cases were recognized in 1985, AIDS has rapidly become the leading cause of death among men and the second leading cause of death, after complications related to pregnancy and abortion, among women (De Cock et al., 1990). In a 1990 study, 41 percent of male and 32 percent of female cadavers were found to be infected with HIV. AIDS kills people in their most productive years, and now ranks among the leading causes of potential healthy life-years lost in sub-Saharan Africa. In the Abidjan study, it was estimated that 15 percent of adult male deaths and 17 percent of male years of potential life lost resulted from AIDS, whereas among women, AIDS accounted for 13 percent of deaths and 12 percent of years of potential life lost. These figures probably underestimate the true mortality due to HIV infection. Factors leading to an underassessment of AIDS-related deaths include the exclusion of pediatric patients, the rigidity of the case definition used, a lack of clinical information concerning cause of death, and the desire of seriously ill persons who leave Abidjan to die in their home areas. Moreover, death due to pulmonary tuberculosis, the third-ranking cause of male adult death, was not specifically counted as caused by AIDS, although 50 percent of these cadavers were HIV-seropositive, and an important fraction of these deaths was probably attributable to HIV infection (De Cock et al., 1990).

In two community-based rural studies, in Masaka district and Rakai district, Uganda, mortality among HIV-infected adults, at over 100 per 1,000 person-years of observation, was found to be 10 times higher than that among adults not infected with HIV (Mulder et al., 1994b; Sewankambo et al., 1994). In both districts, which have an underlying adult HIV prevalence of 8 and 13 percent, respectively, HIV was found to be the leading cause of death among adults. For example, over 80 percent of deaths in the 20-29 age group occurred among those who were HIV-infected. In Rakai, HIV mortality was found to have resulted in substantial slowing in the rate of natural population increase, although the population continues to experience a positive growth rate, even in that stratum of villages where adult HIV prevalence exceeds 30 percent (Sewankambo et al., 1994).

Although data concerning mortality due to AIDS are scarce in other countries, it is likely that AIDS is the leading cause of adult death in several African cities and possibly some rural areas, especially those in the main HIV belt (Kitange et al., 1994; Nelson et al., 1991; Sewankambo et al., 1994; Mulder, 1994b; De Cock et al., 1990).

The demographic impact of AIDS will continue to expand in the remainder of this decade and into the next century as the epidemic continues to spread and mature. The deaths to date have occurred among those individuals infected relatively early in the epidemic, through the mid-1980s. In future years, those infected since the late 1980s will develop AIDS and die. In general, in the countries of sub-Saharan Africa, characterized by high population mobility and urbanization, high levels of STDs, and a doubling of infection rates in less than one year, there is a very limited time within which to curb the spread of HIV



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