|AIDS in Africa (UNAIDS, 1999, 11 p.)|
In Madagascar, an island of 16 million people, HIV is just beginning to raise its head. Surveillance among pregnant women shows exceptionally low levels of infection-perhaps 1 in 5000 (as compared with 1 in 4 in some countries in sub-Saharan Africa, off whose south-eastern coast Madagascar lies). Even among sex workers and patients with other sexually transmitted infections, HIV rates are negligible. An island nation with no need for HIV prevention programmes? Far from it. Madagascar may have been protected by its relative isolation from an early onslaught of HIV, but the high levels of risk in the population are sending alarm bells ringing. The time to act is now.
According to behavioural surveys, sex starts young (at around 15 for the majority of women) and premarital pregnancy is common. Some 14% of pregnant women in a recent survey reported casual partners, and over 9 out of 10 never used condoms in those encounters. Most patients at STD clinics were married, but 16% reported regular extramarital partners and another 14% reported casual partners. Fewer than 10% consistently use condoms in any of these relationships.
STD microbes are already finding plenty of scope for spread. Some 10% of pregnant woman tested positive for syphilis in the most recent round of surveillance-an unusually high rate. Around 15% of STD clinic patients had syphilis. Among sex workers syphilis prevalence ranged up to 28%-not surprising, considering that 35% of sex workers say they never use condoms with any type of clients, and nearly two-thirds never use them with regular partners. Only 14% report using condoms with all of their sex work clients. The potential scope for both STD and HIV spread is alarming.
The government and nongovernmental partners are responding actively. For example, special reproductive health services for 10 to 24-year-olds have been set up in youth centres around the country. The aim is to use these special youth-friendly clinics to spread the word about HIV and to instil a norm of safe behaviour quickly, before the virus can take hold.
For more information, please contact Anne Winter, UNAIDS, (+41 22 791.4577