H.I.V./AIDS in Africa, 2007-2010: Major Challenges Ahead

People stand in line to enter a stadium for World AIDS Day ceremonies in South Africa on December 1. (Photo: Fati Moalusi / AFP-Getty Images)

In an earlier article to mark 25 years of H.I.V./AIDS, I indicated the need for a "mature" phase of the global response to quickly take shape. This mature phase worldwide should focus on:

  1. Accountability issues where past, present and future promises on remedial assistance by the Group of 8 nations, bilateral and multilateral organizations, continental institutions and national governments are met on time and according to an agreed upon timeline.

  2. Benchmarking issues where valid national prevalence and incidence data are the backbone of transparent monitoring and evaluation processes.

  3. Personal responsibility issues with focus on individuals and families as the first line of defense against H.I.V. transmission through directed and specific empowerment programs that drastically reduce poverty rates and gender inequalities, increase legal protection for vulnerable populations and rigorously enforce relevant laws.

In Africa, these issues are extremely important and germane to any serious H.I.V./AIDS remedial effort. However, the continent faces other unique challenges. In 2006, according to the UNAIDS, Africa while representing about 10 percent of the global population accounted for 63 percent of all new H.I.V. infections during the year and 72 percent of all AIDS deaths. In Southern Africa, the frontline region of the global epidemic, although the region represents only 2 percent of the global population, it accounts for 32 percent of all individuals living with H.I.V. and 34 percent of all global deaths from AIDS in 2006. Between 2007 and 2010, Africa, the epicenter of the global epidemic on H.I.V./AIDS faces major challenges as the international community seeks to meet its promise of universal access to H.I.V./AIDS prevention, treatment, care and support. I briefly discuss the challenges to H.I.V./AIDS remedial efforts in Africa between 2007 and 2010.

Major Challenges to H.I.V./AIDS Remedial Efforts in Africa, 2007-2010

The United Nations General Assembly in June 2006 endorsed the Political Declaration on H.I.V./AIDS, which reflects "… the commitment of the present Declaration and the urgent need to scale up significantly toward the goal of universal access to comprehensive prevention programs, treatment, care and support by 2010, and to setting up and maintaining sound and rigorous monitoring and evaluation frameworks within their H.I.V./AIDS strategies..." It is a race against time in Africa to meet the U.N. declaration by 2010.

1. The Challenge of Stable Political Support and Engagement of Policy Makers

This will be a major challenge as African nations gradually evolve into stable governments and peacefully transfer political power between governments. In 2007, there will be lingering concerns in Nigeria when President Olusegun Obasanjo is scheduled to leave office amid heightened political tensions and in Kenya where President Mwai Kibaki will either leave office or subject himself to what promises to be a tough reelection campaign against the background of strident disagreements with powerful erstwhile political allies. These two presidents have been strong political supporters of H.I.V./AIDS remedial efforts. In 2007, Kofi Annan of Ghana will no longer be the secretary general of the U.N., a position he used very effectively to champion H.I.V./AIDS remedial effort. The good news is that his successor, Ban Ki-moon, has promised to keep Africa as a major focus of his term in office. The chairman of the African Union Commission, Alpha Konare, another strong supporter of H.I.V./AIDS remedial efforts, will end his term in 2007 and, reportedly, will not seek reelection. However, the good news is that the African Development Bank and the U.N. Economic Commission for Africa have reaffirmed their commitment to H.I.V./AIDS remedial efforts in the continent. The regional office of the World Health Organization in Africa is strengthening technical and program relationships with other continental organizations and expanding technical capacity by building relationships with member states.

In many African countries that are critical to the success of H.I.V./AIDS remedial efforts in the continent, either because of endemic levels of H.I.V. or at-risk populations, there will be delicate political transitions between 2007 and 2010. These countries include South Africa, Uganda, Sierra Leone, Zimbabwe, Angola and the Democratic Republic of Congo. Countries barely emerging from or still dealing with conflicts, such as Liberia, Ivory Coast, the Central African Republic, Sudan, Chad and Burundi, will face operational difficulties regarding the implementation of robust H.I.V./AIDS remedial efforts amid massive post-conflict infrastructure and social development needs. The inability of political leaders and policy makers in Africa to successfully co-opt religious leaders in the fight against H.I.V./AIDS also complicates long-term political support for H.I.V./AIDS program efforts. Religious leaders in many parts of Africa are very influential among ordinary citizens. African leaders can benefit from the experiences of Uganda and Senegal in working closely with religious leaders as part of sustainable and stable political support for H.I.V./AIDS initiatives in the continent.

2. The Challenge of Sustainable, Stable Financing for H.I.V./AIDS Initiatives

The U.N. General Assembly in its June 2006 Political Declaration on H.I.V./AIDS recognized "that the Joint United Nations Program on H.I.V./AIDS has estimated that 20 to 23 billion United States dollars per annum is needed by 2010 to support rapidly scaled up AIDS responses in low- and-middle income countries." A significant proportion of the estimated money is expected to go to Africa. In 2005, according to UNAIDS, out of estimated $8.3 billion spent on H.I.V./AIDS in low- and-middle income countries, only $2.5 billion or 30 percent came from domestic sources. The possibility of raising and maintaining a stable financial flow for H.I.V./AIDS programs in Africa between 2007 and 2010 and beyond is not encouraging. In another article in 2005, I raised alarm about the looming funding crisis on H.I.V./AIDS remedial efforts. UNAIDS estimates that resource requirements for H.I.V./AIDS remedial efforts in low- and-middle income countries in 2007 will be $18 billion, compared to an estimated available $10 billion — a whopping funding shortfall of $8.1 billion. UNAIDS estimates the financing of H.I.V./AIDS in these countries will be $22.1 billion in 2008. To be on track to meet the U.N. Millennium Development Goal of reversing the global AIDS epidemic by 2015, UNAIDS estimates that $11.4 billion will have to be spent on H.I.V. prevention alone by 2008.

To achieve stable, sustainable funding for H.I.V./AIDS remedial efforts, it is important to hold organizations and institutions accountable for promises made regarding the financing of H.I.V./AIDS programs. The G-8 nations should fulfill their promise on financial support for achieving universal access to H.I.V./AIDS prevention, treatment, care and support made at the Gleneagles Summit in 2005. All bilateral development institutions of Western countries should meet their promise of financial support in accordance with agreed upon time lines with recipient nations. Multilateral organizations such as the World Bank and the United Nations Development Program should fulfill their promises. Continental organizations in Africa and regional economic communities should also fulfill their financial commitments. National governments in Africa also need to meet their stated financial commitments and should lead resource mobilization efforts from the private sector in their countries. It is also important to create transparent verification mechanisms for monitoring and evaluating the financing of H.I.V./AIDS programs.

A transparent and easily verifiable mechanism for assessing stable financial flows to specific countries on H.I.V./AIDS should provide answers to specific questions. For example, the timely access to antiretroviral drugs could be an effective and verifiable benchmark and outcome tool. In this regard, critical policy and program questions may include: Is any individual in need in a specific country unable to receive antiretroviral medicines? If so, what is the specific reason for lack of access? What is the average wait time between clinical qualification for receiving antiretroviral drugs and actual commencement of treatment with antiretroviral drugs? What is the proportion of individuals on antiretroviral therapy that are paying out-of-pocket expenses for the drugs in each country? What is the proportion of individuals qualified to receive antiretroviral drugs that are not on treatment due to (1) lack of money (2) lack of treatment centers and (3) lack of access to available treatment centers?

3. The Challenge of Infrastructure Development and Logistics Management

The need to rebuild primary health care infrastructure in Africa is now receiving the attention of policy makers in Africa. The importance of effective logistics is also widely recognized, especially in the areas of drug procurement, purchase and deployment of public health goods and equipment, the supply chain of perishable items and the role of basic infrastructure. These basic infrastructure needs include timely transportation of goods and services, stable electricity and telecommunication services, and access to proper sanitation and water supplies. The key is to quickly meet infrastructure and logistics challenges so that it does not compromise H.I.V./AIDS remedial efforts through concerted domestic and international partnerships. For example, in the procurement of public health goods and services, research and generic pharmaceutical companies should assist African governments to make lifesaving drugs easily available to those clinically qualified to receive them. International and domestic partners with expertise on information, education and communication campaigns should work closely together so that at-risk populations can be reached through existing health systems. It is important to note that simple outreach programs in resource challenged environments such as the use of community health workers and health volunteers can go a long way in improving access to H.I.V./AIDS treatment, care and support programs while needed improvements in infrastructure and logistics are completed.

4. The Challenge of Legal Protection and Legal Enforcement of Fundamental Human Rights of Individuals Living With and At-Risk of H.I.V

Africa faces a major challenge addressing gender inequality issues in the continent. These issues include lack of property and inheritance rights. The continent also faces the challenge of protecting its women from sexual violence, rape and intimate partner violence. To meet this challenge, African governments need to upgrade their laws on gender equity, rape, intimate partner violence and sexual harassment. African governments also need to establish incentives for African girls and young women to remain in school. The aim should be university education for as many women as possible in Africa so that the continent can have a large pool of educated women who individually and collectively will enforce their fundamental human rights.

There are also major challenges of stigma and discrimination against individuals living with H.I.V./AIDS. In many health care settings in Africa, confidentiality of personal records cannot be guaranteed as a result of many factors such as antiquated record keeping systems, poor funding, irregular ethics training of staff and dilapidated infrastructure. Individuals living with H.I.V./AIDS also face workplace discrimination. Worse, they may also face threats to their lives and properties if their status becomes public knowledge. Providing legal protection for vulnerable segments of the population in the fight against H.I.V./AIDS in Africa is one of the most urgent tasks facing African governments. Effective legal preventive measures will include zero tolerance for stigma and discriminatory practices and the rigorous implementation of relevant national laws.

5. The Challenge of the Health Workforce Crisis in the Continent

There are simply not enough doctors, nurses, pharmacists and other health professionals in Africa to provide effective preventive health and clinical care in Africa. The African Union indicates that the continent with 10 percent of the global population and 25 percent of the global diseases burden accounts for less than 5 percent of the global health workforce. The International Labor Organization, in its latest update on H.I.V./AIDS and the world of work, estimates that 67 percent of the global workforce living with H.I.V./AIDS works in Africa. UNAIDS blames the shortage of a skilled health workforce for less than stellar surveillance, planning and administrative H.I.V./AIDS program efforts in Africa. The shortage of skilled staff, according to UNAIDS, is also responsible for delays in the distribution of funds, difficulties with the implementation, monitoring and evaluation of programs, and shoddy provision of services.

The shortage of a skilled health workforce requires immediate and sustained financial support from the United States and other rich countries in the areas of accelerated training of new workers and retraining of existing workers. National governments have the unique responsibility of designing and implementing quality training programs and creating conducive working conditions. Local academic institutions are critical partners in the design of training and retraining programs that meet national and international standards and in providing evidence-based policy and program options to decision makers and program leaders. The organized private sector should provide financial, technical and logistics assistance toward national and local efforts on increasing the availability of a skilled health workforce. It is also important for national governments to create alternative and simplified mechanisms for delivery of services, especially in remote and resource-challenged environments, while pursuing long-term training programs.


The race is on to meet internationally agreed upon targets for achieving universal access to H.I.V./AIDS preventive treatment, care and support worldwide by 2010. Africa faces major challenges that could prevent the continent from joining the rest of the world in meeting the international targets of 2010. These challenges are not insurmountable. The United Nations General Assembly in June 2006 committed the international community to supporting nationally driven strategies and programs to meet the universal access target to H.I.V./AIDS prevention, treatment, care and support by 2010. Africa will be a proving ground for this international commitment.

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