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date: 15 September 2019

HIV and AIDS in Africa: Global Politics and Domestic Consequences

Summary and Keywords

AIDS is a new disease that was first recorded in 1981. In the 1980s and early 1990s, there were concerns that it would decimate populations; prevention was slow to take hold, and there was no cure. By the mid-1990s it was clear, in the developed world, that it would be mostly contained to specific populations. Effective but expensive treatment was unveiled in 1996. However, in Africa there were fears of a continent-wide epidemic. AIDS emerged in central Africa (HIV1) and west Africa (HIV2) and spread from there. In the 1990s it reached southern Africa, the current epicenter.

It has become evident that AIDS has not meant the collapse of economies and nations or the hollowing out of populations. Treatment options mean people can live normally provided they adhere to the drug regime, but they are costly. The worst epidemic is in the southern cone of Africa. Here it continues to have political consequences, although causality is hard to ascribe.

Unique features of the disease are that the modes of transmission include its geographic location and the excessive involvement of donors in the response; the lack of African ownership makes it a global political problem. At the moment the lives of millions of Africans depend on the generosity of the West, and that future is uncertain. AIDS is a greater challenge to southern and eastern African states than anywhere in Africa and indeed the world. The international engagement particularly in the provision of treatment means the disease has global political ramifications.

Keywords: HIV, AIDS, politics, Africa, development, South Africa, UNAIDS, governance, African politics

The Origins of the Epidemic

AIDS is political. Any disease that involves sex, death, power, and significant amounts of money and that affects some groups and nations more than others inevitably involves both big “P” Politics and small “p” politics. The spread of the disease is determined by a range of factors, including how nations are ruled and interact and how wealth is distributed. Treatment requires resources, and increasingly there will be decisions to be made about access: who lives and who dies. This is political. Indeed, metaphorically, HIV is the water that finds the cracks in society and AIDS is the ice that breaks it apart.

The first harbinger of AIDS was in the Morbidity and Mortality Weekly Report, published on June 5, 1981, by the Centers for Disease Control and Prevention in Atlanta, Georgia. It recorded unexplained clusters of previously extremely rare diseases such as pneumocystis carinii, a type of pneumonia, and Kaposi’s sarcoma, normally a slow-growing tumor (Centers for Disease Control and Prevention, 1981). These infections manifested in serious forms, and, initially, within a narrowly defined risk group—young, homosexual men. The emergence of the epidemic in the West has been well documented in films, in books, and on the stage.1

It soon became apparent that these illnesses were occurring in other definable groups: hemophiliacs, blood transfusion recipients, and injecting drug users (IDUs). By 1982 cases were seen in the partners and infants of those infected. Beyond North America there were reports of similar clusters of cases in Europe, Australia, New Zealand, Brazil, Mexico, Uganda, the Congo, and Senegal.

The name “acquired immunodeficiency syndrome” (AIDS) was agreed on in Washington, DC, in July 1982 (in French it is syndrome d’immunodéficience acquise, or SIDA). The term describes the illness accurately: people acquire the condition; it results in immune system deficiency; and it is a syndrome, not a single disease. Its cause was not immediately apparent, nor were the methods by which it spread or what treatments might be employed. Early cases were treated symptomatically, but most patients were dead within weeks of being admitted to healthcare facilities.

The consensus among doctors and scientists was the cause was a virus. By 1983 this had been isolated and identified by the Institute Pasteur in France, who called it “lymphadenopathy-associated virus” or LAV. In 1987 the name “human immunodeficiency virus” was confirmed by the International Committee on Taxonomy of Viruses. The accepted terminology is HIV for the virus and AIDS for the illness.

HIV is a retrovirus, which means it is slow acting. There may be significant HIV prevalence in a population, but, as there are not immediate, visible illnesses and deaths, people, policymakers, and politicians are not aware of the how far it has spread. HIV is unusual in that it invades and kills the cells of the immune system.

After individuals are infected, they may have years of healthy life, not knowing they are harboring the virus, before illness strikes. During this time there is a constant battle going on in their bodies, and gradually the virus wins. Periods of illness increase in frequency, severity, and duration until the immune system is overwhelmed and the person dies. There is no cure, but drugs can extend lives—provided they are taken consistently.

Science identified two distinct viruses causing AIDS. HIV1, the more aggressive variety, originated in central Africa, probably southern Cameroon. The slower-acting HIV2 had its origin in the west Africa forests. These variants have, in turn, many subtypes. The scientific origin of the epidemic is well described in Goudsmit’s (1997) Viral Sex, while journalist Randy Shilts (1987) documented the first five years of AIDS in the popular And the Band Played On. Shilts was an early victim of the disease, dying in 1994.

AIDS meant people, beyond scientists and epidemiologists, were introduced to the concept of zoonoses, diseases that cross the species barrier from animals to humans. Subsequent examples include severe acute respiratory syndrome (SARS), which first appeared in 2002 and has been linked to civet cats; avian influenza, in 1996, which, as the name suggests, originates in birds; and Middle East respiratory syndrome (MERS), in 2012, which is linked to camels. Ebola, a hemorrhagic fever, has been described as “AIDS on steroids” and is the disease that dominated headlines in 2015 (Whiteside & Zebryk, 2015). First identified in 1976, between 2014 and 2016 Ebola infected at least 28,000 people and killed 11,000 in the west African countries of Sierra Leone, Guinea, and Liberia. It believed to be carried by fruit bats.

HIV is, so far, the most deadly pathogen to have made the leap from animals to humans. It has infected more than 70 million people, of whom about 35 million have died. SARS was, fortunately, not very infectious; avian flu has not (yet) taken hold in humans; MERS outbreaks have been infrequent and controlled; and Ebola has, at the time of writing (late 2018) been contained.

The animal hosts from which the virus spread were chimpanzees for HIV1 and sooty mangabey monkeys for HIV2. This was an immediate challenge in Africa and among people of African descent. In humans the majority of infections are spread through sexual intercourse. When chimps and monkeys were identified as the source of infection, many assumed the implication was that Africans had sex with these creatures, a stigmatizing and demeaning idea and very far from the truth. This was to have far-reaching consequences, notably in the denialism of Thabo Mbeki, South African president from 1999 to 2008.

The likely transmission mechanism was from chimpanzee and monkey blood or saliva to humans during the hunting, butchering, and preparation of “bush meat.” There may have been numerous occasions in which isolated individuals, families, or villages experienced cases of AIDS, but it did not spread into the wider community. It is estimated that the current epidemic, with human to human transmission began in the early 20th century.

A further complication was the identification of AIDS with the homosexual, injecting drug use, and commercial sex work communities in the West. African leaders and their constituencies were (and are), for the most part, extremely prudish and homophobic. Many countries either inherited colonial laws or passed new legislation to make homosexuality illegal. Most denied the existence of sex work in their societies. Drug use was uncommon but also against the law.

Why did HIV spread in Africa and then become a global pandemic? There is no conspiracy (although many look for one); the world was, and is, changing. Colonization and exploitation of Africa provided fertile ground for the spread of disease. The key date was 1884, when Otto von Bismarck, first chancellor of Germany, organized the Conference of Berlin to regulate European colonization and trade in Africa (Dowden, 2008). Within a short time, Africa, with few exceptions, most notably Ethiopia, had been divided up between European nations. The major colonial powers were Britain, France, Portugal, Belgium, and Germany. Belgium, pushed by its King Leopold II, took over a vast area in central Africa, the Congo Free State, and its rule was especially brutal (Hochschild, 1999).

Colonization led to massive social changes. It was exploitative of resources and people. The populations were taxed though poll taxes levied on adults and, in some cases, hut taxes. As a result, men in particular were forced to seek wage employment to pay these taxes. African cities grew rapidly, and this too created massive and rapid social change.

New patterns of sexual contact emerged, including multiple, concurrent partnerships. “Multiple” means more than one partner but can be over a period of time. “Concurrent” refers to when a person has several partners at the same time, for example a migrant worker with a wife at home and one in the city. “Polygamy” refers to multiple concurrent partnering but, provided people are faithful within the family, does not increase risk of disease. There was also increased prostitution and a rise in ulcerative genital diseases. The impact of colonialism and capitalism on sexually transmitted diseases (STDs) was well documented in a classic study of syphilis by Sidney Kark first published in 1949 (Kark, 1949/2003).

The migrant labor system and exploitation of the black population, which reached its zenith in South Africa under apartheid, created the perfect conditions for the spread of STDs. Kark (1949/2003) wrote:

Thus we have on the one hand a set of conditions in urban areas ideal for the spread of syphilis, and on the other hand, a migrant labour force which successfully spreads this urban disease to the rural areas where social conditions are also suitable for its reception.

His work foreshadowed and set out the drivers for the rapid spread of HIV in southern and eastern Africa.

As soon as the virus, and the mechanisms by which it spread, were identified, prevention measures were developed. Most immediate was the provision of safe blood and blood products. The simple actions of reducing numbers of sexual partners, not sharing needles or sterilizing them if they were shared, and using condoms in both heterosexual and homosexual intercourse were shown to be effective preventative measures. HIV can be transmitted from mother to child during pregnancy, birth, or breastfeeding, and interventions (e.g., drugs, formula feeding, and caesarean delivery) were developed to address this. Today, with correct treatment, the risks are minimal.

Developed countries created extensive public education programs. In the United Kingdom, for example, under the Conservative government of Margret Thatcher, cabinet members overcame their distaste for perceived “promiscuous and immoral behaviors,” and every household received a government leaflet with the message: “Don’t die of ignorance” (Fowler, 2014). There is evidence that this, and related programs, such as needle exchange, has had an impact.

The Emergence and Status of the Current Epidemic

HIV spread from central Africa into the Great Lakes region in the 1970s and early 1980s. A significant rise in cases of Kaposi’s sarcoma was recorded in Zambia. In Kinshasa, Zaire (the Democratic Republic of Congo after 1997), there was an upsurge in patients with an unusual fungal infection, cryptococcosis. The Ugandan Ministry of Health was receiving reports of increased and unexpected deaths among young adults in Lake Victoria’s fishing villages.

Unfortunately these cases were primarily reported either by expatriates, such as Wilson Carswell in Uganda, Anne Bayley in Zambia, and Peter Piot in Zaire, or junior local doctors (Piot, 2012; Putzel, 2004). This gave the epidemic deniability: no politician wanted to admit to the spread of a deadly but silent sexually transmitted infection in his country.

The first leader to face the problem openly was Yoweri Museveni of Uganda who had taken power in January 1986. In September of that year Museveni took a personal interest in the epidemic and sought to increase government efforts to combat it. The story is that he did this when he learned that of 60 officers that he had sent to Cuba for high-level military training, 18 (or 30%) tested HIV positive.

South Africa, currently the country with the largest epidemic in the world, faced its own unique demons. The first, sporadic AIDS cases were seen in mostly white, homosexual men in the 1980s. Surveys in the KwaZulu-Natal rural community in 1985, in sex workers in the Transvaal in 1986, and in pregnant women and outpatients in KwaZulu-Natal in 1987 all found no HIV infections (Gouws & Karim, 2008).

The apartheid government was aware of the epidemic and the dangers it posed but its messages had little credibility. Indeed there were rumors in the townships that AIDS had been created, in unspecified laboratories, specifically to kill black people. The exiled African National Congress (ANC) was aware of the possible threat from HIV. At an ANC health conference held in Maputo in April 1990, senior party member Chris Hani warned: “We cannot allow the AIDS epidemic to ruin the realisation of our dreams” (Zeitz, 2007).

During the period from 1990, when opposition parties were unbanned, political prisoners released, and negotiations began, to 1994 when the ANC took power, only lip service was paid to the issue of HIV. It was simply not the main concern.

After 1994 the new government did not prioritize the epidemic. Reasons may have included the stigma associated with AIDS, the fact that so many exiles were returning from countries with high HIV prevalence, and a general distaste for talking about STDs. Nelson Mandela spoke regretfully about this after he stepped down as president. Activist Mark Heywood (2004) wrote:

In an interview with the BBC in 2003 Nelson Mandela admitted that in the 1994 election “I wanted to win and I didn’t talk about AIDS: and that once he was President he “had no time to concentrate on the issue.”

This can be seen against a backdrop of data showing a mounting crisis. In 1990 the first national survey of ante-natal clinic attenders found a prevalence rate of just 0.8 %; by 1994 it was 7.6 %; and when, in 1999, Thabo Mbeki took over as president it had reached 22.4 % (Whiteside & Sunter, 2000). South Africa missed the opportunity to stop, or at least slow, the spread of HIV.

Globally, the early 1990s marked the time of greatest concern about the new pathogen. It was not clear how fast and extensively it would spread. The initial fears of widespread infection in sexually active populations in wealthy countries proved unfounded, but here there were “key populations” of people at greater risk: primarily men who have sex with men (MSMs), IDUs, and, in some locations, sex workers.

The World Health Organization (WHO) was slow to react. In 1986 epidemiologist Jonathan Mann founded WHO’s Global Programme for AIDS, but in March 1990 he resigned in protest over the lack of United Nations (UN) response and the obstructive WHO leadership. In 1996 UNAIDS was established as a separate agency from the WHO, under the leadership of Peter Piot in Geneva, to coordinate the UN and mobilize the worldwide response, tasks that the WHO was mandated, but failing, to do.

Globally the AIDS epidemic is not homogenous. This is also true of Africa. In 2006 UNAIDS and WHO developed four epidemiological scenarios: low level, where HIV has not spread to significant levels in any subpopulation; concentrated, where prevalence is high enough in subpopulations (MSMs, IDUs, and sex workers and clients) to maintain the epidemic; generalized, where HIV prevalence is 1% to 5 % in antenatal clinics attenders and the presence of HIV among the general population is sufficient for sexual networking to drive the epidemic; and hyper-endemic, where HIV is above 15% in adults in the general population (UNAIDS, n.d.).

At the end of the second decade of the 21st century, these scenarios need to be updated for Africa. This is shown in Table 1 for all countries other than those where there is a concentrated, low-level, and stable epidemic: Burkina Faso, Democratic Republic of Congo, Egypt, Eritrea, Libya, Mauritania, Morocco, Niger, Senegal, Somalia, Sudan, and Tunisia.

Table 1. Categorization of African Epidemics and Responses

Country and Category

HIV Prevalence % and Trend

Data Reliability

Total HIV Expenditure ($ ‘000)

Donor Dependence % Resources From Domestic Sources

1. Transitional prevalence 1%–5%

Angola

1.9% rising

Reasonable

20,120

16.4

Benin

1.0% stable

Unknown

22,850

28.1

Burundi

1.1% falling

Good

18,414

1.5

Cameroon

72,549

20.4

Central African Republic

4% falling

Poor

15,784

11.9

Chad

1.3% falling

Unknown

17,632

26.2

Congo Republic

3.1% falling

Poor

16,472

49.1

Djibouti

1.3% falling

Unknown

2,883

9.5

Ethiopia

1.1% falling

Reasonable

351,583

15.5

Gabon

3.6% stable

Unknown

6,452

74

Gambia*

1.7% stable

Poor

3,850

100

Ghana

1.6% falling

Reasonable

92,306

5

Guinea*

1.5% stable

Poor

8,873

7.7

Guinea-Bissau*

3.1% stable

Poor

5,258

11.7

Liberia

1.6% falling

Unknown

31,123

0.61

Mali

1.0% falling

Unknown

21,794

28.1

Nigeria*

2.9% stable

Poor

512,896

11.3

Rwanda

3.1% falling

Good

168,254

NA

Sierra Leone

1.7% rising

Reasonable

20,905

0.8

South Sudan

2.7% rising

Unknown

24,154

9.5

Tanzania

4.7% falling

Reasonable

226,371

47.7

Togo

2.1% falling

Unknown

24,594

8.1

2. Generalized 5%–10%

Equatorial Guinea*

6.2% rising

Poor

8,715

90

Kenya

5.4% falling

Good

1,174,884

29

Malawi

9.2% falling

Good

218,441

2.6

Uganda

5.9% falling

Good

9

13

3. Hyper-epidemic, >10%

Botswana

21.9% stable

Good

390,616

76.6

Eswatini

27.2% stable

Good

96,931

34.2

Lesotho

25% stable

Good

111,570

43.6

Mozambique

12.3% stable

Good

329,521

2.5

Namibia

13.8% stable

Good

201,060

55.2

South Africa

18.9% stable

Good

2,073,272

74.6

Zambia

12.4% stable

Good

282,218

5.6

Zimbabwe

13.5% stable

Good

253,479

13.6

Note. Significant domestic private expenditure is recorded in the UNAIDS data for these countries.

* Means these data are particularly dubious.

Sources: HIV prevalence figures are for 2017 from World Bank data. The Bank provides a graph for each country showing the prevalence from 1990 to 2017; trends (rising, falling, and stable) can be read from these. One important caveat is that in many places, data are extremely unreliable. The assessment of data reliability is based on the frequency of reports, the manner in which the data are collected, and the detail provided. Total HIV expenditure and the percentage from domestic resources is taken from UNAIDS Data 2018. The calculation of the percentage donor is made using expenditure data. The year of the data is given in the original material.

There also needs to be a new category for transitional countries. These are where HIV prevalence is between 1% and 5% in 15- to 49-year-olds. It is time to redefine the generalized epidemic as being between 5% and 10 % among 15- to 49-year-olds. Hyper-endemic countries are where prevalence is above 10% in this population, and these are all southern African.

The key question is: Why is AIDS so serious in the southern cone of Africa? The epidemiology is clear. The epidemics are driven by behaviors such as extensive heterosexual, multiple concurrent partner relations; low and inconsistent condom use; early sexual debut; and intergenerational sex. There are biological cofactors including low levels of male circumcision; the presence of sexually transmitted infections; gender-based violence, including sexual coercion; and gender inequality. HIV and AIDS have political, economic, social, and cultural causes and consequences.

Before discussing the explicit politicization of the disease, mention must be made of the development of treatment. In 1996 it was announced at the 11th International AIDS Conference in Vancouver that using drugs in combination could bring down viral loads, restore health, and effectively allow people to lead normal lives. Up until then desperate doctors and patients battled to find effective drugs, and the ones that were tried only extended patients’ lives by months.

A treatment of “triple therapy,” using three drugs, was developed. This did not eliminate the virus from a patient’s body; reservoirs of infection remained. If treatment ceased, the virus quickly replicated and the patient relapsed. Moreover, the cost of the drugs was considerable, roughly $10,000 per patient per year, beyond the reach of most of the people in the developing world. Initially dosing regimens were complex, with people having to take handfuls of drugs at specific set times, in some cases with food and in others on an empty stomach.

Four years later the theme of the 2000 International AIDS Conference, in Durban, was “Breaking the Silence.” The silence identified by the organizers was around access to treatment and prevention and human rights. There were demands for companies to reduce prices, for donors to make the drugs available, and for health ministries to deliver them. These calls fell on fertile ground, and the price of treatment plummeted.

The Politicization of HIV and AIDS

In the West AIDS was politicized from the start. The gay populations were motivated, active, and organized. In Washington, DC, in 1987, at the Third International AIDS Conference, there were demonstrations against the lack of political commitment, especially President Reagan’s unwillingness to talk about the epidemic. There was pressure to develop and license treatment swiftly. This politicization meant the best (albeit limited) treatments were made available, there were prevention campaigns, and the disease remained high on the agenda.

Stigma and uncertainty remained: the U.S. government banned HIV-positive people from entering the country, citing both public health concerns and the potential financial burden on health services. In most of Africa the local leadership did not, and still does not, face the reality of the epidemic. Resource-poor countries relied on support from WHO’s Global Programme on AIDS, which mobilized “swat teams” of doctors, epidemiologists, and health educators who came “in country” as consultants, set up short-term programs, and then returned to establish medium-term programs. This was in part because ministries of health were stretched, but perhaps more importantly because the epidemic was invisible and concerns were not immediate.

By the mid-1990s, it was clear HIV would be checked in the developed world, the Middle East, Asia, and Latin America. Here epidemics would be low level or concentrated. The global AIDS community began assessing and focusing on the situation in Africa.

The early analysis was extremely pessimistic. In 2000 the U.S. National Intelligence Council stated that AIDS was a disease that would “complicate US and global security over the next 200 years” (Barnett & Whiteside, 2004). In January 2000 AIDS was discussed in a special session of the UN Security Council. U.S. vice president Al Gore said:

It [HIV] threatens not just individual citizens, but the very institutions that define and defend the character of a society. This disease weakens workforces and saps economic strength. AIDS strikes at teachers, and denies education to their students. It strikes at the military, and subverts the forces of order and peacekeeping.

(UNSC, 2000)

Six months later the UN Security Council (2000) passed Resolution 1308 stating the spread of HIV and AIDS could have a “uniquely devastating impact” on all sectors and levels of society and pose a risk to stability and security.

Following the Security Council’s deliberations, there was a period of intense analysis of the potential disruptive impact of the epidemic. There were suggestions of population decline, changing age structures, growing numbers of child-headed households and “feral bands of orphans roaming capital cities” (Whiteside, 2012). It was assumed AIDS would impact economic activities from subsistence agriculture to industry, and economic growth might slow. There were suggestions it might lead to less political engagement and instability.

In hindsight it is apparent that HIV was not, as feared, a significant security, political, or economic risk, although for infected individuals and their families it remains devastating. I was one of the commissioners appointed to the Commission on HIV/AIDS and Governance in Africa convened by Kofi Annan in 2003 (Whiteside, 2012). The mandate was to clarify the data on the impact of HIV/AIDS on state structures and economic development and assist governments in consolidating the design and implementation of policies and programs to handle the epidemic. The first part proved difficult, and the second required political commitment, which was not often evident.

There were only two African countries where, in the early years, leadership grasped the threat. In Senegal the epidemic simply did not spread. This may be attributed to the Programme National de Lutte contre le SIDA (National Programme for the Fight against AIDS), established in 1986. It included condom promotion, sentinel surveillance to determine the scope of the epidemic, confidential counseling and testing, education of sex workers, and integration of HIV into sex education. There was a partnership between healthcare providers and Muslim and Christian religious leaders. Perhaps most important in Senegal, sex work was recognized, tolerated, and targeted for prevention.

Uganda’s President Museveni realized AIDS posed a threat to his rule and country. He spearheaded a mass education campaign promoting the three-pronged ABC prevention message: Abstinence from sexual activity until marriage; Be faithful within marriage; and use Condoms as a last resort. Uganda’s high rates of concurrent partnering were addressed through the “Zero-Grazing” and “Love Carefully” public health messages in the 1990s. Incidence and then prevalence rates fell slowly.

Ownership and Leadership

It became apparent that the largest epidemics were in the resource-poor world, and it was more than a health issue. The initial emphasis was, correctly, on prevention; there was nothing else on offer. The messages, however, instilled fear and prejudice:

Of the three (messages) emphasised in Zimbabwe, “AIDS kills” was understood to mean imminent death. “AIDS cannot be cured” encouraged hopelessness, and “AIDS is spread in promiscuous sex” signified all HIV-positive people were promiscuous.

(Iliffe, 2006, p. 81)

It was hardly surprising that denial or ignoring the epidemic seemed a reasonable strategy for political leaders. This was made more poignant by illness and death in their ranks. Hard data is difficult to come by. In Zambia between 1964 and 1984 there were 14 by-elections because incumbents died. Between 1993 and 2003, the time of high HIV prevalence and little treatment, 39 members of parliament died, 15 were aged 25 to 49 (Barnett & Whiteside, 2004, p. 334).

African politicians did not want to face AIDS as they felt threatened and stigmatized, and there was little they could do. At worst this led to a denial of the disease.2 When Thabo Mbeki took over the presidency in 1999, it marked the beginning of denialism in South Africa. It should be noted that this had historical roots. President Mandela’s government approved the National AIDS Plan for South Africa, which focused on prevention, reducing transmission, treatment and support for those infected, and mobilizing resources. Unfortunately, the response was soon mired in scandal.

In 1994, the Department of Health spent R14.27 million (approximately US$4 million at that time) from the European Union on an anti-AIDS theater production, which HIV/AIDS activists denounced as inappropriate and unclear. In 1997, the cabinet was given a presentation on a locally developed, miracle “drug,” Virodene, which was touted as a cure. The ministers responded positively, but the drug had been banned by the Medicines Control Council because it was toxic (made from industrial solvents). This led to conflict between scientists and sectors of the government. Shortly after this the Ministry of Health blocked the use of an antiretroviral drug Zidovudine (AZT), which had been proven to prevent mother-to-child transmission. Civil society began to organize, and the Treatment Action Campaign was established in 1998.

In October 1999, President Mbeki gave a speech to the National Council of Provinces saying AZT was unsafe. His dissident views became more extreme. He suggested HIV might not be the cause of AIDS. In May 2000, he set up a presidential panel to look at the causes of the epidemic. I was a member of the panel and, like many colleagues, found it a weird experience. The panel met twice, but mainstream scientists withdrew as the bizarre and irrational views of the dissidents became apparent. The minister of health, Dr. Tsabalala-Msimang, supported the president’s controversial views and famously promoted garlic, beetroot, and lemon juice as a treatment for AIDS.

It was only with the departure of Mbeki and Tsabalala-Msimang that government policy on AIDS became properly informed by science. Under President Jacob Zuma (2008–2018) and current President Cyril Ramaphosa, policy was transformed, greatly helped by the appointment of a new health minister Dr. Aaron Motsoaledi in 2009.

Academic and observers have not definitively understood the underlying issues that led to Mbeki taking this stance; it may have been caused by the stigma of a STD, irritation about Afro-pessimism, or personal issues (Iliffe, 2006; others who have documented the epidemic and response in South Africa are Nattrass [2004] and Simelela & Venter [2014]). Unfortunately, in 2016 Mbeki reiterated his statements, asking why the virus behaved differently in Africa and the West and arguing that poverty and nutrition were critical (Mbeki, 2016). This is analogous to trying to decide if the house was set on fire with matches or a lighter rather than dousing the flames.

Mbeki had a number of fellow travelers. The worst was probably President Yahyah Jammeh of Gambia, dictator of the west African state from 2007 to 2016. He claimed to have discovered a herbal cure for AIDS and forced citizens to take it. He has been taken to court by a number of survivors.

South Africa had the most people infected of any country. It has seen, since the mid-2000s, an exceptional response, which has been sustained. In 2017 there were an estimated 7.2 million people infected, of whom 90% knew their HIV status and 61% were on treatment; in addition, 95% of pregnant women received therapy to prevent them from passing the virus to their children (UNAIDS, 2018). Unfortunately, were still an estimated 270,000 new infections in 2017, but this was down from 390,000 in 2010.

South Africa’s legislation and policies are supportive and protective of gay people. Unfortunately this is not the case in most of the rest of the Africa. British Prime Minister David Cameron suggested, in 2011, that aid money could be cut if countries did not respect gay rights. Zimbabwe’s president Robert Mugabe responded by saying homosexuals were “worse than pigs and dogs” and that they would be punished severely (United Press International, 2011).

In much of Africa the antigay legislation is a legacy of colonial laws that have not been repealed; in some countries there is active persecution of gay men. Uganda introduced new antigay legislation when the Uganda Anti-Homosexuality Act of 2014 was passed by the parliament of Uganda on December 20, 2013. The maximum penalty for “sodomy” is life in prison. The bill was signed into law by Museveni on February 24, 2014, but was ruled invalid in August 2014 by the Constitutional Court. The act includes penalties for individuals, companies, and nongovernmental organizations (NGOs) that aid or abet same-sex sexual acts, including conducting a gay marriage.

Although the number of intravenous drug users is small across the continent, nowhere is drug use legal. Sex work is generally criminalized. While these actions may play well at the ballot box (in those countries that hold elections), they make responding to AIDS difficult. The fact that South Africa is a positive outlier is encouraging.

The Politics of Giving

The earliest response to AIDS in the developing world was largely funded by foreign governments, international organizations, and NGOs. There were reasons for this. The science was mostly from laboratories in the United States, United Kingdom, and France. The most influential grassroots activism also occurred in these countries. However, developing-country governments, with the notable exception of Thailand in Asia and Senegal and Uganda in Africa, ignored or, at best, paid lip service to the disease. It was not visible, not a priority, and if outsiders were prepared to deal with it—whatever “it” was—that was fine with these governments.

The early years of the new millennium saw the creation of two major initiatives. First, following the 2000 UN Security Council meeting, Secretary-General Kofi Annan called for a “global war chest” to finance Millennium Development Goal 6: to combat AIDS, tuberculosis, and malaria. In January 2002 the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) opened in Geneva with the motto “Raise it, Spend it, Prove it.” Second, in 2003 Republican President George W. Bush pledged US$15 billion to establish the President’s Emergency Plan for AIDS Relief. In 2015 Bush explained his reasons:

As President I found it morally unacceptable for the United States to stand aside while millions of people died from a disease we could treat. I also recognized that saving lives in Africa serves America’s strategic interests. When societies abroad are healthier and more prosperous they are more stable and secure.

The United States has consistently been the largest donor to both global health and HIV and AIDS (Table 2). Of the $9.5 billion spent on AIDS in 2016 as development assistance for heath, $3.6 billion came from the U.S. government, $3.4 billion from NGOs and foundations, and $1.6 billion from the GFATM; the balance came from a mix of bilateral and multilateral donors. Both the GFATM and many NGOs receive support from governments, thus the amount from taxpayers is considerably higher than reflected in national initiatives. For example, the British Department for International Development gives bilateral aid as well as supporting the GFATM.

Table 2. Global Health Financing, the United States, and the AIDS Epidemic

1990

2000

2010

2016

Total

U.S. (Absolute and %)

AIDS (Absolute and %)

Total

U.S. (Absolute and %)

AIDS (Absolute and %)

Total

U.S. (Absolute and %)

AIDS (Absolute and %)

Total

U.S. (Absolute and %)

AIDS (Absolute and %)

$7.1b

$2b

27.87%

$310

4.41%

$11.4

$2.7b 24.02%

$11.3b 11.23%

$33.7b

$11.6 34.4%

$10.4b

30.86%

$37.6

$12.8

33.96%

$9.5

25.37%

Source: Institute for Health Metrics and Evaluation, Financing Global Health 2015.

International support to AIDS plateaued from 2010 to 2015 at about US$35 billion annually, representing more than 25% of official development assistance (Institute for Health Metrics and Evaluation, 2015). It rose in 2016, but this was probably an aberration. The belief is that, at best, it will remain steady and, at worst, decline.

The AIDS response is a long-term commitment. The WHO guidelines state people should be initiated on treatment as soon as they are identified as HIV positive and remain on it for life (WHO, 2016). As early as 2010, Lyman and Wittels, writing in Foreign Affairs, warned of the commitment the United States was taking on. They noted:

The United States’ dramatic increase in humanitarian and life-saving AIDS assistance creates an acute paradox: it diminishes Washington’s leverage over the governments that get the aid. Aid that is so closely linked to individuals’ survival cannot reasonably be curtailed, even if serious differences arise between the donors and the recipients.

They noted the dependence of millions of people on U.S. foreign aid (especially treatment) should not grow indefinitely because it would become a financial burden and a sensitive political (and humanitarian) issue.

These fiscal challenges were explored in a roundtable event cohosted by the Harvard T. H. Chan School of Public Health titled “From a Death Sentence to a Debt Sentence: Meeting the Challenge of Long-Term Liabilities of HIV Funding.”3 At this meeting critical questions were asked, such as what financing mechanisms are politically supportable; what is the right balance between government and donor funding; how does the international community prioritize which countries and populations receive additional funding; is the financing mechanism technically correct; is front-loaded financing (such as through bonds) appropriate for HIV interventions; does the fiscal space in countries permit new taxes/levies; who bears the burden ultimately; how can a balance be struck between allowing countries to set their own priorities (e.g., eliminating earmarks) and ensuring governments spend donor resources where they originally intended (Atun, Puri, & Seidman, 2018)? These are all excellent questions, but unfortunately there is not much appetite anywhere for answering them. Rethink HIV, a small think tank, commissioned work on this but are unfortunately no longer active. A number of papers have been published on the moral and fiscal responsibilities of providing therapy in Africa (Collier, Manning, & Sterck, 2015; Collier & Sterck, 2018).

The main response recently, in all donor capitals, has been to urge countries to increase domestic resources spending on health generally and HIV and AIDS specifically. Table 1 shows just how little of the money spent on AIDS in Africa comes from domestic resources. There have also been attempts to identify innovative financing mechanisms, ranging from special taxes to bonds. These might have some small impact, but all have costs and in the countries that need this type of innovation there are many competing demands for any funds collected (Booth & Whiteside, 2016).

A 2017 article by Clinton and Sridhar postulates that there have been three major trends in global health governance over the past two decades:

towards more discretionary funding and away from core or longer-term funding; towards multi-stakeholder governance and away from traditional government-centered representation and decision making; and towards narrower mandates or problem-focused vertical initiatives and away from broader systemic goals sought through multilateral cooperation.

This will cause problems for the African AIDS response.

The Politics of Receiving

The early response was mainly donor funded, and there are still many countries in Africa that depend on donors for their programs. The 2017 UNAIDS report shows the hyper-epidemics countries where the greatest amount of money comes from domestic resources are Botswana, (76.6%) followed by South Africa (74.6%). Among the other hyper-epidemic countries the percentages are Lesotho 43.6%, Mozambique 2.5%, Namibia 55.2%, Eswatini 34.2%, Zambia 5.6%, and Zimbabwe 13.6%. Uganda is at just 13% despite the length of time the response has been ongoing (UNAIDS, 2018).

This dependency is a function of the cost of the response, especially where drugs are a major component; the poverty (or wealth of a country); and the importance allocated to AIDS. This last is, in part, a game between donors who are caught in the trap described by Lyman and Wittels (2010) and the ministries of finance who see no need to allocate their own resources if others will pick up the tab.

In those African countries with high incomes, resources can be made available, and this includes South Africa despite the huge numbers. Some countries will not be able to afford treatment in the foreseeable future, such as Malawi and Zimbabwe. Finally there are those that could provide care but how much will depend on economic growth and bringing new infections under control—these might be characterized as “the risky middle” (Debebe, Vinochok, & Whiteside, 2018).

Ultimately countries need to decide on how far they need to prioritize HIV, how much they will provide, and how hard they are prepared to work to gain outside resources. The Global Fund has allocations but countries have to prepare credible applications. In other cases this is, increasingly, a negotiation between recipient governments, the donor governments, and other funders such as the multilateral agencies and large NGOs.

Conclusion

AIDS in Africa is foremost a political problem located in the health sector. The spread, both in speed and location, was influenced by colonization and apartheid. If there had not been exploitative labor migration, the spread of HIV would have been slower. Allocation of resources and levels of social cohesion determine who gets infected, and these are in turn decided by the political situation. The early response in Uganda happened because of the strong, foresighted leadership of Museveni. The catastrophe in South Africa was the result of Thabo Mbeki’s wrong-headedness and intransigence.

The international donor response may seem (and has, on occasion, been) altruistic. It is in fact mostly determined by domestic pressures and foreign policies. AIDS denialism and blaming key populations are allowed or even encouraged by domestic politics, and it is here where international support may be most crucial. For example, development assistance can target gay men who are being persecuted in African countries, drug users, sex workers, and even prisoners. If this is not done by outsiders, then these populations may be ignored. It is politics that brought the price of treatment down, and it is politics that determines who gets treated.

Because of the dependency issue, the U.S. government developed the Sustainable Funding Initiative (SFI) in 2014. The SFI is working on activities in Burma, Cambodia, the Dominican Republic, Kenya, Namibia, Nigeria, Tanzania, Uganda, and Vietnam. Its approaches include advocacy and analytics, using evidence to generate and sustain political will; public financial management; improving technical efficiency through commodity procurement, supply chain system strengthening, health insurance, and other financial management reforms; and expanding the use of private health insurance markets. The results of this will inform policy in the next decade. In 2019 the GFATM will hold a replenishment conference which will provide an indication of donor commitment.

There is ample knowledge on how HIV is spread and how transmission can be reduced. Early responses were technical and generally fairly easily introduced. There is treatment available but effectively this is resource intensive, is usually externally funded, and is “mopping the floor while the tap is running.” Prevention needs to move up on the agenda, and behaviors need to change. This can only occur when there is strong leadership. Whether or not that will happen is a political question. AIDS was and is political, and it needs more engagement from political scientists.

Further Reading

France, D. (2016). How to survive a plague: The story of how activists and scientists tamed AIDS. New York, NY: Alfred A. Knopf.Find this resource:

Haacker, M. (2016). The economics of the global response to HIV/AIDS. Oxford, U.K.: Oxford University Press.Find this resource:

Johnston, D., Deane, K., & Rizzo, M. (Eds.). (2018). The political economy of HIV in Africa. Abingdon, U.K.: Routledge.Find this resource:

Poku, N. K., & Whiteside, A. (Eds.). (2006). The political economy of AIDS in Africa. Abingdon, U.K.: Routledge.Find this resource:

Whiteside, A. (2016). HIV and AIDS: A very short introduction. Oxford, U.K.: Oxford University Press.Find this resource:

Yasmin, S. (2018). The impatient Dr. Lange. Baltimore, MD: Johns Hopkins University Press.Find this resource:

References

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Booth, P., & Whiteside, A. (2016). Expanding the fiscal space for health in Africa. Geneva, Switzerland: The Global Fund.Find this resource:

Bush, G. (2015, October 8). George W. Bush: Better health care in Africa must go beyond HIV. Time.Find this resource:

Centers for Disease Control and Prevention. (1981, June 5). Morbidity and Mortality Weekly Review.Find this resource:

Clinton, C., & Sridhar, D. (2017). Who pays for cooperation in global health? A comparative analysis of WHO, the World Bank, the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, and Gavi, the Vaccine Alliance. The Lancet, 390(10091), 324–332.Find this resource:

Collier, P., Manning, R., & Sterck, O. (2015). From death sentence to debt sentence. Finance and Development, 52(4), 28–31.Find this resource:

Collier, P., & Sterck, O. (2018). The moral and fiscal implications of antiretroviral therapies for HIV in Africa. Oxford Economic Papers, 70(2), 353–374.Find this resource:

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Notes:

(1.) Recent films include 120 Beats Per Minute (2017), The Normal Heart (2014), and the Dallas Buyers Club (2013).

(2.) Possibly this was not the worst; see the discussion of the Gambia.

(3.) This does not appear to have resulted in conference proceedings other than blogs.