By Thomas Goliber
(July 2002) The HIV/AIDS epidemic in Africa is often described as a crisis that demands the same kind of mobilization and response that would be necessary were a country at war. Analogies are often drawn with the liberation struggles that freed much of Africa from colonial rule. Yet, the political response to the HIV/AIDS epidemic has been, and remains, inadequate, although a dramatic trend toward a more favorable political environment has emerged in just the past few years.
Avoidance vs. Commitment
Throughout the 1990s, a pervasive silence surrounded the HIV/AIDS epidemic in sub-Saharan Africa. At an individual level, this silence meant that many adults were not finding out their own sero-prevalence status, were not recognizing the risks involved in certain sexual behaviors, and were continuing to engage in risky sexual practices. At a cultural level, the silence has meant limited public and private discussion on HIV/AIDS and the continued stigmatization of those who are HIV-infected. At the public policy level, the silence meant that African political leaders were slow to recognize the crisis nature of the epidemic and to formulate a national resolve to use all available resources to address the emergency.
Uganda is an example of the importance of political commitment and resolve in addressing the HIV/AIDS epidemic. The East African nation of some 24 million people is perhaps the only country in sub-Saharan Africa that witnessed a steady decline in adult HIV prevalence throughout the 1990s. While prevalence estimates lack precision, adult prevalence is estimated to have dropped from about 14 percent around 1990 to 5.0 percent today.1 It is reasonably clear that significant changes in sexual behavior led to this decline, although what is more difficult to determine is exactly what interventions helped to bring about the behavior change.2 One universal answer, however, is that the leadership provided by President Yoweri Museveni and other national figures led to an openness about the epidemic and to an effective programmatic response.
Why the political silence elsewhere on the continent in the face of such a crisis? Cultural and religious taboos have inhibited open discussion about an epidemic that spreads mainly through sexual contact. Part of the answer also lies in the invisible nature of the HIV/AIDS epidemic itself. Because of the long lag between HIV infection, development of AIDS, and death, the consequences of the epidemic are not immediately felt. Even today, most Africans who have HIV are not aware of it. For a long time, it was difficult for African governments, pressed with many immediate and daunting problems, to come to terms with an epidemic whose consequences lay primarily in the future. Now, as the brunt of disease and death from infections earlier in the 1990s hits Africa, the epidemic becomes more visible by the month. (Because Uganda had one of the earlier epidemics on the continent, it also experienced rising AIDS mortality earlier than other countries. Some analysts believe that increasing AIDS mortality was a catalyst for changing sexual behavior in Uganda.)3
A lack of political stability in some African countries has also contributed to the failure to generate an effective public sector response to HIV/AIDS. The World Bank reported that in 1999, one out of every five Africans lived in countries that were severely disrupted by wars or civil conflicts.4 How could countries such as Burundi or Congo be expected to mount an effective response to HIV/AIDS in the face of protracted civil war and lawlessness? Quite the opposite, roving armies, refugees, and other migrating populations have fed the epidemic.
The World Bank also reported that about two-thirds of African states, while not undergoing violent conflict and state disintegration, were caught in a “low-level equilibrium of poor institutional capability and ineffective economic transformation.”5 In this environment, these states have had a difficult time mobilizing a strong and comprehensive response to HIV/AIDS. Military regimes with little interest in health or development governed giant Nigeria for much of the 1990s. Zimbabwe, despite suffering from one of the worst HIV/AIDS epidemics in the world, has been in a downward economic and political spiral for much of the 1990s and has failed to develop a strong policy or programmatic response to HIV/AIDS. Kenya, at one time one of the promising African states, has witnessed institutional decay, economic mismanagement, internal violence, and declining donor support for many years.6
While the political and economic environments have contributed to the inadequacy of the political response, they are far from the only factors related to high prevalence. Botswana has been one of the most stable, politically open, and economically prosperous African states. That Southern African nation is also undergoing what is perhaps the worst HIV/AIDS epidemic in the world. UNAIDS estimates that a staggering 39 percent of adults 15 to 49 years old in the country have HIV.7
Response From Leaders
Apart from external political and economic circumstances, African political powers have often not provided good leadership on HIV/AIDS. For example, South Africa is by far the most powerful and influential of the African states, and its leaders are in a position to influence political thinking across the continent. President Thabo Mbeki, however, has spent a considerable amount of time on fringe debates, including one over whether HIV is really the cause of AIDS. For a long time, he also blocked use of antiretrovirals to prevent mother-to-child transmission on the grounds — and in contrast to existing scientific evidence — that their efficacy had not been established. (The South African courts have lately ruled, however, that pregnant women with HIV who are under state care are entitled to drugs that help reduce mother-to-child transmission.)8
More recently, many governments, either of their own volition or under pressure from the international donors and lenders, have accepted a prominent role for nongovernmental organizations (NGOs) in HIV/AIDS activities in what is called a multisectoral approach. Such an approach requires all sectors of society — government institutions, the profit-making private sector, NGOs, and faith-based institutions, for example — to be fully engaged in mounting a truly effective response to HIV/AIDS.
Since 1999, there have been signs that the political response in Africa to the HIV/AIDS epidemic has been changing with marked rapidity. A series of international meetings has highlighted HIV/AIDS and African development and has significantly heightened the environment for national governments to respond to the epidemic.
Significantly, in July 2000, the XIII International AIDS Conference in Durban, South Africa, became the first international AIDS conference to be held on African soil, and it received enormous international and pan-African coverage. That same year, the Organization of African Unity (OAU) — which has now been transformed into the 53-member African Union — included HIV/AIDS in its Summit in Togo. Later in 2000, the United Nations Economic Commission for Africa (UNECA) organized an African Development Forum in Addis Ababa that was attended by senior government officials and devoted exclusively to HIV/AIDS. In April 2001, African leaders met at the Abuja Summit in Nigeria and produced a Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases as well as a Framework Plan of Action in which they resolved to accord HIV/AIDS the highest priority in national development and to significantly increase health budgets.
Also, several African leaders, including President Olusegun Obasanjo of Nigeria, President Daniel arap Moi of Kenya, and President Benjamin Mkapa of Tanzania, attended the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS in New York in June 2001 and pledged intensified action against HIV/AIDS across the continent. One year later, following the XIV International AIDS Conference in Barcelona, the wives of 18 African presidents met at a UN-sponsored gathering in Switzerland to discuss ways of convincing their governments to do more to fight the epidemic.
Overall, important events have transpired over the past few years that are rapidly changing the HIV/AIDS political landscape in Africa, and major steps have been taken to break the political silence on HIV/AIDS in a relatively short time.9 A window of opportunity now exists to build and consolidate the political backing needed to deal with HIV/AIDS. But it is a window of opportunity that can also close quickly, especially given world attention to the post-September 11th campaign against terrorism.
- The Ugandan sentinel surveillance system has not been designed over time to be representative of urban and rural areas and all sections of the country. Accordingly, it is difficult to make estimates of national HIV prevalence, especially for earlier years in the epidemic. The estimates given here are consistent with those prepared by the STD/AIDS Control Programme, Ministry of Health. In turn, the STD/AIDS Control Programme bases its estimates on a series of sentinel surveillance reports, the most recent of which is HIV/AIDS Sentinel Surveillance Report, June 2001 (Kampala: STD/AIDS Control Programme, Ministry of Health, 2001). See also UNAIDS, Report on the Global HIV/AIDS Epidemic: July 2002 (Geneva: UNAIDS, 2002).
- See, for example, Rand L. Stoneburner and Manuel Carballo, An Assessment of Emerging Patterns of HIV Incidence in Uganda and Other East African Countries. Final Report of Consultation for Family Health International, AIDS Control and Prevention Project (AIDSCAP) (Geneva: International Centre for Migration and Health, 1997); UNAIDS, HIV Prevention Needs and Successes: A Tale of Three Countries. An update on HIV prevention success in Senegal, Thailand and Uganda (Geneva: UNAIDS, 2001): 1-3; Sam Okware et al., “Fighting HIV/AIDS: Is Success Possible?” Bulletin of the World Health Organization 79 (2001): 1117-18.
- Stoneburner and Carballo, An Assessment of Emerging Patterns of HIV Incidence in Uganda and Other East African Countries: 51-54.
- World Bank, Can Africa Claim the 21st Century? (Washington: The World Bank, 2000).
- World Bank, Can Africa Claim the 21st Century?
- World Bank, Can Africa Claim the 21st Century?
- UNAIDS, Report on the Global HIV/AIDS Epidemic: July 2002. Despite exceptionally high levels of HIV prevalence, there has not been sufficient analysis of the HIV/AIDS epidemic in the small southern African countries. Most of the co-factors that contribute to high levels of prevalence in the African AIDS belt exist in Botswana. Of note, Botswana has traditionally sent large numbers of workers (mostly male) to work in South Africa, including the mines. This has resulted in long periods of partner separation and exposure to high-risk sexual situations for many in Botswan. Botswana is largely ethnically homogeneous and most of the population lives in a small corridor of the country that is well connected by good transport. These are conditions that facilitate the rapid spread of HIV.
- Henri E. Cauvin, “South African Court Orders Medicine for HIV-Infected Mothers,” New York Times, Dec. 15, 2001.
- See, for example, Peter Piot and Awa Marie Coll Seck, “International Response to the HIV/AIDS Epidemic: Planning for Success,” Bulletin of the World Health Organization 79 (2001): 1006-7.
Thomas Goliber is a senior fellow at Futures Group International, an international development organization headquartered in Washington, D.C. and Bath, United Kingdom. He is a reproductive health policy specialist with expertise in sub-Saharan Africa, a region where he has been working for more than two decades.
This Publication first Appeared in www.prb.org in 2002