussed. For instance, in addressing parents, they should be categorized (uneducated and educated) including the community leaders. REFERENCES 1. Durkheim, Emile (1915): The Elementary Forms of the Religious Life; (trans.) J.W. Swain; London; Allen and Unwin. 2. Nigeria Youth AIDS Programme: Religion and Reproductive Health Behavior of Youth. Monograph Series No. 2 April 2000, pp 4-5, 38. 3. Makinwa, Adebusoye, Pauline K. (1919): Adolescent Reproductive Behavior in Nigeria: A study of five cities Ibadan: Nigeria Institute of Social and Economic Research (NISER) Monograph Series, No. 3, 1991. 4. O'Dea, Thomas F. (1966): The Sociology of Religion: New Jersey: Prentice Hall, Inc. 5. Feyisetan Bamikale and Pebley, Anne R. (1989): Premarital Sexuality in Urban Nigeria in Studies of Family Planning. Monograph Series Vol. 20, No. 6, Nov./Dec., 1989; pp. 343-354. 6. Nigeria Youth AIDS Programme: Intergenerational Communication and Reproductive Behavior of Youth. Monograph Series No. 3, April 2000; pp. 5, 27. 7. Nigeria Youth AIDS Programme: Community Empowerment and Reproductive Behavior of Young People. No. 4, April 2000; pp. 3, 4, 24. Back to top RECOMMENDATIONS BY MR. MOHAMMED FAROUK AUWALU (1). The various regulatory bodies should wake up to their responsibilities and checkmate the various claims of cure in the region. (2). Health professionals should be adequately sensitized on the issues that have to do with HIV/AIDS. (3). I will like to appeal on behalf of PLWHA to the FDA to help in providing us with a computer to be hooked to the internet, so as to have most current information on the latest drugs and other activities. It will also enhance Networking. (4). PLWHA should stop seeking help where there is none. They should seek information instead. (5). I urge the relevant authorities to make the ART available to the affected people if possible today. (6). PLWHA should be involved in all decision making in matters that involves HIV/AIDS at the highest level. (7). Donors agencies should start focusing attention on how to subsidize ART drugs. (8). I recommend that there should be a sensitization workshop for journalist so as to assist them to report the issues of HIV/AIDS better. (9). Am also appealing to media managers to discourage situation whereby PLWHAs are the basis of jokes by comedians, cartoonists and other media practitioners. I will want to end here and say God bless you all Amen. Back to top   INTEGRATING HIV/AIDS CONTROL INTO PRIMARY HEALTH CARE By *Dr. M.M. Ogbalu: Executive Director, NPHCDA *Dr. C.O. Akpala: Director, Manpower Dev. & Training *Dr. C.C. Ibeh: Deputy Director, Executive Director's Office *Dr. A. Ikpeazu: Assistant Director & Special Assistant to the ED Dr. G. Okafor: Snr Lecturer, College of Medicine, Enugu *ADDRESS: National Primary Health Care Development Agency, Abuja A paper presented at the Regional Conference on HIV/AIDS in West Africa, at the Sheraton Hotels Abuja, June 5-8, 2000 INTEGRATING HIV/AIDS CONTROL INTO PRIMARY HEALTH CARE INTRODUCTION At the end of 1998, more than 33 million people in the world were living with HIV infection, almost half of whom were women in their reproductive years. HIV related diseases may account for 75% of annual deaths in the 15-60 age group within the next 15-20 years. (1) Majority of HIV infected persons are found in the developing world while approximately 90% of all infected children are found in Africa alone. (2) In Nigeria, the skepticism with which both policy makers and the general populace had regarded the issue of the level of prevalence of the disease in the past is gradually giving away to the realities of a situation where majority of medical impatient beds in our hospitals are today occupied by patients with AIDS related infections. Available statistics show that the country currently has a national HIV prevalence of 5.4% while 4.3 million persons are projected to be infected by the year 2003. (3) At the current rate of transmission, the outlook is quite gloomy. Although epidemiologically, three main routes of transmission of the infection have been documented i.e. sexual intercourse, maternal-fetal and blood and blood products, available evidence shows that in Nigeria, most infections are acquired through unprotected sexual intercourse. In the absence of an effective cure or vaccine for the disease, primary prevention through Information, Education and Communication (IEC) remains the most viable strategy towards reducing the incidence of new infections. The objective of IEC should be to produce a change in risk behavior. Although the IEC should be targeted at the entire population, emphasis would be placed on those with high risk of infection such as youths. For control measures to have any meaningful impact on the populace, they need to be brought down to the grassroots level in villages and wards and especially in rural areas where more than 70% of Nigerians reside. Primary preventative measures in the rural areas poses enormous challenges to health workers as a result of the relatively high level of illiteracy, poverty and ignorance. This is further complicated by the relatively long incubation period of HIV which blurs the relationship between the individuals lifestyle and infection. PHC AND HEALTH DEVELOPMENT IN NIGERIA Since the concept of PHC was defined and given international recognition in the Alma-Ata more than two decades ago, it has become the main focus for the promotion of health all over the world. PHC is the level of health care closest to communities and the individual and therefore the first point of contact between health workers and the population. In Nigeria PHC is constitutionally the responsibility of LGAs. A National Health Policy was launched in 1988 and in which PHC forms the basis for its implementation. The health policy therefore recognizes that the adoption of strategies based on the principles and goals of PHC is necessary to ensure health for all Nigerians. These principles include the following. : a. Universal accessibility of services to provide adequate coverage on the basis of need. b. Community involvement and self reliance. c. Intersectoral action for health d. Appropriate technology and cost effectiveness in relation to the available resources. INTEGRATING HIV CONTROL INTO PHC The major problem facing HIV/AIDS control in Nigeria and most developing countries is a lack of proper coordination of activities at the grassroots level. Most of the activities had been run as vertical programs parallel to the formal health services. The arguments on the merits and demerits of vertical programs have been overflogged and will not be repeated here. Suffice it to say however, that this has constituted one of the major obstacles to an effective and coordinated approach to HIV/AIDS control in Nigeria. There is not doubt therefore that the answer lies in a full integration of HIV control into PHC. The National Primary Health Care Development Agency (NPHCDA) has the necessary structure on ground in all the 774 Local Government Areas and down to ward and village levels to ensure that control activities are carried down to the grassroots and covering the entire country. The mandate of the agency involved the supervision, monitoring and evaluation of the implementation of PHC at all levels of government in Nigeria. To effectively fulfill this role, the agency has six Zonal offices corresponding to the geopolitical zones in the country. The Zonal offices are headed by experienced Community physicians as Zonal coordinators and most of whom have been involved in HIV/AIDS control programs at community level. The NPHCDA also has as part of its staff, three zonal technical officers in each state of the federation. These are experienced community health officers with MCH background whose function involves the supervision of PHC workers in all the LGAs within the assigned state. In each LGA there is also a PHC coordinator who is a Community Health Officer with MCH background and responsible for the day-to-day implementation of PHC in the LGA. Assistant PHC coordinators coordinate PHC activities at district levels while Village Health Workers deliver PHC down to the household level. Health development committed at Local Government, District and Village levels are also in place to assess the community health needs, manage the services as well as ensure community participation. The NPHCDA has just concluded PHC project formulation workshops in all the 774 LGAs in the country. This is a prelude to the development of a comprehensive PHC plan that will guide the implementation of PHC in the entire country. The agency provided technical assistance to the PHC coordinators and their assistants which enabled them to draw up PHC workplans tailored specifically to tackle identified health problems peculiar to the LGAs. Having identified HIV/AIDS as a problem in all the LGAs in the country, the workplans in each of the LGAs contains a number of programs aimed at tackling the HIV infection at the LGA level. To ensure that the LGAs are able to implement the various interventions on HIV/AIDS control, the NPHCDA will provide the necessary training for primary health care workers in all LGAs. The training will be in the form of continuing education programs for PHC workers. This will involve periodic training workshops for the PHC workers to bring them up to date on new concepts in PHC and HIV/AIDS control. In addition the curriculum for institutions responsible for training of health workers will be reviewed to incorporate current concepts on HIV/AIDS prevention and control. Primary Health Care workers already in this field, ranging from Community Health Officers down to Village health workers would be imparted with the necessary knowledge and skills required for effective HIV control as well as be trained to understand their expected roles. The various health development committed at LGA, District and Village levels are also not left out in the training programs. After the training, the health workers will be expected to carry out the following interventions under the framework of PHC. 1. IEC (Information, Education and Communication) This is the main strategy for he control of HIV/AIDS. All PHC workers are health educators and will be actively involved in this exercise as part of integrated health care delivery at the health centers as well as during outreach programs and home visits. They will however need to be supported with health education material in the form of posters and leaflets, all of which should be tailored to the local conditions in terms of culture, language and level of education. This in turn means that the materials should be produced locally. 2. Counseling The workers will provide pre- and post-screening counseling especially for those that are HIV positive. This will also be directed at people living with HIV/AIDS including their families. 3. Health Information System/ Surveillance As part of PHC implementation in the entire country, and efficient and accurate record and data collection system has been put in place to provide the information which forms the basis for the National Health Information system. The data covers information from the most peripheral clinics and outreach centers to comprehensive health centers in each LGA. The data will be very useful for monitoring trends in HIV infection and mortality. 4. Treatment of Common Ailments All PHC workers have been trained to treat common infections and disorders using their standing orders. Most of the opportunistic infections associated with AIDS are covered in the standing orders and modalities for referral of more complicated cases clearly spelt out. The Bamako Initiative component of PHC has been recently strengthened all over the country to ensure that there is regular drug supply within the PHC system. Primary Health Care workers will also accept referrals from hospitals for patients who will need community care. 5. Home Based Care and Support Health workers will also deliver home based care and support to people living with HIV/AIDS as well as their family members. CONCLUSION The National Primary Health Care Development Agency has the necessary structures and network to ensure that HIV/AIDS control activities reach local communities in the entire country. This we believe is the most cost effective approach to tackling the HIV/AIDS scourge in Nigeria. This will ensure sustainability in control programs. REFERENCES 1. UNAIDS/WHO. HIV in Pregnancy: A Review. Geneva, WHO/CHS/RHR/99.15 UNAIDS/99.35E. 1999 2. Global Program on AIDS. WHO/MCH/GPA/90.2. Geneva, World Health Organization. 1990. Back to top HIV and AIDS Care and Support Presented at plenary session during the regional conference on HIV and AIDS West in African region, held at hotel Sheraton, Abuja, Nigeria, organised by Foundation for democracy in Africa, Washington.DC   Dr. Megh Raj Catholic diocese of Makurdi ______ "……..AIDS kills those on whom society relies to grow crops, work in the mines, factories, run the schools, and hospitals and govern countries. It creates new pockets of poverty when parents and breadwinners die and children leave school earlier to support the remaining children…" President Nelson Mandela Introduction: The AIDS epidemic in Nigeria, largely invisible and insidious as it began, is now visible in, what should have been the unlikely sites, that is, rural communities in the country. The years of dissemination of HIV are now surfacing, as evidenced by the ever-increasing number of HIV/AIDS related admissions in our health settings and deaths in the communities. Yet, AIDS is supposed to be more evident in towns and cities, where HIV testing and hospitalization are more available, and where the epidemic is more fueled by over crowding, commercial sex industry, cultural and corporate diversity. The dramatic improvements in clinical outcomes of recent drug therapies in the world have led to the hopes of HIV infection becoming life-long manageable condition. In resource-constrained settings, however where the very basic necessities for human existence like clean water is almost miracle, this remains an elusive goal. Even when these therapies become accessible, they will leave a lot of unattended problems, problems like lost human dignity, financial hardships and violated rights. So, the tremendous need for multidimensional care will still remain a challenge. Care for the People Living with HIV AIDS: Every human person would like, not only to live in dignity, but also to die in dignity…Caring for people with and HIV, may not be easy, but is very crucial for the remaining period of PLHA's life. Caring can be emotionally demanding, involving and yet can be gratifying. The over all objective of care for a person with HIV is to: · restore the self esteem and dignity · recognise the and sustain the self-potential · and … to help restoring relationships While the clinical objectives are: Effective management and prevention of common symptoms and, opportunistic infection, Enhancing the immune system and postponing progression to AIDS. So, the nature and extent of care depends on their needs; physical, psychological and social. The expressed and observed needs of PLWHAs are great and include; physical needs, access to basic drugs, need for psychosocial and religious support, financial assistance, consideration of their families, household help, and empathy from health staff. As a consequence, the HIV/AIDS epidemic demands development of innovative, yet realistic care approaches involving many sectors, such as clinical, nursing, social welfare groups. That care must be based on continuum, encompassing effective preventive and pastoral work in the families and community. Models Of Care: Realization by the health care institutions of the futility of trying to manage all AIDS patients in the hospitals, and expansion of NGOs which in addition to their HIV awareness and prevention services, response to the wider care needs of PLWHA and their families, led to the development of two different care models. They are: a) Hospital Based, hospital, b) Hospital initiated home care model, and c) Community rooted initiative. There are other care models now focus on links between various initiatives they are; a) Church based, b) NGO based, and c) PLHA support network care models. Advantages and shortcomings of various care models: Model Types Advantages ShortcomingsNo single care model can be 'ideal'. A 'perfect' initiative needs to be designed depending on the local situation and the needs. Final objective in care is to provide wholistic home based- care on continuum. Home - Care Home - Care means any form of care given to sick people in their own homes. It can mean the things people might do to take care of themselves or care given to them by the family or health care worker. The care includes physical, psychological and spiritual activities. Rationale for Home - Care · Good basic care can be given successfully at home. · People who are very sick or dying would often rather stay at home, especially when they know they can not be cured in the hospital. · Sick people are comforted by being in their own homes and communities, with family and friends around. · Home care can mean that hospitals will be less crowded, so that doctors, nurses and other hospital staff can give better care to those who really need to be in the hospital. (e.g. St.Thomas' Hospital in Ihugh is a 200 beds facility, and serves a catchment area with population of around 250,000. With current HIV sero-prevalence of about 5.4%, 1000 people are likely to get infected every year. If all require admissions for a duration of 2 weeks, this implies 2 to 5 patients a day will be admitted with HIV related problems, and they will occupy about 40 beds a year. We already have an overwhelming number of other chronic and terminally ill patients) · It is usually less expensive for families to care for some one at home, for example they will not have to pay for the hospital bill and transportation to and from the hospital. · If a sick person is looked after at home, family members can meet their other responsibilities more easily. This can be difficult if they have to stay at the hospital, or have to travel frequently to help and take food to the sick person. · Sometimes hospital care is simply not possible. Care at home can be provided by those who are personally committed to care and may involve any body, besides, doctors, nurses, volunteer health workers, social workers, religious leaders, family members friends and others. It does not require to be a specialist, but only basic knowledge and skills. Both can be acquired from health workers. Home based care for PLHAs is not exclusive for rural areas or patients. It can also be provided for people living in urban areas. Components of Home - Care: Comprehensive wholistic care involves; teaching, physical care, psychological care - counselling, pastoral - spiritual care and social support. Physical care: Involves looking after physical needs and providing comfort for the sick person. It also includes identification of common symptoms, their possible causes, what to do at home and when they must seek help. Counselling, spiritual and pastoral Care: Counselling. Naturally, any patient who is suffering from a disease with no possible cure, but only stigmatization, will develop psychological problems because of his own perceptions of the disease and society's attitudes as well. Counselling enables a client /patient to open up and share his/her emotions, fears, guilt, anxiety as well as more practical issues about the future, survival and planning one's future. For various reasons, any one who is considering having an HIV test for any reason should receive pre- and post test counselling. Post and follow-up counselling facilitate sharing the result with the family members, and eases provision of care. How ever, post counselling is not complete until the client has made plans to meet the challenges of living with HIV infection. Counseling helps to find a balance between confidentiality and revealing his/her serostatus to a few significant people in life. Counselling will ensure the integration of prevention and care, and it does well when incorporated into home care. Spiritual and Pastoral Care. Many people with terminal illness such as AIDS find spiritual support a source of comfort and strength, besides helping them cope with feelings of guilt and fear. The spiritual care depends upon patient's religion and faith. Most people with HIV say they need God the most, and religious isolation on the basis of their former life style is not only moralistic but will also seriously affect the patient's morale to live. Pastoral care can be given not only by a religious leader, but any body who is committed to give loving help to another person. Social Support Gender, social, economic inequity makes some people vulnerable HIV infection, and drives them further to the point of brink. Social security is part of enhancing self -potential, to improve and enhance option minimize social impact unfortunately, many countries including Nigeria do not provide such security, but social support can be possible. Social support to PLHA can be demanding and often is difficult in the prevailing economy, social structure and society's (non) response. The needs of PLHA and their families are constantly changing. They will need; a). To be educated about the services and options available to them, b). To save access to the available facilities, c). To understand the potential violation of their rights, d). Legal help, and e). Material assistance such as food, clothing, medicines and supports for surviving children. There are no welfare offices or NGOs that have relevant Programme towards assisting the patients. Useful alternatives like; a) Vocation guidance and training for PLHAs and families, small scale income generating ideas and interventions can be provided by volunteer groups. b) Community based services including day care centres, community farming to assist in food production, and also for social integration of PLHA. c) PLHA support groups run by and for PLHAs and other affected people for mutual support have proved to be successful in countries like Uganda, Tanzania, Malawi, Zambia, Zimbabwe and others. These activities may not be immediately practical in Nigeria due to present level of awareness and lack of political will. * PLHAs may stand the risk of disclosure of their HIV status and be ostracized, and may be reluctant to seek help. This stresses the need for counselling, sensitization of the communities and enhance the African traditional spirit of community living. Conclusion: AIDS care, support, and counselling are becoming increasingly important issues in Nigeria. They are most effective when based on continuum of care, and home- based-care needs to be viewed as part of that care to PLHA and not as an isolated parallel initiative. Half-way houses, day-care centres hospice care especially in the cities, and other possibilities should be explored as appropriate in different settings. Because of the obvious reasons, the home-care -gap is widening in areas where home care services are expanding. Lack of AIDS care standards and protocols and skepticism among the health workers and community members, of the effectiveness of care must be broken. A concerted effort will be required. To facilitate this and coordinate services, a network including all those involved in such activities, though difficult, will be essential. Role of a person living with HIV, in providing care for others living with HIV: Human beings are generally are very strange in a sense, that don't like to be alone in certain circumstances. Specially, when placed in crisis, they look for others in the similar situation. Probably to derive some strength in a sense of companion ship. Its natural to look for others suffering from the same situational crisis, same with people with HIV, does certainly NOT mean they others to get infected as well. NO. It's often observed in our counselling sessions for persons with HIV, their expression and inclination to meet other persons with HIV. Based on that expressed desire, we designed our counselling sessions to offer introduction and friendship with other HIV infected persons. Besides, there are some gray areas in counselling. Not often discussed, never the less are experienced. That gray area is a subtle psychological advantage has over his client, unethical maybe, but natural especially when counselling is smart mind game, entails skillfully helping the clients to examine viable alternatives and options. Two people faced with similar situations tend to help each other better than when in situation where both are different planes of crisis. Here HIV serostatus is decimator. With this idea we started introducing then positive clients to each other (with obtained consent) Later we developed the concept of training PLHA in counselling skills and pastoral care. It is quiet evident with psychological well being and disposition, that persons living with HIV have a tremendous role to play in helping other PLHA with cope with HIV infection. It further nurture the self potential in the clients, restore dignity and makes them happy for being able to help others. Vadeikya and Adikpo are two sleepy towns, 500kms away from Abuja in Benue state. There has been overwhelming demand on the home care team to look after them and the volunteers were not enough and they ran a risk of developing burnt syndrome. The clients were living in far places, making frequent and scheduled visits impossible, because of inadequate transport and hostile weathers. So, the idea of bringing them together on planned days was discussed with the clients.. Response was great. The result is to two AIDS self support groups initiated and nurtured by the missionary sisters in Vandeikya. Mwuese is one such person from that support group. She has been living with HIV for 5 years. She is a trained counsellor and pastoral care workers helping others with HIV and offering them hope and reason to live. Later they were in trained in workshop in examining income generation options…they were taught vocation skills Commonly used drugs to treat the symptoms in people with AIDS: Drugs for infections (Antibiotics): (Avoid Sulfa's and any drugs that is not understood) Medicines for fever: Aspirin, Paracetamol Medicines for diarrhea Acute: ORS, antibiotics. Persistent: adsorbents, antimotility agents Medicines for skin conditions General: calamine lotion Bacterial infections: GV gentian violet, potassium permanganate, hydrogen peroxide. Yeast infections: gentian violet, ketoconazole, nystatin, clotrimazole, potassium permanganate Medicines for nutritional problems Vitamin and mineral supplements Medicines for nausea and vomiting Anti-emetics Medicines for pain Aspirin, Paracetamol, narcotic pain killers Medicines for tuberculosis Streptomycin, Isoniazide, ethambutol, rifampicin, pyrizinamide Back to top HOME-BASED CARE AND SUPPORT FOR PEOPLE LIVING WITH HIV/AIDS USING TRADITIONAL HERBAL MEDICINE TONY ELUJOBA1,4, LOLA IRINOYE 2 AND YEMI FAKANDE3 DEPARTMENT OF PHAMACOGNOSY1 AND DEPARTMENT OF NURSING2,OBAFEMI AWOLOWO UNIVERSITY, ILE-IFE. STATE HOSPITAL, ILESA3. NIGERIA   ABSTRACT As Africans, traditional medicine has been and is still our socio-cultural heritage for the care of the sick from time immemorial. Members of the African community, surrounded by different species of medicinal plants and curative herbs, practised and are still practising a lot of self-medication using those herbs. Strategies for home-based care and support for the People Living HIV/AIDS (PLWHA) can be derived from this ancestral heritage at very little costs and energy. The major objective of such a design is to reduce the treatments of the various opportunistic diseases to a home-based or community-based or better still, self-based care programmes, utilising the various advantages that can be derived from herbal medicines over any known anti-retroviral drugs in current use. Such an endeavour if successful, would reduce the stress on the hospital resources. Examples of such medicinal plants, matching individual opportunistic diseases, are presented together with suggestive indices for measuring their success. Practical application and demonstration of this protocol on the Living-Hope Care and Support Group, a charitable, non-governmental organisation of PLWHA in Osun state, is hereby presented to include the development of some pharmaceutically formulated herbal medicines used for the treatment of opportunistic diseases in those PLWHA, while recognising all issues of ethics and human rights. 4Address For Correspondence: Professor Tony Elujoba, Department of Pharmacognosy, Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria. Presented at the FDA Regional Conference on Strategies for Combating the Spread of HIV/AIDS in West Africa at Abuja, Nigeria, June 5-8, 2000.   INTRODUCTION Traditional medicine is defined by the World Health Organisation (WHO,1978) to mean the totality of all knowledge and practices, whether explicable or not, used in diagnosis, prevention and elimination of physical, mental or social diseases, handed down from generation to generation either verbally or in writing. It is said to include all such medicines and practices that have been used for several hundreds of years and are still being used without any observed or recorded adverse effects. Though, we are well aware and familiar with the existing controversy on traditional medicine as well as the various limitations of its practice in Nigeria and perhaps in other countries of the West African sub-region, this paper will only address the positive relevance of the exploitation of herbal medicines for home-based care and support for the People living With HIV/AIDS and will consciously avoid controversial statements on traditional medicine.   STATEMENTS OF FACTS HIV/AIDS is currently an incurable disease by western drugs and there is little or no definite protocol for effective management of the opportunistic diseases in most hospitals in several countries of the West Africa sub-region. Traditional medicine can be said to be a controversial issue among medical scientists of all makes and forms, probably due to the fact that, little is known about its potentials in the care of the sick. However, traditional medicine has been used and continues to be sought openly or blindly by the People Living With HIV/AIDS under the alternative therapy everywhere in the world and more often than not, it is in the desperate bid to search for cure. It is often one of the major sub-themes for discussion any time there is World AIDS Conference. The quest for cure and management of HIV/AIDS in the forests of Africa has since advanced in the East African countries e.g. Kenya, Tanzania and Uganda as well as in Cameroon, the eastern neighbour to Nigeria. This has led to various spurious claims and counter claims while traditional medical practitioners continue to proclaim proficiency in HIV/AIDS management with no evidence yet of effectiveness. The Chinese and the Indians have spent and are still spending large resources in the search for cure of HIV/AIDS among the Traditional Chinese Medicine (TCM) and Ayurveda, respectively. Neither the Chinese nor Indian medicines had yet produced the most needed cure. Thousands of basic and applied scientists all over the world continue to have sleepless nights in their laboratories looking for cure, and no one can say who of the sleepless scientists would find it? Could the magic drug for effective management or total cure of HIV/AIDS, not come from the African bush? It is general belief by the African traditional medical practitioners that no disease exists in Africa without an effective remedy somewhere among the trees and shrubs of Africa. Will a cure for HIV/AIDS come soon or later? Are we expecting such cure in the same way that the clinical answer came to the world on syphilis, gonorrhoea, smallpox and hepatitis? Or, will a cure never come like for many other chronic ailments such as hypertension, diabetes, asthma which never got permanent curative management up till today? ADVANTAGES OF HERBAL MEDICINE IN HIV/AIDS MANAGEMENT The raw materials for the preparation and formulation of herbal medicines are readily available within the community and in the home. Most of the common, O.T.C medicinal herbs are found naturally in many residential surroundings growing either wildly or as cultivated plants. Even in rare cases when they have to be acquired from herb dealers for self-medication, it is invariably cheap and affordable. Hence the resulting final herbal medicinal products become low-cost and easy to purchase. Accessibility remains a very valuable merit of herbal medicine, the practitioner being resident within the same community and he is known by every community dweller to be capable of helping in health and disease state. It is recalled that a traditional healer is defined by the World health organisation as a person who is recognised by the community in which he lives to be capable of providing healthcare delivery system using plant, animal and mineral substances as well as such other means. He is readily approachable and trusted to provide holistic management of diseases afflicting his people in the community. He is normally trusted and put in confidence with inherent assurance that the treatment prescribed would be effective. The herbal remedies prescribed are happily acceptable to the members of the community since most of the remedies are culture-based and socio-culturally compatible. Some of the remedies are culturally peculiar and identified with specific families within the community and children in such homes grow with the knowledge of such remedies. Privacy and confidentiality are parameters of ethics and human rights in HIV/AIDS which have defied all solutions in the orthodox medical setting. An HIV-positive patient has to be in contact with several hospital departments e.g. haematology, STD clinic, nursing departments, pharmacy department, medical records etc and in a short while, every hospital worker is fed with the information on the sero-positive status of the patient. On the other hand, in the traditional medical setting, the only person that knows about the sero-status of the patient may be the traditional healer himself. Secrets are better confined in this circumstance and this may further strengthen the reason why HIV/AIDS patients would prefer traditional medicine. This health-seeking behaviour is encouraged by the mentality that a possible cure with less risk of toxicity could come their way either by design or serendipitiously. Although, none of the several cure-claims has been proved beyond any reasonable, scientific doubt, whether in Nigeria or anywhere in the world, we make bold to say also that none of the vital advantages enumerated above can be used to describe any currently available anti-retroviral drugs. None of them whether singly or as combination medication is affordable, readily acceptable, accessible or culture-compatible. The circumstances, which usually have faced several unethical options and which eventually lead to the prescription of anti-retroviral drugs, cannot guarantee privacy or confidentiality among the various health care providers in the hospital. STRATEGIES FOR ANTI-HIV HERBAL SCREENING FOR HOME-BASED CARE MANAGEMENT In the absence of cure for HIV/AIDS, it is our opinion that research in Africa should find, among the thousands of plant species, such herbs that can be used for the management of the individual opportunistic infections, so that the infected people can live a relatively more comfortable life and perhaps with longer life expectancy. There are many previous studies in the sub-region reporting the ethnobotanical and ethnopharmacological wealth of our forests which could be used to select plants for the following opportunistic diseases: respiratory disturbances (cough), mouth thrush, gastro-intestinal discomfort, dermatological affections, fevers and urinary tract infections. Documentations abound in the literatures on West African plants, their medicinal uses and properties that would suggest anti-opportunistic activities e.g. anti-viral, anti-microbial, anti-tussive, anti-spasmodic, anti-inflammatory, anti-pyretic, analgesic, anti-U.T.I., anti-skin rashes and anti-cancer (e.g. Kaposi's Sarcoma). Such plants, if effective, would be used to manage the diarrhoea, lower the viral load, reduce persistent fevers, eliminate pains, remove skin rashes, cure the tuberculosis and coughs, as well as challenge any other STD infection. Some examples of such plant species extracted from literature that can be examined as anti-opportunistic medicinal herbs are presented in Table 1.   TABLE 1: SOME HERBS WITH ANTI-HIV INDICATORS Garcinia kola Heckel (Clusiaceae) Anti-viral/Antimicrobial Aristolochia ringens Vahl (Aristolochiaceae) Antidiarrhoeal/Analgesic Ocimum gratissimum Linn (Lamiaceae) Antidiarrhoeal/anti-rashes Alstonia boonei DeWild. (Apocynaceae) Antipyretic/Antimalarial Cassia podocarpa Guil.et Perr. (Caesalpinoideae) Anti-UTI/Antimicrobial Zanthoxylum zanthoxyloides Waterm. (Rutaceae) Antiviral/Anticancer Heliotropium indicum Linn (Boraginaceae) Anti - TB/Anti-infective The management success indices when using such herbal treatments can be postulated to include increased body weight, physical resolution of signs and symptoms, reduced frequency of diarrhoea, reduced incidence of fatigue and depression, lack of gastro-intestinal disturbances, reduced frequency of skin rashes, absence of respiratory infections and reduced medical visits for hospitalization.   LIVING-HOPE CARE AND SUPPORT OUTFIT This is a non-governmental, non-political, non-profit making but charitable, model of community-based, home-based incorporating self-care programme for the care and support of the People Living With HIV/AIDS. It is situated at Ilesa in Osun State of Nigeria, representing an outfit of the African AIDS Research Network (AARN, Nigeria Chapter) at Obafemi Awolowo University, Ile-Ife, Nigeria. The main objectives of the Living-Hope Care, as contained in its constitution are as follows: - (a). Provision of comprehensive support for those infected with HIV and the affected, acceptable within the social context of community in which they live, (b). Collaboration with governmental and non-governmental organisations in a bid to provide comprehensive care for the People Living With HIV/AIDS along a continuum. (c). Dissemination of relevant knowledge with the aim of achieving changes in the attitude of the communities around and outside the state towards giving support for the infected and affected. In the recent past, the PLWHA have readily participated in awareness education programmes even at State Assembly levels with excellent success. With a total of over 120 PLWHA on the register and close to 30-40% attending the fortnight clinical/counselling meetings at a time, a purely community-based, home and self-care setting is practised using mainly locally-available, low-cost materials including common herbal medicines. The whole exercise of keeping them together in such a community and compartmentalized manner, ensuring constant counseling on safe sexual behaviour, has proved effective as an additional control strategy in the state. The set-up is also seen as a potential research laboratory taking cognizance of strict compliance to all ethical and human right issues involved. The official careers, most of whom are university workers and registered members of the African AIDS Research Network, with multi-disciplinary expertise, include Pharmacists, Clinicians, STD Nurses, Laboratory Scientists, Community Nurses and Dental Surgeons. The Network has since developed some herbal preparations, pharmaceutically modified to improve quality, safety and efficacy for cough, mouth thrush, diarrhea, fever and skin rashes. The Table 2 shows the various preparations under each of the opportunistic diseases.   TABLE 2: HOME-BASED CARE HERBAL PREPARATIONS FOR DIFFERENT OPPOTUNISTIC INFECTIONS OPPORTUNISTICDISEASE HERBAL/DRUG PRESCRIPTION ROUTE OF ADMINISTRATION 1. COUGH Bitter Kola in Honey(Bitakolin Syrup) Oral 2. MOUTHTHRUSH Bridelia mouthwashCashew Nut ChewingStick Oral Gargle 3. DIARRHOEA Ocimum infusionGuava infusionMormodica infusion Oral 4. SKIN RASHES Aloe vera gelCassia alata concentrate Topical 5. LOSS OFAPETITE VitaminsFruit meals Oral 6. GENERALWEAKNESS Rest/HaematinicsFruit meals Oral 7. FEVER Antipyretic analgesicsHerbal anti-malarials Oral 8. U. T. I. Antibiotic Oral/Parenteral One of the preparations (Ocimum gratissimum) for management of opportunistic diarrhea, was investigated scientifically and has led to a fairly formulated emulsion which is expected to be more active than the currently used Ocimum gratissimum infusion, when all safety assessments had been undertaken and is found to be safe for human consumption. This also serves as a typical example of drug discovery from traditional medicine and the results have since been accepted for publication in a learned international journal in Germany. DISCUSSION We, in the African AIDS Research Network (Nigeria Chapter), believe that traditional medicine has a role to play in the effective institution of home-based care for HIV/AIDS in the sub-region of West Africa even if the services are limited to the treatment of opportunistic diseases using locally-available, low-cost materials. The present non-availability of cure for HIV/AIDS ought to be a great challenge to every medical and basic scientist in the sub-region. This should then lead us to persuading our governments to invest in drug research on the medicinal plant flora of the sub-region as an additional way-forward in our fight against HIV/AIDS pandemic. Let us congesture that the answer can be found in our forests, therefore pursuing the challenges with adequate scientific procedures, compliance to fundamental scientific guidelines and protocols as well as to unchallengeable ethical obligations. Our success in providing the sub-region (in particular) and the whole world (in general) with local medications that would effectively address the individual opportunistic diseases and probably with lower viral load, would have reduced the stress on hospital resources, increasing the life expectancy of PLWHA, thereby reducing the menace of HIV scourge to a more, manageable chronic disease as well as standing the chances of serendipitous discovery for the cure of HIV/AIDS in the sub-region! ACKNOWLEDGEMENTS The authors wish to thank the African AIDS Research Network (Nigeria Chapter) for encouragement and for individual members' financial contributions towards this cause and greater gratitude goes to the Foundation for Democracy in Africa (FDA) for the opportunity given to one of us (Professor Tony Elujoba) to attend this conference. Back to top SOCIO-ECONOMIC IMPACT OF HIV/AIDS IN THE AFRICAN SUB-REGION BY PASTOR (MRS) PAT U. EKOH A SYMPOSIUM PAPER PRESENTED AT THE FOUNDATION OF DEMOCRACY WEST AFRIC REGIONAL CONFERENCE ON HIV/AIDS, ABUJA, FCT, NIGERIA JUNE 7, 2000 IMPACT SYMPOSIUM 4 SOCIO-ECONOMIC IMPACT IN THE SUB-REGION PRESENTER: PASTOR (MRS) PAT. UGONMA EKOH STATE OF THE ART Since the Conference opened on Monday, Epidemiological survey issue of HIV/AIDS prevalence has been extensively discussed and to cap it up, Dr. Desalu gave a very comprehensive data on the State of the Art and this presentation will not want to duplicate this aspect. However, some epidemiological information that has to do with the economic impact of HIV/AIDS pandemic in the sub-region will be worth mentioning. Some sero-prevalence survey in Africa has shown that Zambia has nearly four-fold increase in AIDS - related deaths of employees under 45 years between 1989-1992, Ugandan in the 1990's had the loss of potential productive years of workers between 20-49 triple by 12% from 1989 according to WHO report on AIDS. Abidjan, Cote d'Ivoire moved from 1% in 1986 - 10% in 1991. As we have heard, Nigeria has about 2.6 million adults between 15-49 years infected with HIV/AIDS. With these facts before us, we do not need any one to tell us again that those who society depend on to score a plus are being snatched away from the society. 90% HIV/AIDS victims are among adults in prime working years. Assessing the socio-economic impact of the pandemic is important because a knowledge of this, widely circulated and disseminated to every sector of the society will remove the habit of most nations in the sub-region trying to bury their heads in the sand oblivious of the impending doom awaiting the Generation Next. We should not be like a rock in the midst of a lake that does not know the sun's hotness that is scourging the land. I am quite optimistic that the government will react with speed, if the peace/stability/lives of citizens are being threatened by war. Tanks and missiles will be promptly rolled out to contain the force. It is time for all stakeholders to respond with same speed as at during war situations. SOCIO-ECONOMIC IMPACT The impact of HIV/AIDS in this presentation will focus on Family, Public Sector and the Society at large. FAMILY - The impact of the disease on the family starts from when a member is diagnosed HIV positive. There is a lot of emotional stress, anger, distrust and casting of blames. It is a trying moment and most people will rather keep mute than disclose their HIV status to their spouse. There was this case in Nigeria in 1999 where a 419 doctor - that is fake doctor, played on a man who, kept visiting the hospital for an ailment he couldn't understand. The fake doctor convinced him to do a secret test which he conducted. After sometime, he came back bringing a positive HIV report from a doctor in LUTH for him. He promised managing the case also. Due to ignorance, the man gave in. On weekly bases, he took money from this man and gave him some injections. At a point the man in question couldn't pay anymore after he had sold all his household properties. He then decided to inform the wife, he was tested more properly but was found negative. Imagine his stress, the finances, the estranged relationship etc that he went through during this period in question. An announcement of being HIV positive can ruin happy marriage relationships. Apart from this, members of the family will spend huge amount of family income in managing the situation. The cost of management is sometimes more than five times the workers salary. Before the worst happens, poverty will have taken a greater toll on the family. When eventually death strikes, both parents, children become orphans and the extended family might not be able to cope. Child labour will increase, and most of them become really vulnerable to contacting the diseases from their male customers who entice or even rape them. The children left behind who might not be able to fend for themselves will add to the number of miscreants in the society. The impact is much and we can go on and on without end. PRIVATE AND PUBLIC SECTOR HIV/AIDS is the greatest challenge facing African's business. The pandemic threatens health and stability of the work force. HIV/AIDS is seen to be claiming the best entrepreneurs, managers and technical specialists. It increases the cost of doing business apart from causing illness and death of employees. This is so because when trained and experienced skilled workers are affected and can no longer work due to ill health, the employer will have to train new hands adding to the cost of training. Employers are also going to be faced with the burden of health care of affected staff, pay death benefits, pensions and other costs. The impact is also seen in decreased productivity, as workers are absent, or away to take care of sick relatives or attend burials. Also because the majority of productive members of the society are sent out of work by the pandemic, then fewer people will have the resources to purchase goods. Let us try to quantify these impacts in monetary terms. A typical company in Kenya was estimated to have incurred an average annual loss of KSH 1.9 million to HIV in 1994, I am sure Nigerians situation will be higher than this, if such research is also conducted. IMPACT ON GOVERNMENT The impact of the Epidemic on government is also overwhelming. The disease is taking its toll on the provision/delivery of effective health care. The hospital beds are being taken over by a great number of patients suffering from HIV related symptoms. The total cost of managing one AIDS patient is put at $327.55 and $588.0 when this is multiplied to accommodate the 2.6 million people already infected, the nation will be spending between $851,630,000 - $1,528,800,000. The total budget for health sector cannot take care of this. PROBLEMS AND LIMITATIONS Knowing the impact of HIV/AIDS pandemic is the first step but there are a number of factors that limit this knowledge being properly translated into workable policies thereby making impact assessment a bit difficult. One, Epidemiological data - Generating accurate epidemiological data is a bit difficult. For instance there should be a sero-prevalence surveillance in the work place, this will give accurate picture of this impact in monetary terms to awaken employers and government from their non-activity and make them to act promptly.   Second, there is a problem in monitoring and Evaluation. There is a strong need to monitor and evaluate actions already taken at different levels of intervention to ascertain their strength and weakness so this can stand for a future frame-work for further intervention. This is a strong area of problem, there is limited funds for NGO's and the Government to do this. If this is not done our progress will be very slow. Thirdly - Testing is very expensive for government, employers and individuals. This makes it a bit difficult for a vigorous action and more positive response in this area. Also the fact that there is no cure yet makes it difficult for individuals to be motivated to go for test. When we do not have accurate information on who is affected, the impact will not be fully felt and controlling the spread will be difficult. Lastly, the claim that there is a cure for AIDS at a time, this claim has not been fully ascertained will increase risk behaviour. People are made to have false hope. The negative impact of this little result that has been achieved in combating the pandemic will be serious. RECOMMENDATIONS AND SUGGESTIONS In order to reduce the impact of HIV/AIDS, I recommend that Epidemiological data should not only be done to generate data for statistical purposes, but this data should be converted to people. We should do test that can identify the individuals, follow-up on them through counseling and make arrangement for their care and support. Generating data from the work place can be done anonymously as is being done for ANC. Employers can make genotype and blood group testing mandatory. The blood samples at the same time could be use to test for HIV/AIDS. Since the private sector is being affected in terms of profitability and productivity, they should get involved in funding, educating their staff and in support and care programmes. They have been involved in funding Education and Sports, they should also be encouraged to give towards combating the disease. A good care and support package should be put in place for PLWA. If there is a good welfare package that will include housing, upkeep of victims and families, many more people will come out to be tested and in the Nigerian set up, I am sure some people who are not, will even want to claim to be so as to enjoy the package on the ground. Thank you and God bless. Back to top AIDS AND DEVELOPMENT: THE SOCIO-ECONOMIC IMPLICATIONS OF THE HIV/AIDS EPIDEMIC IN SUB-SAHARAN AFRICA BY DR. A. ARKUTU INTRODUCTION By some estimates, nearly 200 million people in SSA, slightly more than one third of the entire population of the region, have been directly affected by the HIV/AIDS epidemic. They include the 12 million men, women and children who have already died of AIDS, approximately 22 million currently living with HIV/AIDS and their dependents. But what impact has the epidemic had on the demography, health and economic and social development of the countries of the region? What does the future portend and what lessons can we in West Africa learn from the experience of the nations to the East and South of the sub-continent? The HIV virus is thought to have crossed from chimpanzees to humans somewhere in the Democratic Republic of the Congo 50 or 60 years ago. The disease was first recognized in the United States in the early '80s. By the late '80s and early '90s, however, East Africa had become the epicenter of the spread of HIV/AIDS in SSA with Uganda, Tanzania and Kenya the most affected. In the mid to late '90s, concentration of the epidemic shifted to Southern Africa, notably Zambia, Zimbabwe, Malawi and more recently, Botswana, Namibia and South Africa. West Africa has been relatively spared, with only Cote d'Ivoire, Benin, Burkina Faso and Guinea-Bissau being classified as having a generalized epidemic with more than five percent of the adult population infected. Impact Studies Research on the socio-economic impact of the HIV/AIDS epidemic began only in the early '90s. Most of the studies were conducted by various multilateral as well as bilateral organizations including UNDP, UNESCO, ILO, UNAIDS, The World Bank, USAID in collaboration with national research institutions and individuals. Naturally, to date, most studies have focused on the Eastern and Southern African countries where the epidemic was concentrated. The findings and lessons learnt from the results of those studies are, however, relevant to West Africa because apart from the severity of the epidemic, social, cultural and economic conditions are remarkably similar. West Africa has much to learn from the experience of her neighbors to the east and south. Demographic Studies Cumulatively, 12 million people have died from AIDS since the epidemic became established in SSA. Three times as many people are currently living with HIV/AIDS and an estimated 4 million Africans are newly infected each year. All these people, mostly young adults and children, will die within the next 10 years or so. HIV/AIDS will thus cause a significant rise in the Crude Death rate in nearly all African countries where more than five percent of the adult population is infected. Infant and child mortality rates in severely affected countries will rise by 50 percent more than would have been the case without HIV/AIDS. The World Bank, the US Bureau of the Census and the Population Division of the United Nations have analyzed demographic data using different methodological techniques and assumptions in order to estimate the likely impact of HIV/AIDS in countries most affected by the epidemic. There are significant differences in their findings but there is general agreement that many countries in SSA will experience net losses in numerical terms due to HIV/AIDS. For example, Nigeria had an estimated 1.1 million fewer people in 1997 than it would have had without HIV/AIDS. Similarly, there were 900,000 fewer people in South Africa and 1.6 million fewer people in Zimbabwe. The Population Division of the U.N. in its 1999 report "The World at Six Billion" revised its long-term population projections for countries in SSA taking account of the status of the HIV infection in each country. While severely affected countries will suffer significant reductions in the size of their population over the next two decades, no country is expected to experience negative population growth as a direct result of the epidemic. The impact of HIV/AIDS on fertility and population growth rates, both of which remain high in SSA, will not be great enough to produce the negative growth predicted and feared by many international and African commentators. Life Expectancy at Birth Life Expectancy at Birth is a much more reliable measure of the health status and well being of a population than GNP or GDP. In the first twenty years following independence, African countries made huge development efforts and invested heavily in health, education and other social services in a determined effort to raise the living standards of their people. As a result of improvements in the availability of health services including child immunizations, the control of communicable diseases, improved nutrition and sanitation and education, life expectancy increased by 15 to 20 years by the mid-'80s in most countries. This represented one of the few concrete achievements of the post-colonial era. The HIV/AIDS epidemic has wiped out the hard won gains in life expectancy and reversed the trend in several countries. Of the eighteen countries in SSA classified as having a generalized epidemic, all except Togo, have experienced declines in life expectancy between 1990-1995. Life expectancy in Burkina Faso, currently estimated at 46, is 11 years shorter than it would have been without HIV/AIDS. The World Bank estimates that in nine African countries with infection rates of more than 10 percent of the adult population, HIV/AIDS will erase 17 years from the life expectancy meaning that instead of reaching 64 years, by 2010-2015 life expectancy will only be 47 years. Examples include Zimbabwe, Botswana, Uganda and Cote d'Ivoire.