How Africa learned to live with HIV

A health worker administers a COVID-19 vaccine to a student at Duduzile Secondary School in Mpumalanga, South Africa on March 9, 2022. (Photo by Waldo Swiegers/Bloomberg via Getty Images)

In the early 2000s, an HIV diagnosis was viewed as a death sentence in Africa. Entire communities were facing extinction and the disease was affecting the most productive and reproductive parts of society. At the time, an estimated 36 million people were living with HIV/AIDS, and nearly 22 million had died from the disease and related complications across the globe. The hardest-hit communities were found in sub-Saharan Africa. While treatment resources were more available in developed countries, few in Africa had access to lifesaving antiretroviral drugs.  

That changed with the launch of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003. The generosity of the American people, the political will of its leaders, and the dedication of advocates and communities have allowed PEPFAR to save over 25 million lives and have prevented over 5.5 million babies from being born with HIV. Data-driven programming, deep community engagement, and long-term partnerships between the public and private sectors have supported health systems to combat HIV. PEPFAR’s work has also helped communities survive other health emergencies such as Ebola and COVID-19 while contributing to democratic and economic stability in the countries where it operates. 

PEPFAR changed the trajectory of the HIV/AIDS pandemic. But the global health community will soon face a novel threat – an aging population that has survived HIV but now faces new challenges, such as noncommunicable diseases and declining global health resources. PEPFAR and partner countries must therefore ensure they sustain progress toward ending HIV as a public health threat while finding ways to help older people living with HIV continue to enjoy healthy, prosperous lives. PEPFAR must work with partner countries to integrate HIV health services with services for other diseases. They must continue to use targeted HIV programming that reaches the most affected populations. Finally, they must increase national ownership to ensure that countries and communities sustain decades of progress.  

PEPFAR’s payoff

A 2021 study conducted by KFF (an independent health policy organization) found that in PEPFAR countries, the mortality rate, regardless of cause, was more than 20% lower than it would have been without the program’s involvement. And thanks to civil society activism, private sector partnerships, and the work of programs like PEPFAR, Gavi, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, lifesaving antiretroviral treatment has become much more affordable. In 2022, highly effective antiretroviral treatment cost as little as $58.97 per person per year in low- and middle-income countries – down from around $1,200 some 20 years earlier. 

By shifting the tide of the pandemic, PEPFAR has contributed to positive demographic trends across the globe. In addition to the millions of lives saved over the last 20 years, access to HIV treatment and prevention has led to healthier, more productive societies and provided economic benefits amounting to over $1 trillion globally. Without the support of PEPFAR, it is possible that many countries would have lost populations that are now driving their economic growth.   

PEPFAR has also promoted transparency and accountability in the countries in which it operates. Over half of PEPFAR’s funding goes to local communities and countries, and local populations are put at the center of the decision-making process. This structure allows civil society to hold governments accountable for programming and spending, ensuring that funding has the greatest impact. 

These innovations have paid off. Countries with PEPFAR investment have become more politically and economically stable, giving their citizens greater ability to participate in the global economy. Indeed, today, PEPFAR’s partner countries represent some of the fastest-growing economies in the world.  

By the 2030s, it is estimated that approximately one-third of the people entering the global workforce will be African. In the same period, the populations of major powers in Europe and East Asia, like China, Italy, and Spain, will age significantly. Many African nations are positioned to compete with these economic powerhouses. Thanks to its vast amounts of arable land and natural resources, the region now holds 13 of the world’s 25 fastest-growing economies. Over the past 15 years, for example, as HIV has come under control, Ethiopia has grown at an average of almost 10% per year, and the country is expected to reach middle-income status by 2025.  

HIV prevention and treatment created a domino effect of benefits beyond health, too. Many people living with the disease are now living longer, opening the door for greater opportunities in other aspects of their lives, such as secondary education and long-term employment. But the fight to end HIV is not over, and new health threats loom.  

President and Mrs. Bush visit Therisanyo Primary School in Gaborone, Botswana on April 4, 2017 (Photo by Paul Morse/Bush Center)

The future of HIV/AIDS

People living with HIV are living longer, but they are not in the clear. The median age on the African continent is 19 years old, and many of the babies born HIV-free as a result of PEPFAR’s partnership 20 years ago are now young adults themselves. Nevertheless, HIV continues to be the leading cause of death for women of reproductive age. More broadly, young people have an increased risk of contracting HIV, making them vulnerable to a surge in cases. PEPFAR, host country governments, civil society, and the private sector must continue to work together to ensure these maturing populations are protected. Through economic and educational opportunities and geographically targeted programming in areas with the highest HIV prevalence rates, PEPFAR has the tools to ensure that Africa’s young people are protected.  

Meanwhile, older populations living with HIV are now more likely to encounter a growing number of comorbidities – simultaneous diagnosis of two or more diseases – as they age. People living with HIV are more prone to comorbidities because the disease attacks and weakens their immune systems, leaving them more susceptible to infections like tuberculosis and hepatitis. Women living with HIV are up to six times more likely to develop cervical cancer, and people living with HIV have an increased risk of developing cardiovascular disorders.  

PEPFAR’s success means that the HIV pandemic doesn’t look the same as it did 20 years ago. And for international financial donors, the pandemic is becoming less appealing. In 2021, the World Health Organization ranked HIV/AIDS as the 21st leading cause of death worldwide – down from No. 7 in 2000. In 2023, financial targets for HIV program resources in low- and middle-income countries were almost $10 billion short of the amount needed by 2025. As HIV falls out of the high-threat threshold, global health funding from international donors for HIV is declining, and many donors are experiencing funding fatigue in the wake of the COVID-19 pandemic. PEPFAR must work with country governments to increase their financing to ensure that they can mitigate any potential shortages.   

And although African governments are investing more than ever in their people, there’s still more that can be done. Domestic funding for HIV fell for the fourth year in a row in 2023. Rising debt, inflation, conflict, and other international crises have pushed health programs onto the back burner. Attention to noncommunicable diseases, which are now the leading cause of death and disability worldwide, is quickly surpassing that paid to infectious diseases like HIV. But if those living with HIV don’t get access to antiretroviral treatment, they risk developing and spreading drug-resistant HIV – a version of the disease that is immune to treatment and much harder to control. As we focus on the environment of the HIV/AIDS pandemic of the future, it’s important to remember that complacency could erase decades of progress.  

Addressing demographic shifts

World leaders have pledged to end HIV/AIDS as a global health threat by 2030, which is now less than six years away. Despite the progress made over the last two decades, in 2023, more than 39.9 million people were living with HIV and 630,000 people died from the disease. The global community is fighting HIV by decreasing the number of new infections and AIDS-related deaths. But according to recent reports from UNAIDS, the world isn’t working quickly enough. Collectively, countries are not on track to meet 2025 targets related to new HIV infections and AIDS-related death rates. Should the international community fail to reach these targets, it is very likely the world will not end HIV as a public health threat by 2030.  

To get closer to these targets, PEPFAR, host country governments, and program implementers must continue to invest smartly in global health. Doing so will ensure that countries, health care institutions, and communities sustain decades of progress.  

To achieve this, PEPFAR must continue to use data-driven programming to reach communities most vulnerable to HIV – with the highest priority given to increasing access to prevention and lifesaving treatment. This should mirror the shifting geographic and population demographics of the HIV/AIDS pandemic and ensure that U.S. taxpayer dollars are directed to where they’re needed most.  

Take as an example Eswatini (formerly known as Swaziland) – a sub-Saharan African country that is already on track to meet globally recognized HIV prevention targets. In Eswatini, more than 98% of people living with HIV knew their status in 2023; 93% of HIV-positive individuals were in treatment and 92% of those in treatment were virally suppressed. Despite these accomplishments, HIV prevalence among Eswatini adolescent girls and young women aged 18-29 remains at 7.5% – an unacceptably high rate for a country that has enjoyed so much success fighting HIV in its general population. This is particularly dangerous given young people’s tendency to pause treatment and cycle on and off antiretroviral drugs. Doing so undermines the protection antiretrovirals provide for the immune system, increases the chance that individuals pass the virus to others, and heightens the opportunity for HIV to mutate and develop resistance to safe and effective medicines. And in sub-Saharan Africa, only about 42% of districts with very high HIV incidence are covered with dedicated prevention programs for adolescent girls and young women.  

School girls being screened at the launch of DREAMS program in Durban, South Africa on April 7, 2021. (Photo by Darren Stewart/Gallo Images via Getty Images)

In Eswatini, PEPFAR has made a concerted, data-driven effort to address the key population of adolescent girls and young women. By implementing the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) program in 2014, PEPFAR now provides young women and girls with economic and educational opportunities to help prevent them from contracting HIV. To meet the goal of ending HIV as a public health threat by 2030, all countries suffering from high HIV infection rates need similar programs to address their key populations and target funding and programming toward them.   

Integrating successes

In areas where the pandemic is seemingly under control, PEPFAR and its partners must start to think about the future for those living with HIV. Many of them often face additional or more complex health challenges. Health ministries across Africa will need to integrate complementary services within existing HIV health systems. For example, hospitals with significant focus on HIV will need to begin to integrate other aspects of the health system – such as primary health care and screening for noncommunicable diseases – in their system.  

PEPFAR has already had some success doing so through its work on HIV comorbidities like cervical cancer. Through the Go Further partnership, PEPFAR, the George W. Bush Institute, and UNAIDS work across 12 countries in sub-Saharan Africa to screen and treat precancerous lesions for women living with HIV. PEPFAR and UNAIDS also work closely with African governments to provide treatment options for people living with both tuberculosis and HIV.  

While some countries have started the integration process, the world has a long way to go. Last year, only 39 of the 151 countries reporting to UNAIDS had national strategic HIV plans that were integrated with other health strategies. Integration will allow HIV programming to have a long-term position in national health systems, ensuring that people have access to prevention, screening, and treatment services for years to come. Integration also ensures that resources – such as infrastructure and personnel – from the HIV/AIDS pandemic are transferable to other diseases. Creating these strategies now means that countries are prepared for the future. It also creates a platform for the creation of valuable strategic government partnerships alongside bilateral programs like PEPFAR, international organizations, communities, and the private sector. 

The greater financial and strategic ownership a country has of their health system, the more capable they are of developing sustainable responses to not only HIV but also other diseases or future pandemics. This made PEPFAR and other U.S. foreign assistance programs like the Millennium Challenge Corporation and the President’s Malaria Initiative so innovative. By partnering directly with beneficiaries, these programs changed the way foreign aid is considered and gave power back to communities rather than to large international nonprofits. Communities have since been able to hold governments accountable and ensure that dollars go directly toward those who need it most.  

These partnerships have also affected diplomatic relationships between the United States and many countries across Africa. According to a study by the Bipartisan Policy Center, public opinion of the United States in PEPFAR-supported countries is higher than the global average. As international funding becomes less reliable because of pandemic fatigue, PEPFAR must prioritize increasing national ownership and financing in host countries while continuing to build long-term public-private partnerships.  

U.S. health and development agencies must also work with African finance ministries to collect and spend resources efficiently. At the same time, bodies such as the U.S. Agency for International Development (USAID) must continue to work with health ministries and the private sector to make health care affordable and accessible. Continued engagement with local communities and civil society throughout the strategic planning, programmatic implementation, and monitoring and oversight processes for HIV and other diseases will ensure needs are met while holding governments and other partners accountable.  

The HIV/AIDS pandemic of 2024 looks different than the pandemic of 2003. As we quickly approach 2030, PEPFAR and its partners must continue to implement data-driven programming, invest in civil society, and increase public-private partnerships to ensure countries sustain decades of progress. At the same time, they must prepare for a future where global health financing is difficult to come by and people living with HIV face more complex challenges. The good news is that the international community has the tools and the time to prepare for that future.