HIV/AIDS in Africa: Politics, Policies, Programs and Logistics
By Chinua Akukwe
December 1, 2003
The UNAIDS 2003 update on the AIDS crisis in Africa paints a gloomy picture after more than two decades of battling the epidemic: 26.6 million Africans live with HIV/AIDS; Southern Africa account for 30% of all HIV/AIDS in world while representing only 2% of the global population; Africa is the only region where more women than men live with HIV, with highest disparities among the 15-24 age group; less than 1% of all infected Africans have access to lifesaving antiretroviral therapy; a mere 1% of pregnant women in countries with the highest rates of HIV have access to proven strategies that can drastically reduce mother-to-child transmission, although 95% of such transmissions occur in Africa; and, two countries, Botswana and Swaziland have at least 39% of their adult population living with HIV/AIDS. Projections for the next decade in the continent are also discouraging. Why is Africa facing potential long-term destruction from HIV/AIDS? I briefly review the political, policy, program and logistic issues that require immediate attention in the fight against HIV/AIDS in Africa.
THE POLITICS OF AIDS
Every political leader in Africa now understands that it is important to be seen, domestic and international, as “doing something” about HIV/AIDS. Flowery speeches about HIV/AIDS are now standard: how perverse the effects of HIV/AIDS could be; how it is the “biggest war” right now; what “my government will do to stop this menace”; and, the need for the international community to do “more.” For politicians in the West, AIDS is a “global pandemic”; nobody is “safe”; we must act to secure the future of the “global community”; and, we cannot “stand-by” and let people die, even when they live thousands of miles away. Virtually every bilateral and multilateral agency resorts to similar political languages while addressing various components of the epidemic in Africa. While the political vocabulary of AIDS has become remarkably similar, the specifics are missing: direct actions to save individual lives or to prevent individual families from long term suffering that invariably result in the death of a loved one of AIDS. In addition, the issue of governance, especially the transparent use of international resources on HIV/AIDS, is becoming very political. Western leaders want “verifiable progress” on governance while African leaders speak of the need to “meet national aspirations and priorities.” Governance is gradually emerging as a potential bulwark against comprehensive international response to HIV/AIDS in Africa. The Economic Commission for Africa recently set-up a high-level Commission on Governance and HIV/AIDS in an attempt to highlight and reach a common ground on this potentially divisive issue.
It is now fashionable for countries to develop or announce plans to implement “comprehensive,” “participatory” and “inclusive” action plans on HIV/AIDS. An approved action plan on AIDS is now an accepted barometer of national government seriousness on AIDS. It is still a mystery on how centralized strategic planning processes could be inclusive and participatory or reflect the felt and perceived needs of target populations. Today, national coordinating authorities on AIDS remain the major drivers of remedial efforts for a condition that wrecks havoc at individual, family and community levels. Community-based remedial policies on AIDS are rare in Africa, and, are not a strategic priority of donor agencies.
The initial dichotomy of prevention versus treatment is now history, as African nations forcefully demanded access to lifesaving medicines and the international community accepted the challenge. The Global Fund to Fight AIDS, TB and Malaria is a demonstration of such an international response. The proposed World Health Organization strategy of providing three million individuals living with HIV/AIDS with lifesaving medicines by 2005, is another example. For Africa, emerging program issues include how to achieve effective information, education and communication (IEC) campaigns against HIV transmission given past uneven record; how best to target high risk populations such as migrant workers, commercial sex workers, women and youth; how to integrate prevention with access to care; how to provide support for the growing numbers of AIDS orphans; and, how to mainstream HIV/AIDS remedial efforts into poverty alleviation strategies. For all these issues, significant challenges remain in Africa. Very few remedial efforts in Africa have direct impact on individuals living with HIV/AIDS or those providing supportive care.
LOGISTICS OF AIDS REMEDIAL EFFORTS
With the global consensus on the need to provide Africans living with HIV/AIDS with lifesaving therapy if they meet clinical protocols, logistical challenges of scaling up remedial efforts are now becoming clearer. It is important to note that the former director general of the World Health Organization, Gru Brundtland had advised that clinical care for individuals living with HIV/AIDS, including those that need antiretroviral therapy, could be provided safely in the most resource challenged environments. For those familiar with health systems of Africa countries, that advise is not surprising. However, African countries face the long-term challenges of resuscitatating their health systems, training new health workers and re-training old ones, and improving sanitary standards. These countries also face the challenge of developing or revamping road, telecommunication, electricity, and water supply networks that are critical in implementing scaled up remedial efforts. For program lessons and best practices, it is likely that most African countries will analyze ongoing efforts to provide lifesaving AIDS medicines in Nigeria, and the new South Africa treatment plan. The challenge of implementing effective IEC remains, particularly on how to reach at risk populations in environments that increases their receptivity to preventive messages. While rudimentary efforts are ongoing to support national logistic efforts in many African countries, there is very little attention paid to augmenting community-based remedial efforts.
HIV/AIDS is showing no signs of slowing down in Africa. Remarkable success has been achieved in the last few years regarding focused attention on the plight of millions of Africans living and dying of AIDS. The last seemingly insurmountable hurdle of providing lifesaving treatment to Africans living with HIV/AIDS is now overcome. International resources to scale up remedial efforts in Africa have either reached advanced mobilization stages or are under serious discussion. The next step is to zero in on the individual African or family living with HIV/AIDS or at the risk of contracting HIV. It is now time to focus on how to resolve the mechanics of providing community-based services that meet the preventive, clinical and support needs of individuals, families and communities. A comprehensive community-based approach will force politicians, policy makers, academics, and activists to focus on what really matters in the fight against this deadly condition: the number of individuals prevented from contracting HIV or the number of individuals benefiting from lifesaving medicines and supportive care. Today, between 90 and 92% of Africans are HIV negative according to the UNAIDS. We need to keep these people free of HIV while providing care and support for those already living with HIV/AIDS. In another article, I had presented an overview of how to implement a community-based but internationally driven remedial effort against AIDS in Africa (www.globalhealth.org/publications/article.php3?id=693). It is time to stop this epidemic where it really counts: at individual, family and community levels.