Impact of long-term civil disorders and wars on the trajectory of HIV epidemics in sub-Saharan Africa

HIV Incidence Prior to, during, and after Violent Conflict in 36 Sub-Saharan African Nations, 1990-2012: An Ecological Study

Objectives

The aim of this study was to determine the association between violent conflict and HIV incidence within and across 36 sub-Saharan Africa countries between 1990 and 2012.

Methods

We used generalized linear mixed effect modeling to estimate the effect of conflict periods on country-level HIV incidence. We specified random intercepts and slopes to account for across and within country variation over time. We also conducted a sub-analysis of countries who experienced conflict to assess the effect of conflict intensity on country-level HIV incidence. All models controlled for level of economic development, number of refugees present in the country, and year.

Results

We found that, compared to times of peace, the HIV incidence rate increased by 2.1 per 1000 infections per year (95%CI: 0.39, 3.87) in the 5 years prior to conflict. Additionally, we found a decrease of 0.7 new infections per 1000 people per year (95%CI: -1.44, -0.01) in conflicts with 25 to 1000 battle-related deaths and a decrease of 1.5 new infections per 1000 people per year (95%CI:-2.50, -0.52) for conflict with more than 1000 battle-related deaths, compared to conflicts with less than 25 battle-related deaths

Conclusions

Our results demonstrate that HIV infection rates increase in the years immediately prior to times of conflict; however, we did not identify a significant increase during and immediately following periods of violent conflict. Further investigation, including more rigorous data collection, is needed, as is increased aid to nations at risk of violent conflict to help in the fight against HIV/AIDS in sub-Saharan Africa.

Spatiotemporal dynamics of the HIV-1 subtype G epidemic in West and Central Africa

The human immunodeficiency virus type 1 (HIV-1) subtype G is the second most prevalent HIV-1 clade in West Africa, accounting for nearly 30% of infections in the region. There is no information about the spatiotemporal dynamics of dissemination of this HIV-1 clade in Africa. To this end, we analyzed a total of 305 HIV-1 subtype G pol sequences isolated from 11 different countries from West and Central Africa over a period of 20 years (1992 to 2011). Evolutionary, phylogeographic and demographic parameters were jointly estimated from sequence data using a Bayesian coalescent-based method. Our analyses indicate that subtype G most probably emerged in Central Africa in 1968 (1956–1976). From Central Africa, the virus was disseminated to West and West Central Africa at multiple times from the middle 1970s onwards. Two subtype G strains probably introduced into Nigeria and Togo between the middle and the late 1970s were disseminated locally and to neighboring countries, leading to the origin of two major western African clades (G_WA-I and G_WA-II). Subtype G clades circulating in western and central African regions displayed an initial phase of exponential growth followed by a decline in growth rate since the early/middle 1990s; but the mean epidemic growth rate of G_WA-I (0.75 year⁻¹) and G_WA-II (0.95 year⁻¹) clades was about two times higher than that estimated for central African lineages (0.47 year⁻¹). Notably, the overall evolutionary and demographic history of G_WA-I and G_WA-II clades was very similar to that estimated for the CRF06_cpx clade circulating in the same region. These results support the notion that the spatiotemporal dissemination dynamics of major HIV-1 clades circulating in western Africa have probably been shaped by the same ecological factors.

The evolution of our knowledge of HIV-associated kidney disease in Africa

Human immunodeficiency virus (HIV) infection started in Africa circa 1930. South Africa has the highest prevalence rate in the world. Although reports of HIV-associated nephropathy (HIVAN) appeared in the early 1980s, the earliest report from sub-Saharan Africa (SSA) came in 1994. Geographical, socioeconomic, political, and ethical factors have worked in concert to shape the character of HIV disease as it is seen in SSA. Political leaders within SSA have, through their actions, significantly contributed to the incidence of HIV infection. Black females, who often face cultural suppression and disadvantage, have a higher prevalence of HIV than males. Too few studies and outcomes data have bedeviled the statistics in SSA in relation to HIVAN prevalence and its management. Much of what is written is approximation and anecdotal. The largest reliable biopsy series comes from the University of Cape Town, where a workable classification of HIVAN has been developed to enable standardization of terminology. Histologic and clinical prognostic indicators with outcomes have been evaluated using this classification. Patients with HIV who present with acute kidney injury appear to have mainly acute tubular necrosis due to sepsis, dehydration, and nephrotoxic drugs. Since the rollout of combination antiretroviral therapy, the extent of HIV infection and kidney disease continues to be modified and possibly retarded.

Phylodynamics of HIV-1 subtype F1 in Angola, Brazil and Romania

The HIV-1 subtype F1 is exceptionally prevalent in Angola, Brazil and Romania. The epidemiological context in which the spread of HIV occurred was highly variable from one country to another, mainly due to the existence of a long-term civil war in Angola and the contamination of a large number of children in Romania. Here we apply phylogenetic and Bayesian coalescent-based methods to reconstruct the phylodynamic patterns of HIV-1 subtype F1 in such different epidemiological settings. The phylogenetic analyses of HIV-1 subtype F1 pol sequences sampled worldwide confirmed that most sequences from Angola, Brazil and Romania segregated in country-specific monophyletic groups, while most subtype F1 sequences from Romanian children branched as a monophyletic sub-cluster (Romania-CH) nested within sequences from adults. The inferred time of the most recent common ancestor of the different subtype F1 clades were as follow: Angola=1983 (1978-1989), Brazil=1977 (1972-1981), Romania adults=1980 (1973-1987), and Romania-CH=1985 (1978-1989). All subtype F1 clades showed a demographic history best explained by a model of logistic population growth. Although the expansion phase of subtype F1 epidemic in Angola (mid 1980s to early 2000s) overlaps with the civil war period (1975-2002), the mean estimated growth rate of the Angolan F1 clade (0.49 year(-1)) was not exceptionally high, but quite similar to that estimated for the Brazilian (0.69 year(-1)) and Romanian adult (0.36 year(-1)) subtype F1 clades. The Romania-CH subtype F1 lineage, by contrast, displayed a short and explosive dissemination phase, with a median growth rate (2.47 year(-1)) much higher than that estimated for adult populations. This result supports the idea that the AIDS epidemic that affected the Romanian children was mainly caused by the spread of the HIV through highly efficient parenteral transmission networks, unlike adult populations where HIV is predominantly transmitted through sexual route.

Dialectical theory and the study of HIV/AIDS and other epidemics

Epidemics have been important in human history. This article discusses epidemics as part of a metabolic dialectics of humanity within nature. The creative thoughts and actions of those people most threatened by HIV/AIDS, and the thoughts and actions of science, have shaped both each other and the virus. The virus has reacted through mutation in ways that mimic strategic intelligence. The dialectics of capital and states has shaped these interactions and, in some cases, been shaped by them. Practical action to minimize the harms epidemics do can be strengthened by understanding of these epidemics, and Marxist theory and practices can be strengthened by understanding the dialectics of public health and the struggles around it more fully.

Political and socio-economic instability: does it have a role in the HIV/AIDS epidemic in sub-Saharan Africa?

Many sub-Saharan African countries are confronted by the HIV/AIDS epidemic. This article reviews academic literature in the social sciences and health to discover why HIV/AIDS has become an epidemic in sub-Saharan Africa and not in other parts of the world. This was studied by examining the social determinants of diminishment of tradition and social cohesion in terms of political, social and economic problems. Four countries in this region were selected for this case study, namely South Africa, Botswana, Uganda and Zimbabwe. The findings showed that instability in socio-economic and political aspects in these nations was responsible for creating a suitable environment for the spread of HIV/AIDS infection. This paper concludes by using the theories of collective action/responsibility and social cohesion to hypothesise that the breakdown of social ties due to various kinds of conflicts and unrest is one of the main contributors to the HIV/AIDS epidemic.

How to contain generalized HIV epidemics? A plea for better evidence to displace speculation

In the worst generalized HIV epidemics in East and Southern Africa, from one-quarter to three-quarters of women aged 15 years can expect to be living with HIV or to have died with AIDS by age 40 years. This disaster continues in the face of massive HIV prevention programmes based on current inexact knowledge of HIV transmission pathways and risks. To stop this disaster, both the public and public health experts need better information about the specific factors that allow HIV to propagate so extensively in countries with generalized epidemics. This knowledge could be acquired by tracing HIV infections to their source - especially tracing HIV infections in women of all ages, and tracing unexplained HIV infections in children with HIV-negative mothers.

STD/AIDS prevention in Portuguese-speaking Africa: a review of the recent literature in the social sciences and health

The article reviews academic literature in the social sciences and health on the problems and challenges of STD/AIDS prevention in Portuguese-speaking African countries. Based on a bibliographic survey of the SciELO, PubMed, and Sociological Abstracts databases between 1997 and 2007, the research under review was organized into two groups, according to content. The first group of studies sought to understand STD/AIDS vulnerability among social groups by examining local cultural and socioeconomic factors as related to gender dynamics, sexuality, color/race, religion and health care. The second group encompassed critical assessments of shortcomings in the STD/AIDS educational messages delivered by governments and international agencies. Attention is called to the way in which the presence of traditional medicine systems and the occurrence of civil wars in the post-colonial period impact the STD/AIDS epidemic in the African countries under study.

Some data-driven reflections on priorities in AIDS network research

Risk networks can transmit HIV or other infections; social networks can transmit social influence and thus help shape norms and behaviors. This primarily-theoretical paper starts with a review of network concepts, and then presents data from a New York network study to study patterns of sexual and injection linkages among IDUs and other drug users and nonusers, men who have sex with men, women who have sex with women, other men and other women in a high-risk community and the distribution of HIV, sex at group sex events, and health intravention behaviors in this network. It then discusses how risk network microstructures might influence HIV epidemics and urban vulnerability to epidemics; what social and other forces (such as "Big Events" like wars or ecological disasters) might shape networks and their associated norms, intraventions, practices and behaviors; and how network theory and research have and may continue to contribute to developing interventions against HIV epidemics.