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A theatre group in Mozambique educates communities about HIV/AIDS and other health issues: Prevention programmes are helping to cut down the number of new HIV infections in many African countries.

Photograph: Panos / Giacomo Pirozzi

It was long years and hundreds of thousands of deaths in coming. But on 1 December, South African President Jacob Zuma stood before a cheering throng in the capital city, Pretoria, and marked World AIDS Day with a pledge 鈥渢o deploy every effort, mobilize every resource and utilise every skill that our nation possesses鈥� to turn back the advance of the disease. There comes a time in the life of all nations when the only choice is to submit to the enemy or fight, the former anti-apartheid leader told the crowd. 鈥淭hat time has now come in our struggle to overcome AIDS.鈥� We shall not submit.鈥�

It was the second major speech on AIDS in as many months for Mr. Zuma. In the view of most observers it represented a final, welcome break with the controversial policies and pronouncements of his predecessor, Thabo Mbeki. Mr. Mbeki鈥檚 public doubts about the cause of the disease, and his suspicions about the safety of the lifesaving anti-retroviral (ARV) drugs that target the HIV virus that causes AIDS, were thought by many to have contributed to South Africa鈥檚 grim distinction as the country with the largest number of infected people in the world.

Mr. Zuma has had his own difficulties with the issue. His 2006 comments about showering after unprotected sex with a woman living with HIV to prevent infection were widely ridiculed and caused outrage among activists. But he added substance to his World AIDS Day speech with the announcement that, beginning in April 2010, the public health service would expand ARV treatment programmes to include all infants testing positive for the virus, a change expected to save thousands of newborns every year. He also announced that treatment to prevent the transmission of the virus from mother to child at birth would begin earlier, as would treatment for those with both HIV and tuberculosis, in line with new recommendations from the UN鈥檚 World Health Organization.

UNAIDS Executive Director Michel Sidib茅: New infections and AIDS-related deaths are declining in sub-Saharan Africa, thanks to prevention policies and the wider availability of anti-retroviral medicines.

Photograph: UN / Mark Garten

The new commitments follow those made a few weeks earlier to cut South Africa鈥檚 rate of new HIV infections in half and provide ARV treatment to at least 80 per cent of those in need. He called on all citizens to be tested for the virus and promised to lead a 鈥渕assive campaign鈥� to raise public awareness, encourage safer sex and promote other prevention practices, as well as combat the stigma and discrimination that still surround the illness. The changes in substance and tone over the seven months Mr. Zuma has been in office 鈥渕ark a fundamental break from the past,鈥� Michel Sidib茅, executive director of the Joint UN Programme on HIV/AIDS (UNAIDS), told the crowd in Pretoria.

Standing alongside the South African leader, the senior UN official, a Malian and the first African to head the agency, said Mr. Zuma had 鈥渟hattered years of official ambivalence, rallying citizens to take responsibility for learning their [HIV] status, reducing their risk and seeking treatment.鈥� In a sign of how welcome the dramatic shift in South African government policy is internationally, Mr. Sidib茅 declared him 鈥渢he architect of ending this epidemic鈥� and described the mood among HIV/AIDS experts and activists as one of 鈥渆uphoria.鈥�

Good news at last

The changes are very good news for the 5.7 million South Africans now living with the disease, and for a continent that has already lost perhaps 20 million people to AIDS, seen hard-won development gains wiped out and now accounts for two of every three infections globally.

But the good news is not confined within South Africa鈥檚 borders. According to , the number of new infections in all of sub-Saharan Africa has declined by 25 per cent since the mid-1990s, amidst signs that the global pandemic may have peaked in 1996.

The main cause for the drop, UNAIDS asserts, is the success of prevention and education programmes that have finally begun to change the behaviour of people at high risk, including men who have sex with men, commercial sex workers, intravenous drug users and, particularly in Africa, young women.

In South Africa, for example, condom use during the first sexual encounter more than doubled to 64.8 per cent between 2002 and 2008. Zimbabwe, Zambia and Tanzania, among the countries hit hardest by the disease, all reported sustained declines in new infection rates. In Zimbabwe鈥檚 case the rates have been in decline for a decade, as education and prevention programmes have persuaded sexually active adults to practice safer sex and reduce the number of their partners.

Treatment to prevent HIV-positive mothers from infecting their babies at birth has also made a difference. Between 2004 and 2008, UNAIDS reports, the percentage of women receiving such treatment increased fivefold to 45 per cent, producing a sharp drop in the number of babies born with HIV. Globally, UNAIDS estimates, over 400,000 new infections were prevented in 2008 alone.

鈥淣ew HIV infections and AIDS-related deaths are declining in sub-Saharan Africa,鈥� Mr. Sidib茅 confirmed to Africa Renewal in a written interview. 鈥淭he drop in infections is a result of the positive impact of 鈥榗ombination鈥� HIV prevention,鈥� an approach that combines public education, access to condoms and other prevention technologies. It also results from a reduction in discrimination and bias against those with HIV and those at high risk of infection, along with policies that have promoted more responsible sexual behaviour.

Treatment access saves lives

鈥淲ith increased access to anti-retroviral therapy in developing countries, we are seeing a drop in AIDS-related deaths鈥� compared to the number of people with the disease, Mr. Sidib茅 says. 鈥淏y the end of 2008, an estimated 4 million people in low- and middle-income countries were on anti-retroviral treatment.鈥�

Although that figure represents only about 44 per cent of all Africans who need the drugs, it nevertheless reflects a remarkable increase in access to treatment. In 2003, the update notes, only 2 per cent of Africans in need had access to the medicines. ARVs are administered to patients in later stages of the illness and have become widely available in Africa only in the past few years as high costs dropped and disputes over patent rights and international trade rules were resolved (see Africa Renewal, April 2005).

The availability of the drugs through such programmes as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and, in the US, the President鈥檚 Emergency Plan for AIDS Relief (PEPFAR) kept the number of deaths in Africa stable at 1.4 million in 2008. The drugs also contributed to an increase in the number of Africans able to live with the disease, which rose by 2.7 million.

Despite the progress, Mr. Sidib茅 cautions, infection rates in sub-Saharan Africa remain five times higher than in any other region. 鈥淭he AIDS epidemic continues to evolve. Much more is needed to turn back the epidemic. Countries need to adopt a prevention approach that focuses on those most at risk of infection.鈥�

The new UNAIDS report underlines the point. Despite the drop in infections, Africa still accounts for most of the people living with the virus globally, as well as 36 of the 50 countries with HIV rates exceeding 1 per cent of the total population. All nine countries with HIV rates above 10 per cent are African, as are over 90 per cent of babies born with the disease. With new infections far exceeding the number of people able to get ARV treatment, UNAIDS notes, treatment and prevention programmes still lag behind the need.

Empowering women is key

Mr. Sidib茅 notes that reducing infection rates among women, who make up 60 per cent of Africans living with HIV, will be key to Africa鈥檚 long-term success. 鈥淕ender inequalities, sexual abuse, violence, conflict and poverty often increase women鈥檚 vulnerability to HIV. Protecting women from becoming infected with HIV and treating women living with HIV can turn back the epidemic. Stopping women from becoming infected and increasing their access to treatment also contribute to reducing the number of orphans and the number of children born with HIV.鈥�

Entrenched economic and social inequalities and cultural attitudes towards women, however, make overcoming gender aspects of the pandemic particularly challenging. For this reason Mr. Sidib茅 welcomed the announcement last September of the creation of a new UN women鈥檚 鈥渟uper agency鈥� that would consolidate the UN鈥檚 scattered gender-related activities under one roof and make them more effective. 鈥淲e are hopeful that the creation of a new UN agency on women will help address the issue of gender inequality and advance the rights of women and girls, particularly in Africa. UNAIDS will work closely with the new agency to promote women鈥檚 access to health and development [and] deliver critical maternal and child health services to women and girls at the grassroots level.鈥�

Challenges ahead

Building on these modest signs of progress in the battle against AIDS will be vital if the continent is to make strides towards achieving the Millennium Development Goals, which include achieving universal access to treatment by the end of 2010 and halting and beginning to reverse the spread of the virus by 2015.

But the challenges are still formidable, Mr. Sidib茅 observes, including:

• unaffordable medicines
• insufficient and unpredictable funding
• weak health systems
• the failure to tailor HIV prevention and treatment programmes to local conditions, and
• stigma and discrimination against vulnerable populations

Mr. Sidib茅 affirms that prejudice against homosexuals is a particular concern in Africa, noting that 鈥渕en who have sex with men are often denied access to HIV prevention and treatment programmes. UNAIDS believes the criminalization of any group of people at risk of HIV increases stigma and discrimination. Experience has shown us that effective responses to HIV are those grounded in human rights, tolerance and unimpeded access to HIV prevention, treatment, care and support.鈥�

He goes on to say, 鈥淩eports of arbitrary arrest, violence and other forms of discrimination based on a person鈥檚 sexual orientation have occurred in many countries. In the case of Senegal, international groups 鈥� including UNAIDS 鈥� assisted in the release of nine gay men who were imprisoned since December 2008.鈥�

Human rights and health advocates have also raised concerns about legislation under consideration in Uganda. If enacted, the bill would impose the death penalty on sexually active HIV-positive homosexuals under some circumstances and require family, friends and employers to report homosexuals to authorities under penalty of imprisonment.

Financing is another obstacle. 鈥淎lthough funding for the global AIDS response has grown over the years, there is still a funding gap,鈥� the UNAIDS head explains. 鈥淚n 2008, $15.6 bn was estimated to be available from all sources for HIV, leaving a funding gap of $6.5 billion.鈥� For 2010, he says, the global need will rise to $25 bn 鈥� half of which will be in Africa.

Funding under fire

The prospects for raising that amount, he admits, are not good: 鈥淓ven though we do not yet know what the full impact of the economic crisis will be on HIV programmes, we are already seeing adverse effects of the crisis on national and local AIDS responses, such as declines in household incomes, increases in poverty levels and reductions in national government spending on HIV, as well as reductions in HIV funding from multilateral and bilateral donors.鈥� The effect of the crisis on exchange rates has also made imported HIV medicines and equipment more expensive, he notes.

HIV and AIDS funding is also coming under criticism from some doctors and medical researchers. They assert that large-scale financing for the fight against AIDS comes at the expense of other vital health needs. HIV/AIDS advocates respond that the campaign against AIDS has generated billions of additional dollars for health care in African and other developing countries and has saved millions of lives with prevention and treatment programmes.

The critics may also have a hard time convincing President Zuma. AIDS, he declared, 鈥渋s not merely a health challenge. It is a challenge with profound social, cultural and economic consequences. It is an epidemic that affects entire nations鈥�. We have done much to tackle HIV and AIDS, but it is not enough. Much more needs to be done.鈥�