AIDS in sub-Saharan Africa: the epidemiology of heterosexual transmission and the prospects for prevention.

As the epidemic of the acquired immunodeficiency syndrome (AIDS) in sub-Saharan Africa enters its second decade, much has been learned about the distribution and determinants of the disease and its causative agent, the human immunodeficiency virus (HIV). Over 6 million people, or 2.5% of the adult population, are thought to be infected with HIV. The distribution of HIV is largely determined by sexual behavior; as for other sexually transmitted diseases, the characteristics of sexual networks determine the extent and rate of spread of HIV. Female sex workers and their male clients are at high risk for HIV and have been important in initiating the epidemic in many African countries. The dynamics of HIV in the rest of the population are complex; men with multiple sexual partners are largely responsible for transmission of HIV to women in the general population. Other sexually transmitted diseases and lack of male circumcision may increase the probability of transmission of HIV during sexual intercourse and probably are partially responsible for the rapid diffusion of HIV in Africa. Interventions among high-risk groups are needed, but they must be accompanied by attempts to induce behavior change among men and women in the general population. Epidemiologic studies of the determinants of sexual behavior and sexual contact patterns, as well the design and evaluation of interventions, are urgently needed. Key areas for development are the study of behavioral exposures and outcomes, the evaluation of interventions, developing new methods for conducting interventions in resource-poor environments, and increasing the number of African scientists with the skills and resources to conduct epidemiologic studies.