Introduction
When humans are faced with threats they become inventive. There is particularly rapid scientific development during periods of conflict and tension. The Second World War gave us radar, jet engines and the atom bomb. The Cold War led to the development of satellites and, eventually, GPS systems. In the 1960s the United States’ Department of Defense work on getting computers to talk to each other paved the way for the Internet.
Health threats too can lead to innovation, as was seen in the response to HIV. In 1981 the first cases of this frightening, unique, new disease were identified at a time of complacency about progress in health. The development of antibiotics in the 1940s and introduction of mass immunisation programmes in the 1950s and 1960s greatly improved global health. In 1977 the World Health Organization (WHO) was able to announce the elimination of smallpox, the first disease to be eradicated. Polio was confined to sporadic outbreaks in remote areas, and there was significant progress in understanding and combating cancer (Mukherjee 2011). Globally, life expectancy was climbing steadily, although challenges such as malaria and malnutrition remained. AIDS, the acronym for the Acquired Immune Deficiency Syndrome, burst this bubble.
As the number of AIDS cases rose exponentially there was a period of confusion, blame and denial. There was also rapid and unprecedented global mobilisation and scientific progress. The causal retrovirus, the Human Immunodeficiency Virus (HIV), was identified in 1983. An understanding of how it operated, modes of transmission and disease progression followed quickly. However in the last 30 years, despite progress, AIDS has thrown into stark relief critical questions about the meanings of health, equity and how we value lives.
In this debate I will discuss the key challenges we face in HIV and AIDS in 2015. My perspective is that of an economist who lived and worked in the heart of the epidemic, and has over 25 years’ experience writing on and researching the disease. The issues I address include: changing perceptions of HIV and AIDS; issues of prevention and treatment; financing for the response; and the need to understand fundamental drivers of HIV. Each is controversial. I begin with a brief history of the epidemic.
A (very) short history of the epidemic
In the 1980s AIDS grabbed media attention. It was incurable, a horrible way to die, and a number of high-profile people (Magic Johnson, Arthur Ashe, Rudolf Nureyev and Rock Hudson to name but a few) were among those first affected. Science swung into action; driven, it must be acknowledged, by extraordinary activists who were mainly gay men. Their anger and outrage mobilised attention to the disease, an exceptional event in a field dominated by medical sciences, public health and epidemiology. Understanding what caused the disease, how the virus worked, how it was transmitted and developing treatment were priorities.
By 1985 it was apparent that HIV was not confined to men who had sex with men (MSM) in primarily the major western cities. In Thailand there were significant numbers of cases among commercial sex workers (CSW) and their clients. In Eastern Europe, particularly Russia and Ukraine, infections were seen in intravenous drug users (IDU) and their partners. AIDS was reported from a growing number of African countries, Uganda and Senegal among the first to admit they faced a problem. Everywhere there was a concern that HIV had the potential to spread among general populations, defined as adults aged from 15 to 49, without the specific risk profiles of MSM, CSW or IDU (Fowler 2014). It was further recognised mothers could transmit the virus to their infants, and identifying methods for prevention of mother-to-child transmission was a priority.
In 1987 the WHO established the Global Programme on AIDS, primarily to assist developing countries in the creation of national responses – initially through Short Term, then Medium Term Programmes, known as STPs and MTPs. By the 1990s it was apparent the epidemic would be contained in most rich countries, but it remained uncertain as to what would transpire elsewhere.
This was happening in a context where health was moving up the global political agenda. This began with the Alma Ata Declaration, adopted at the International Conference on Primary Health Care in September 1978, which called for urgent action by governments, health and development workers, and the world community to protect and promote the health of all. This recognised access to health care was a human right. The World Bank's 1980 World Development Report endorsed the ideas of health care as a human right and committed to primary health care, however the Alma Ata Declaration did not have much impact outside the health sector, although it did set revolutionary foundations for thinking and policy.
Critically important in the evolution of health care thinking was the 1993 World Development Report Investing in Health. This was published as the HIV epidemic took off in much of Africa and was both positive and negative. Under the subheading ‘Why health matters', the report stated: ‘Good health, as people know from their own experience, is a crucial part of well-being, but spending on health can also be justified on purely economic grounds. Improved health contributes to economic growth … ’ (World Bank 1993, 17). This gave reason for investing in health. At the same time it was based on neoliberal and neoclassical principles such as the introduction of user fees, decentralisation and privatisation, all of which were later shown to be controversial. This was also the report where the concept of Disability Adjusted Life Years was unveiled as a way of measuring the economic burden of disease.
In 1996 in Geneva, UNAIDS, the new agency charged with coordinating the United Nations’ response to the epidemic, began operations. It argued for comprehensive responses to AIDS, and that these multifaceted (social, economic, behavioural, developmental, medical) responses had to reach beyond ‘health’. This approach did not last. At the XI International AIDS Conference in Vancouver in the same year, the development of effective drugs to treat AIDS was announced. The medical discourse became dominant again, although the initial price of US$12,000 per person per year meant treatment was confined to patients in the wealthy world. In 1996 there was $300 million available for HIV/AIDS in low- and middle-income countries, enough money to treat just 25,000 patients at the prevailing prices (and do nothing else).
In 2000 the Millennium Development Goals (MDGs) were established following the Millennium Summit of the United Nations. Goal six was specifically to combat HIV/AIDS, malaria and other diseases. In the same year the UN Security Council passed Resolution 1308, stating ‘the HIV/AIDS pandemic, if unchecked, may pose a risk to stability and security.’
The theme at the International AIDS Conference in Durban in 2000 was ‘Breaking the Silence'; this covered ‘silences’ on access to treatment and care; prevention of HIV transmission; governmental and private-sector support of education and resources; human rights; access to appropriate and meaningful information; and support for people living with HIV (The Body 2001). Health and especially AIDS was firmly on the agenda, including in South Africa (despite the denialism of Thabo Mbeki, the country's president at the time).
In 2001 the WHO released the report of the Commission on Macro-Economics and Health (CMH) (WHO 2001). It argued: ‘Improving the health and longevity of the poor is an end in itself, a fundamental goal of economic development. But is also a means to achieving other development goals’ (Ibid., emphasis in the original). Its third key finding (of ten) was: ‘The HIV/AIDS pandemic is a distinct and unparalleled catastrophe in its human dimension and its implications for economic development. It therefore requires special consideration’ (Ibid., 16). There were extensive critiques of the work and underlying ideology. For example, Katz wrote: ‘Clearly the era of hidden agendas is over. The purpose of the CMH report is explicitly to promote and legitimize corporate-led globalisation of capitalism’ (Katz 2005). However, there was incontrovertible increased global attention to health and AIDS was one of, if not the, key driver of this.
Health was not just desirable on an individual and national economic level, but the absence of health (and the AIDS epidemic) was seen as a threat to development. This was evidenced when, in 2003, the UN Secretary-General Kofi Annan established The Commission on HIV/AIDS and Governance in Africa, with its secretariat at the Economic Commission for Africa. I was a member of this Commission and our task was to clarify the impact of HIV/AIDS on state structures and economic development, and examine design and implementation of policies and programmes to govern the epidemic.
The rhetoric was, unusually, matched by resources. In 2001 Annan called for spending on AIDS to be increased tenfold in developing countries, and the Global Fund for AIDS, TB and Malaria was established. In 2003 US President George W. Bush pledged $15 billion toward the Presidential Emergency Program for AIDS Relief (PEPFAR), and the WHO launched the ‘3 × 5’ campaign to have 3 million people on treatment by 2005.
The first decade of the new century saw an unprecedented increase in funding. According to the Kaiser Foundation, at the peak, in 2011, HIV assistance commitments were $8.8 billion, falling to $8.3 billion in 2012 and $8.1 billion in 2013 (Kates, Wexler, and Lief 2013). Although the amount of new money decreased, disbursements, the amount of money being ‘moved out of the doors’ of agencies, was at the highest recorded level in 2013. The cost of drugs plummeted dramatically, falling to US$115 per person per year for first-line antiretroviral therapy (ART) (WHO 2014a). As a result the numbers on treatment rose rapidly and, at the end of 2013, stood at 11.7 million people in low- and middle-income countries.
The environment in which AIDS was spreading, being responded to and being funded was complex. The IMF and World Bank influence on domestic policies meant there were simply no new domestic resources because tax bases were not growing (Rowden 2009, 2010). At the same time, the sheer cost of the disease meant foreign assistance was essential if prevention and treatment programmes were to be put in place. The confluence of neoliberalism and the spread of HIV were unfortunate in the extreme.
The challenges to the HIV and AIDS response
In 2015 there are significant challenges facing those working in and on HIV and AIDS. Some are new while others have been brewing for the past decade and more. We know where the disease is located, how it is transmitted, and have a good idea of the numbers that are and will be infected. The doomsday scenarios of 1990s, fears of uncontrolled spread and that, in the worst affected countries, it would lead to economic collapse and political implosion, have not come to pass. However, AIDS has not gone away. The remainder of the debate addresses the key challenges. Table 1 provides selected data for a sample of the worst affected countries and helps illustrate the issues.
| Country | Adult HIV prevalence 2011 (in %) | Actual per capita govt health exp. 2011 in US$ | External funding as % of total health exp. 2011 | External HIV funding as % of total HIV exp. 2011 |
|---|---|---|---|---|
| Botswana | 23.4 | 263 | 9.2 | 23 |
| Kenya | 6.2 | 14 | 38.8 | 81 |
| Lesotho | 23.1 | 105 | 25.2 | 51 |
| Malawi | 11.0 | 23 | 52.4 | 99 |
| Mozambique | 11.2 | 15 | 69.8 | 97 |
| South Africa | 17.8 | 329 | 2.1 | 12 |
| Swaziland | 26.5 | 184 | 19.4 | 59 |
| Uganda | 7.2 | 11 | 27.0 | 87 |
| Zambia | 13.0 | 52 | 27.2 | 85 |
Adult HIV prevalence ranged from 6.2% in Kenya to a shocking 26.5% in Swaziland. The actual per person government health expenditure is, in some settings, much lower than the cost of AIDS treatment. In Uganda in 2011 the government was only spending $11 per person per year and the country is heavily dependent on donors. By contrast South Africa's per capita expenditure was $329, and here external funding accounted for just 2.1% of the health budget. The percentage of HIV and AID funding from external sources is larger, reaching 97 and 99% in Mozambique and Malawi respectively.
Many countries face what UNAIDS has called the ‘AIDS dependency crisis’, the situation where countries are reliant on external funds (UNAIDS 2012b). However, this dependency is more than financial. There is an erosion of state sovereignty. Citizens are reliant on external governments and agencies for the drugs that keep them alive. Their governments have no choice but to accept even though the programmes may distort their priorities (Šehović 2014). The thoughtful analysis by Rowden into why governments are, and feel, hampered in increasing public expenditure, points to a dominant development model promoting policies that work against building up strong health systems (Rowden 2010). It is against this background that we now turn to the challenges.
Challenge 1. Keeping AIDS on the agenda
AIDS is no longer a discourse-defining health emergency. It is not a global issue. In wealthy countries, and most of Latin America, North Africa and the Middle East, the epidemic is concentrated and stable. This means HIV prevalence is below 1% in the general population. It may exceed 5% in specific ‘at-risk' populations but, as will be discussed, these are people on the margins. In Asia the feared extensive epidemic has not materialised.
This raises the issue of who is infected and how much of a voice they have. In most of the world the epidemic is primarily located in ‘at-risk’ groups: socially and politically marginalised populations including injecting drug users, men who have sex with men, and commercial sex workers. AIDS is generally worst in areas on the global margins whether they be geographic, social or political.
There are places and populations where HIV must be a priority. Two-thirds of global HIV infections are in sub-Saharan Africa. Here the worst epidemic is in east and southern Africa where between 5% and 30% of adults are infected. Of the estimated 21,800,000 million people living with HIV here, 12,800,000 are women (UNAIDS 2014a). In Africa, particularly women and especially younger women are most likely to be infected. Gender relations are such that violence against women is common. This ranges from ‘corrective rape’ to physical and psychological abuse. In 2013 the WHO released its estimates of violence against women (WHO 2013). When data for intimate partner violence (IPV) are grouped by the regions used for Global Burden of Disease (BOD) assessments, the highest prevalence is in central sub-Saharan Africa. Here 65.6% of ever-partnered women have experienced IPV. All of sub-Saharan Africa is above the global average of 26.4%. In Western Europe and North America the rates are 19.3% and 21.3% respectively.
Gay men and drug users are discriminated against, criminalised and targeted in many countries. Legislation against homosexuality was inherited in much of Africa, but rather than repealing or at least ignoring it, some countries have introduced new and more restrictive laws. Drug use is criminalised across Africa. In only two African countries is sex work legal and regulated – Senegal and Côte d'Ivoire (Wikipedia 2014). Those bearing the burden of AIDS have the least voice and seeking help or identifying need may result in prosecution and persecution. In addition, despite the higher prevalence in these groups, there is, at best, an attitude that they are not important and deserving of services, and at worst the view that they ‘deserve it’ for ‘unnatural’ and immoral practices.
Keeping AIDS in the spotlight is made more difficult because internationally health is no longer a priority. Of the eight MDGs three are directly related to health, and goal six was specifically to combat HIV/AIDS. Post-2015 there will be 17 sustainable development goals (SDGs) and 169 targets. Only SDG number three mentions HIV/AIDS, and it is just one of the targets within the goal.1 Economic development and growth, and environmental sustainability are the dominant themes. The first SDG is to ‘End poverty in all its forms everywhere’ (UN 2014). This switch of focus is partly a function of attention spans, but also reflects the new challenges humankind faces. Global environmental change is, correctly, very high on the international agenda.
Even within the health sector there are other issues competing for consideration. The BOD study shows in 1990 the top three causes of BOD were lower respiratory infections, diarrheal disease and preterm birth complications. In 2010 they were ischemic heart disease, lower respiratory infections and stroke (Institute for Health Metrics and Evaluation 2014). In 2011 the United Nations held the first high-level meeting on non-communicable disease prevention and control. These diseases are more relevant to both global populations and leaders than infectious diseases generally and AIDS specifically. The possible exception is Ebola (Quammen 2014). In the second half of 2014 the world was gripped by the emergence of Ebola in southeast Guinea and its subsequent spread to Liberia and Sierra Leone. The WHO declared an ‘international public health emergency’ in August 2014, with the US-based Centers for Disease Control (CDC) warning that ‘the Ebola outbreak in West Africa is unlike anything since the emergence of HIV/AIDS’ (BBC 2014). By early 2015 it seemed that Ebola was under control. It is ironic that the lack of HIV in these countries may have partly led to an unpreparedness that is ‘a direct consequence of years of insufficient public investment in underlying public health infrastructure’ (Rowden 2014).
Finally, it is ironic that the availability of treatment has compounded the perception that the epidemic is over. There is a view that people who are infected can simply take drugs (this generally involves just one pill a day, similar to hypertension or statins, not the complex multi-tablet regimens that were the case), and live regular healthy lives.
Challenge 2. The prevention: treatment tension
In the absence of treatment, an HIV-infected person can expect to live for between 8 to 12 years. They will experience periods of illness that increase in severity, duration and frequency until they die. The advent of antiretroviral therapy changed this. Today a person receiving and adhering to early treatment will have a near-normal life span (UNAIDS 2014b).
In recent years incontrovertible evidence has emerged that a person on treatment is extremely unlikely to infect any one with whom they have sex. Treatment prevents HIV transmission. The HPTN052 trial showed a 96% reduction in new infections in couples where the infected individual was taking antiretrovirals (ARVs) (Cohen et al. 2011). In KwaZulu-Natal each 1% increase in treatment coverage gives a 1.1% decrease in HIV incidence (Tanser et al. 2013).
Other biomedical prevention interventions are medical male circumcision, condoms and microbicides. Circumcision is a one-off intervention which, in trials, showed a 60% reduction in transmission. This intervention brings its own challenges: how to ensure uptake; the risk that men, thinking they are protected, might be complacent; and the fact that it protects men not women. Condoms are a barrier protection, but making sure they are used consistently and correctly is critical. Microbicides have limited effectiveness and are relatively new.
Behaviour change interventions such as reducing the number of partners, using condoms properly, delaying sexual debut and so on are all critically important. At the moment available evidence suggests they are less effective, complicated, require individual and societal change and may be costly. These interventions are not easily evaluated by science's gold-standard randomised control trials. Some would argue that it is easier to simply treat those who have the misfortune to become infected, intervening when they are identified and perhaps even seeking them out.
The current WHO guideline is that ARV treatment should be initiated once a patient's CD4 count falls below 500 cells per cubic millimetre of blood. Pregnant women should be placed on therapy for the rest of their lives, as should the infected individual in discordant couples, those with active TB, and HIV+ children (WHO 2014b). There is pressure from a number of health professionals and activists for all infected people to be put on treatment as soon as they are identified. It is believed the earlier HIV-infected people get treatment, the better they will do. The evidence of prevention benefits is seen as the clinching argument. The view of this camp is we have the drugs, so all we need to do is fund the roll-out.
This prevention: treatment dichotomy should not be a debate, but it is, as prevention is often put in opposition to treatment. A basic public health tenet is prevention is better than cure. We would prefer people to never start smoking and not become obese, rather than have to deal with long-term health consequences of these behaviours. It is exactly the same with HIV. The challenge is to put behavioural prevention back on the HIV and AIDS agenda, make sure it is given the priority it deserves and the resources it needs.
One way is to point to the costs. Treatment is expensive and for life. The July 2014 Médecins Sans Frontières report on prices put the average cost of drugs alone, for first-line treatment, at $136 per person per year (Médecins Sans Frontières 2014). The UNAIDS 2011 estimate of the average annual per patient cost was $177 for established patients and $354 for newly initiated patients (UNAIDS 2014b). The long-term nature of the disease can be illustrated by thinking of a young adult infected in 2014. That individual will need treatment by 2022 (or before) and can expect to live, taking drugs until 2054, assuming a conservative 60-year life expectancy.
Mead Over, of the Center for Global Development in Washington, DC, developed the concept of the AIDS Transition. Put simply:
The rate of new infections outpaces the rate of AIDS related deaths,2 the number of people living with AIDS – and therefore the number of people needing treatment – is growing faster than the funding needed to treat them. … Only by sustaining recent reductions in mortality and bringing down the number of new infections will the total number of people with HIV finally decline. (Over 2011, 1).
Challenge 3. Funding the fight
There is a gap between what is available and what is required. The UNAIDS Smart Investments document states:
… despite the leadership shown by low and middle-income countries, the US$18.9 billion available for HIV programmes in 2012 was well below the target of $22–24 billion of annual investment required in 2015 set forth in the 2011 United Nations Political Declaration. (UNAIDS 2013b)
The size of the international contribution is significant for two main reasons. Firstly, it gives rise to a mindset of dependence. A Results for Development review of 12 PEPFAR countries noted, ‘deeply ingrained perceptions by finance and other senior government officials that “donors will take care of the AIDS programme”, as indeed donors have done over the past decade’ (Results for Development Institute 2013, 1). This observation, linked to the lack of voice of the majority of HIV-infected people, may give rise at best to a shortage of domestically raised resources and, at worst, a lack of response and abnegating of responsibility in some countries.
Furthermore, as discussed above, there may be imposition of donor-determined strategies and priorities that do not reflect local needs or conditions. A prime example was the abstinence ‘earmark’ in the PEPFAR funding. An economic ‘golden rule’ is ‘the people who have the gold make the rules.’ Even if the donor does not impose on the recipient country, they may write their proposals in order to satisfy the donor or, even more insidiously, what they believe the donor wants.
The cost of treatment could be crippling in some high-prevalence countries. Writing in 2014, Wilson and Fraser said: ‘application of current costs to estimates suggests that initiating treatment at a CD4 count of 500 cells/µL could equal South Africa's entire health budget and ‘treatment as prevention’ (TasP) could equal 10% of Nigeria's health budget’ (Wilson and Fraser 2014, S30). The South African national health budget in 2012–2013 was R27.5 billion; the cost of putting everyone with a CD4 count of 500 or less on treatment would be R35.5 billion. Treatment for all would cost R43.5 billion. Clearly this is unsustainable in high-burden countries.
The funding of the response in Africa varies. In general there is a good understanding of funding flows, shares and needs. There is work and analysis being carried out by, among others, the World Bank, UNAIDS, Results for Development, the Clinton Health Access Initiative and the Economic Reference Group of the World Bank and UNAIDS. In a few richer countries, domestic resources cover the majority of the costs with some supplementation by international donors. This is far from the norm. In most settings external funding covers the bulk of the HIV budget. The proportion of the financial contributions by national governments and donors varies and depends on domestic availability of funding, international commitments and the size of the resource gap in each country. There is an indication of this in Table 1.
The challenge is to ensure sufficient sustained funding from all sources. This is becoming increasingly difficult as the numbers on treatment increase and international development assistance declines. The mantra of ‘value for money’ is increasingly heard. Resources must be spent in the best possible manner. Linked to this are the macro-economic policies. If economies can grow then there is more potential for taxes, and a critical constraint is removed. However, then the challenge is to allocate more to health, and often, even before this is done, to make sure health money is spent.
Challenge 4. Understanding the drivers of the epidemic
Why is Africa the worst affected continent? Why does Lesotho have an adult prevalence rate of 22.9% while in Angola it is 2.4% and in Ethiopia just 1.2% (UNAIDS 2014b)? There have been various attempts to answer this – ranging from the distinguished scholar of Africa John Iliffe to my own work (Iliffe 2006). These range from arguing for biological factors, and social, political and cultural factors. The subtype of the virus, the genetics of the population and the interplay may be partly a cause. Not all southern African tribal groupings circumcise, a proven protector. The brutal history of the region with the repressive exploitative colonial regimes, especially in Mozambique, the illegal Rhodesian government and apartheid in South Africa, all created fertile ground for the spread of the virus. This was well documented decades ago for syphilis in a seminal paper by Sidney Kark (1949). What Kark described in the 1940s was just as relevant up to the end of the minority rule, and indeed the militarisation and conflict of the 1970s and 1980s all contributed further to the spread of HIV.
Those were the drivers of the spread of HIV. Today, while the governments are for the most part democratic and accountable (there are exceptions – Swaziland, the last absolute monarchy, is one), there are still critical drivers. Urbanisation means more people are living in cities, often in squalid conditions. There is a crisis of formal employment; young men especially find themselves without incomes and a role in the world (this is not just a problem in Africa, of course). In 2015 in a globalising world the challenge is to get to grips with the links between poverty, inequality and health. In a comment in the Lancet and University of Oslo Commission on Global Governance and Health, Charles Clift notes that ‘the essential point is that globalisation has promoted growth but exacerbated inequality. Inequalities in power and economic status drive poor health outcomes for those at the bottom of the pile' (Clift 2014). This is magnified in the case of HIV and AIDS.
The relationship between poverty, inequality, marginalisation and HIV was the focus of the Structural Drivers meeting in Cape Town in 2013. In January 2014 UNAIDS and the World Bank convened a meeting to discuss HIV and AIDS, and global health and development agendas. Under the title ‘Action on Social Drivers to End AIDS', the meeting programme noted ‘social, economic and legal disadvantages increase vulnerability to HIV, worsen the epidemic's impact and undermine the effectiveness of biomedical tools.’ The effects of the epidemic are entangled not only with social drivers but also with other diseases, especially TB. There is no bandaid fix; this will take decades, social change and possibly even revolution, to address the causes of the HIV epidemic.
Unfortunately, while ART is lifesaving, there is an increased risk for many non-communicable diseases in HIV patients compared with age-matched uninfected people (Frieberg et al. 2013; Schouten et al. 2014). These include cardiovascular disease, non-AIDS malignancies, liver and kidney disease, and osteoporosis. Questions about how the health sector will respond, be prioritised and be funded remain to be addressed.
A critical part of the complexity is the long-term nature of the epidemic. The epidemic has been growing and evolving over more than 30 years. The evidence is that, despite the many interventions, the response in parts of Africa and certainly in southern Africa has been insufficient. Furthermore, even where prevalence and incidence rates are low, long-term commitment must be maintained to ensure transmission rates stay close to zero.
The consequence of HIV infection is illness and death, unless people receive treatment. The mortality shows up in various international indicators from life expectancy to maternal mortality. Two examples show this. Swaziland's life expectancy rose steadily from 46 at independence in 1968 to a peak of 58.98 in 1992. As a result of the AIDS epidemic it fell precipitously to 45.74 in 2004 and had only climbed to 48.85 in 2012 (World Bank 2014). South Africa's maternal mortality rate rose from 230 deaths per 100,000 live births in 1990 to a shocking 410 in 2008, far above the 2015 target of just 58 (WHO 2012). It is quite baffling that the cause of this deterioration in indicators is not explicitly recognised as HIV. The stigma of this epidemic still, it seems, extends to the data. In turn it means politicians and policy makers have manifestly failed to get to grips with the causes and consequences of the epidemic, the greatest challenge Africa has faced in the last 30 years.
Conclusion: the politics of HIV and AIDS
Health and therefore HIV and AIDS are no longer high on the global agenda.3 This is understandable; there are many new and pressing concerns. There is a need for careful strategising around the epidemic to ensure resources are available. One key way to do this will be to show that the needs are time-bound – that prevention is working and treatment will not consume an ever-increasing share of the money.
The scientific advances and increased funding are astonishing. Commitments have come from Africa. In 2001, the Abuja Declaration bound African heads of state to allocate at least 15% of their annual budgets to the health sector by 2015. Although this target has not been achieved, progress has been made. At the Abuja+12 Special Summit, leaders committed to take action towards the elimination of HIV and AIDS, tuberculosis and malaria in Africa By 2030’ (African Union 2013). There is a need to monitor the money and make long-term plans.
The drivers of the epidemic talk to development, equity and equality. In the early years of the epidemic we saw HIV as a lens through which we could see the fractures and schisms in society. This is as true now as it was then. The HIV epidemic is a long-wave event that will need to be managed for decades, even once numbers start falling and it is no longer considered an emergency anywhere. There are few other examples of things to be considered on the same scale as this epidemic (global environmental change is one). The timeline for dealing with it is therefore far longer than most governments, politicians, strategists and donors are willing to consider, even in their ‘long-term’ plans.
Health and development is ultimately political. The HIV epidemic showed this up starkly. The challenges for those concerned with this are to keep the epidemic on the agenda – and recognise that it has slipped off it; ensure sufficient resources are available – and that they are spent in the best possible ways; face the apparent conflict between treatment and prevention – and show they are complementary but in the long term prevention (which may be treatment) is essential; and finally understand what drove the epidemic – at a social but also personal level. The response to AIDS will driven by political economy questions. This is, above all, an epidemic that is crying out for deeper and better political analysis, and this special issue is an important beginning.