The United States government’s withdrawal of President’s Emergency Plan for Aids Relief (PEPFAR) funding earlier this year has left budget deficits in countries across the Sub-Sahara. The program has been crucial in the fight against human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) on the African continent.
Since its inception in 2003, the U.S. government has invested over $100 billion in HIV/AIDS response globally, reportedly saving over 25 million lives, preventing new infections, and supporting countries with HIV epidemic control.
How has Africa coped with the disease that has claimed over 42 million lives in just 44 years?
With the 120-day review of the U.S. foreign assistance period set by the Trump administration coming to an end, we look at how Africa has managed HIV/AIDS in the past, lessons that can be learned, and how African governments have developed new ways of thinking to forge a sustainable future in fighting the disease.
We start with the history.
It’s 1980, and a new disease has just been discovered. Top scientists across the world are working against the clock to figure out how to prevent a pandemic. The disease would spread fast in the ‘80s, but in these early years it is a focus for scientists and discussed quietly among the general public.
In Uganda, there was growing concern about this strange disease. The small East African country was in the middle of a civil war, and while medical practitioners were sounding the alarm, no one was listening. Uganda’s embattled president Milton Obote was given findings on AIDS, but he was distracted by the civil war that threatened to see him ousted. He ignored doctors’ advice. In following years, the “slim disease”, as it was known in Uganda at the time, ravaged cities and villages. People wasted away, many falling to their death each week with residents helplessly watch their friends and relatives die.
There was confusion about the slim disease. It was unclear how it was transmitted, hence increasing public anxiety. People thought AIDS was contracted by sharing food, others believed obese people did not have it, others thought that you could catch the disease just by looking at a person. This confusion bred fear, and fear bred stigma. The stigma associates HIV with promiscuity, prostitution, and other risky behaviours. The effect is that most people do not go for testing, so they live without knowing their status.
By the mid-‘80s, over 1.9 million people are living with HIV in Africa. Uganda is among the leading countries, but the civil war is on its last days. Soon Uganda will have a new government, and maybe it will join the movement to prevent AIDS from becoming a pandemic.
In the global north, United States President Ronald Regan makes a public declaration of AIDS being a priority. His statement sets a number of initiatives in motion from different levels of government. First, funding for research to find a cure. Second, mass testing including in the military. |
In Africa by 1986, HIV/AIDS is on a rampage, more than 3 million people are living with AIDS, and the death toll rises steadily. After ending a decade-long war, Uganda is keen on rebuilding. But this new disease is among the first challenges Uganda’s new leader, General Yoweri Museveni, has to overcome if he is to be successful. Uganda neighbours Kenya, Tanzania, and the Democratic Republic of the Congo (DRC) are still in denial with their leaderships ignoring the issue.
Kenya’s Daniel Moi fears losing tourists, a key foreign exchange earner, if his government acknowledges presence of AIDS in the country. Mobutu Sese Seko of the Congo banned the subject from the press from 1983 to 1987, and the picture is similar in other African countries.
Zimbabwean doctors are instructed not to mention AIDS on death certificates. But in Uganda, roaming armies, displaced populations, poverty, malnutrition, economic collapse, and a health-care system in shambles is a recipe for viral infections. People are dying in great number, and Uganda has Africa’s highest number of reported cases of the disease. In some towns, the prevalence is well into double digits. Museveni does not have time to settle into office. He must act.
As a new president, Museveni listened to the doctors who had investigated the first AIDS cases. Based on scientific advice, he made HIV/AIDS a priority. He spearheaded an aggressive anti-AIDS policy. Every government department issued anti-AIDS warnings. Unlike its neighbours who leaned on a more religious and cultural standing, in Uganda, sex was discussed openly in explicit terms. Roadside billboards promoted safe sex. The government’s proactivity paid dividends.
Working with the World Health Organization (WHO), Uganda is among the countries to draft a comprehensive five-year anti-AIDS plan focused on blood safety, surveillance, treatment of opportunistic infections, management of other sexually transmitted diseases, education and prevention. Uganda was also one of the first to produce educational materials on the disease. Donors pledged around $20 million to assist Uganda in tackling the disease. The government mobilized the army to distribute condoms and activate communities.
The president went around the country encouraging public debate and defying cultural and religious taboos against discussing sex. Uganda’s approach to information, education, and communication relied less on high-tech media interventions and more on personal communication. This made it easier to personalize risk, convince people, and encourage real behaviour change.
Shattered by war and poverty, communities placed immense trust and hope on this new advice. Packaged as a “patriotic duty”, the fight against AIDS brought the nation together.
In a short time, Uganda seemed to have found a working model for AIDS prevention. It was based on the promotion of monogamy, fidelity, faithfulness within polygamous marriages, abstinence (or delay of sexual debut) and reduction of multiple sex partners. Often known as the ABC of AIDS: Abstinence, Being faithful, and using a Condom.
While Uganda had a working formula, many other African countries were struggling to provide crucial information on this taboo disease to their population. This had consequences. As 1986 ends, Zambia, a country in the southern part of the continent comes to terms with the disease in the most public way. The country’s President Kenneth Kaunda admits that his son has died of AIDS. He was 30 years old. His father did not know how he contracted the disease.
President Kaunda’s son would be among the 100,000 deaths reported on the continent that year. Infections had grown to 3 million from 1.9 million two years earlier. There was growing concern that the numbers might be much bigger with many more cases unreported. As the ‘80s come to a close, art and especially music become a strong tool for talking about the disease across the continent. Celebrities infected with the disease came out to put a face on the illness while sensitizing people.
In 1988, two major global events made AIDS an urgent conversation. At the beginning of the year, experts met in London for the first World AIDS Summit. At the summit, Princess Anne describes the disease as “a classic own-goal scored by the human race against itself.” The WHO has estimated that 5 to 10 million people worldwide may be carriers of AIDS. The summit ended with declarations making 1988 the year of communication and co-operation about AIDS – while promoting responsible behaviour. Had results from Uganda presented the model for success in behavioral change?
1988 ended with yet another high-profile meeting, the first World Aids Day (WAD), which has been held every year since. WAD was created to raise awareness and counter the stigma of fear around the disease. Infected people globally were facing serious discrimination. Some were fired from their jobs, children were prevented from going to school. But there was a shift in Africa.
The early 1990s were characterized by serious economic challenges. There are coups, widespread political unrest, and most governments shift their focus to keeping their countries in one piece. Over 1 million people in Africa died from the disease by the start of this decade. The number of countries with national AIDS programs rose from 7 to 130. There are conversations around a cure as early as 1993, but WHO is being blamed for a lack of strategy on tackling AIDS in Africa, where at least 10 million people are believed to live with AIDS. With governments busy with political and economic issues, Africa could not afford to lose its already-scarce skilled manpower, so the fight was left principally to the continent’s medical experts.
Some of them were returning from the global north to help their countries overcome AIDS. However, this global health crisis was moving south. Southern African countries were witnessing an increase in infections.
The biggest economy in this region, South Africa, was experiencing political change with Nelson Mandela’s release from prison in 1994. Unlike its neighbours, cases of AIDS in South Africa were still low. The new government was indifferent about the disease cutting across every aspect of life on the continent. This was a dangerous step, but President Mandela, who took power in 1994, does not know that yet.
In the md-1990s, UNAIDS is launched to provide global leadership in response to AIDS. There is also a breakthrough on antiretroviral drug AZT that reduces transmission from mother to child. First trials of antiretrovirals make the drugs available, but they are pricey and limited in supply. Generally, only the privileged could afford them. While the South African government remained mum on the issues, news media became the only source of meaningful information.
Broadcasters and their partners came up with educational material for the general public. Religious leaders also weighed in on the issue, advocating for behaviour change and use of condoms. By the end of 1996, more than 14 million Africans were living with AIDS. South African prevalence of the disease is nearing double digits.
In 1997, one incident put South Africa squarely on the AIDS map, and revealed the challenges the country had been facing. Early that year, an eight-year-old AIDS orphan sparked outrage when he sought to join a primary school in a Johannesburg neighbourhood, and parents and the school board were split on whether to admit an HIV-positive child to the school. Nkosi Johnson wanted to read, make friends, and tell the time like other children his age. His bravery led to the country openly discussing stigma around HIV-infected people.
At this time, South Africa was reporting around 1.5 million people living with the disease. AIDS was no longer a disease of gay men in the country. Nkosi’s case brought into the open the prohibitive costs of antiretroviral treatments that locked out many South Africans. AZT, the drug mostly used to protect mother-to-child transmission, cost $10,000/year per patient, while the average household income in the country was between $7,000 and $9,000/year. With no money to afford any form of antiretroviral, Johnson, became South Africa’s longest-living child born with the disease, thanks to a healthy diet, vitamin supplements, and minimizing the stress of being HIV positive.
The cost issue became a growing concern in South Africa after Nkosi’s case. The government made an attempt to make ARVs available. Through parliament, President Mandela’s government passed the “Medicines and Related Substances Control Amendment Act“, a law that sought to make ARVs more affordable by allowing parallel imports, especially generic substitution. This was going to affect price and make it accessible to more people.
There was urgency because numbers were rising fast. But big pharmaceutical companies in the west were displeased. Thirty-nine of them went to court claiming that South Africa overrode their patent. As the case dragged on, Mandela’s government seemed to avoid the AIDS topic, and no alternative ARV roll-out programs were attempted. The country was facing a public health crisis, and the government did not recognize the scale of the problem.
When Thabo Mbeki took over from Mandela in 1999, the situation went from bad to worse. New president Mbeki would break the government’s silence by famously claiming that HIV does not cause AIDS. The Mbeki government felt that ARV treatment was being promoted so the West could profit. So, his government did not buy drugs that might have prevented mother-to-child transmission. This antipathy toward antiretroviral drugs is believed by some to have led to the deaths of over 300,000 South Africans, but it also awakened citizens to hold the government to account.
While South Africa was busy dancing at the edge of the precipice, something amazing was happening in Uganda. A country that had seen two million people die of AIDS, was turning the tide. The intervention of the government was paying off; prevalence was going down, and life expectancy was going up. According to the World Bank, There was an overall decline in the HIV prevalence rate, from 18.5% in the early 1990s to 8% in 1999. The level of HIV awareness was found to be over 90% in the general population. Fewer Ugandans were having sex at young ages, levels of monogamy increased across the country, and condom use rose steeply among unmarried sexually active men and women. Uganda was becoming a success story. But not everybody was celebrating.
The revelation that HIV prevalence was declining in a poor, war-ravaged region receiving little foreign assistance – primarily due to behavior change – ruffled some feathers. People in the donor community were convinced that fidelity and abstinence had little or no relevance, so this effective strategy was gradually phased out as the new millennium began.
What was left was reliance on ARVs. But it had been four years since the global community agreed on ARV treatment, and the prices were still high. Just as in South Africa, Uganda found it hard to access the drugs for its mass population. Africa was finding itself in peril; by the year 2000, AIDS has already killed at least 11 million Africans while another 24.5 million people were living with the disease in sub-Saharan Africa. With costs of drugs high, many, especially in South Africa, were turning to traditional healers to find help with the disease. Activists, medical professionals, and legal experts were seeking alternative avenues to compel the government to make ARVs available and affordable.
In July 2000, South Africa hosted the 13th International Conference on AIDS. It was the first time a conference of such magnitude was happening in Africa, a perceived epicenter of the disease.
As the conference opened, about 2,000 AIDS activists took to the streets of Durban to protest the high price of ARVs. But this was not the top highlight in the conference halls where 12,000 delegates from across the world gathered. First up was the South African government. President Thabo Mbeki’s controversial opening speech claimed that AIDS was not caused by a virus, and blamed poverty. Then Nkosi, the 11-year-old boy who helped put a face to the disease, pled the government to help more children access drugs needed to live longer. South African judge Edwin Cameron, meanwhile, showcased how help was out of reach for those who could not afford ARVs.
One of the speakers at the convention was one of Africa’s top researchers, Dr. Peter Mugyenyi. a man who had gone through the thick of it in Uganda. Mugyenyi asked the delegates to make the drugs available where the disease was spreading fast.
Mugyenyi was very familiar with matters related to HIV; he returned to Uganda from exile in 1990 and started a research facility to help fight the scourge. He was in Uganda when the disease picked to 18% of the population in 1994, and when behavioral change brought infections down to single digits in the late ‘90s. He was there when many Ugandans refused to just be given aspirin, good wishes, and no hope, and instead participated in an ethically challenging AIDS vaccine trial.
After the conference, there was renewed vigour in South Africa to call for accountability from government. Across the continent there was a clarion call for cheaper ARV treatment. The cost of antiretroviral therapy was US$10,000 per person per year. In courts, Big Pharma was sticking to its argument against the importation of generic drugs mainly from Asia to Africa. But soon things would turn. First, 39 big pharmaceutical firms withdrew their lawsuit on patent. Then the South African government was compelled to provide ARVs to HIV-positive pregnant women immediately, this to save the more than 70,000 children born with the virus annually.
Despite the progress in the corridors of justice, the fight was far from being won. Big Pharma and western governments feared removing patent and allowing Africans access to cheaper drugs would result in misuse of the drugs and cause the virus to mutate, thus making it resistant to the drug.
At this point, Africa had over 28 million infections, representing more than 70% of global infections. Just 1 in 2,000 Africans with HIV was being treated with ARV. While things were stuck in South Africa, ABC phased out in Uganda, other African countries were picking up lessons and trying to use the knowledge to save their people.
In Kenya, where one in 15 people was infected, President Daniel Moi was asking people not to have sex for two years to curb the spread. He threatened death by hanging to those found deliberately spreading the disease.
After his appeal in Durban, and following the defeat of the big pharmaceuticals, Peter would proceed to import low-cost generic ARVs from India, in direct defiance of Uganda’s patent laws.
He boldly challenged authorities to arrest him and refused to leave the airport until the drugs were allowed into the country. Mugyenyi’s actions in Uganda helped many African countries break barriers and import generic ARVs as part of Public Health Emergency exemptions. But it was not just African governments that were noticing. A politician in the United Stated interested in running for presidency was looking at this as a key agenda of his African Policy during and after the campaign. In 2003, George Bush announced PEPFAR, a $15-billion fund that was part of the U.S.’s five-year strategy for global emergency AIDS relief.
In the years that followed, PEPFAR together with the UN Global Fund launched by Koffi Annan in 2002 made rolling out of the drugs much easier across Africa. Soon thereafter, more than 100 000 Africans had access to treatment, with an ambitious plan to reach 3 million in two years. The African Union committed to increase access to antiretrovirals. To achieve this needed a lot of efforts from culture shapers, governments, and thought leaders to get the message to as many people as possible in Sub-Saharan Africa.
With South Africa as the new epicenter of AIDS, Nelson Mandela made up for his silence as president to launch an awareness campaign. Two years after the launch of the 46664 initiatives, Mandela would face the world again, this time with an admission that highlighted the discriminatory nature of the disease. He had lost his only surviving son to AIDS. And Mandela was not mourning alone; his neighbouring statesmen were also affected. Zimbabwe’s Robert Mugabe admitted to AIDS affecting his family. In Zambia, Kenneth Kaunda, who was the first head of state to admit the death of a child to AIDS in the late ‘80s, had seen how the disease claimed so many young people in the country. He had been working on awareness campaigns, even recording a music album as part of his campaign against the disease.
While all of this is happening, scientists and researchers are busy working to find medical and behavioral breakthroughs. Trials in Kenya and Uganda show male circumcision is an effective tool for HIV prevention in Africa.
The second half of the first decade of the new millennium saw progress; for the first time, HIV infections on the continent were falling. Intervention was helping.
The last 15 years have seen more effort put toward the goal of zero new HIV infections, zero discrimination, zero AIDS-related deaths, access to antiretroviral therapy across Africa, and reduction on the reliance on foreign aid. African governments have been finding alternative sources to fund the purchase and distribution of antiretroviral therapy, helping them better control the narrative in the face of sanctions and funding freezes.
(George Mutero, BIG Media Ltd., 2025)
