H.I.V. and AIDS in Africa: Ten Lessons From the Field

Children affected by AIDS in Africa appear abandoned to their fate. (Photo: Alexander Joe / AFP-Getty Images)

Twenty-five years into the H.I.V. and AIDS epidemic in Africa, it is appropriate to pause and share lessons learned in fighting an epidemic that shows no sign of slowing down or ending its destructive outcomes. We hope that people and organizations active in international and domestic remedial efforts will share their unique insights into the fight against the epidemic. In Africa, the rate of H.I.V. transmission and the rate of AIDS deaths appear immune to the flurry of high profile domestic and international remedial initiatives. Simply stated, Africans living with H.I.V./AIDS and the millions of others at high risk of contracting H.I.V. are not benefiting significantly from current domestic, regional, and international high profile remedial efforts.

Rhoi Wangila, as the executive director of the Ark Foundation in Washington, D.C., continues to visit most of the H.I.V./AIDS heavily impacted countries in Eastern and Southern Africa. Ms. Wangila has worked with, lived among, and constantly seen individuals and families suffering from the day-to-day effects of AIDS. She has witnessed first hand the hopelessness and despair in devastated villages and communities in Africa, and the befuddlement of grandparents suddenly saddled with AIDS orphans. As someone who spends most of her time in rural parts of Africa, Wangila constantly notes the eerie disconnect between the flurry of domestic and international AIDS remedial efforts and the excruciating suffering among poor families who care for their loved ones dying of AIDS. In particular, Wangila remains disturbed by the brazen neglect of the plight of AIDS orphans in Africa.

Chinua Akukwe has written extensively in the print and electronic media about H.I.V./AIDS in Africa. As the former vice chairman of the largest voluntary organization dedicated to global health issues in the world and a member of the board of directors of a well known advocacy organization dedicated to African issues in Washington, D.C., Dr. Akukwe has extensive knowledge and experience on H.I.V./AIDS issues in Africa. Akukwe is aware of the extraordinary suffering wrought by AIDS in Africa and the mismatch between the extreme urgency on the ground in Africa and the pace of domestic and international remedial efforts.

Twenty-five years into a devastating epidemic, the apparent contradiction between the rhetoric on H.I.V. prevention and AIDS relief and the situation on the ground in Africa remains a major source of concern. What lessons have we learned in 25 years in AIDS remedial efforts in Africa and who are the real victims?

First, and this has to be stated as many times as possible, families and communities battling AIDS in Africa barely receive support from current domestic and international relief efforts. The mismatch between domestic and international intentions or actions on AIDS and the reality on the ground in Africa is unprecedented. We believe that this situation is now the real crisis of AIDS in Africa. It appears that conferences, workshops, media announcements, and sound bites are now replacing the urgent need to develop and implement robust H.I.V./AIDS remedial programs for families infected or affected by AIDS. We suggest that the emphasis on H.I.V./AIDS remedial efforts in the coming years should be on how to meet the preventive needs of at-risk populations and how to provide timely clinical and social support services to families battling the epidemic, in their neighborhoods and communities.

Second, children affected by AIDS in Africa appear abandoned to their fate. The plight of millions of orphans and other children affected by AIDS in Africa, have disturbingly very little social, economic, or political support. Entire generations of African children who lost one or both parents to AIDS now grow up in abysmal poverty, largely abandoned by local and national governments, and, for all practical purposes, neglected by the international community. These AIDS orphans are often under the care of penniless ailing grandparents or AIDS widows too sick to care for themselves.

Ongoing studies and a soon to be released book by the authors of this article show another dark side of the AIDS orphan saga in Africa: sexual predation of AIDS orphans.

Female AIDS orphans are now easy fodder for sexual predators. In this ongoing study, some female AIDS orphans in Africa are visibly pregnant or caring for young infants. Many of the AIDS orphans are not in school or have no hope of ever receiving structured education. Most of these AIDS orphan mothers are fending for themselves with little or no social support. The inability of African governments and the international community to protect AIDS orphans and provide social and economic support is troubling. There is need for an immediate, global, and comprehensive initiative to be launched to rescue African AIDS orphans from their current life of squalor, degradation, and hopelessness. This is a problem that deserves immediate attention.

Third, domestic and international H.I.V./AIDS remedial efforts continue to ignore indigenous community-based organizations and civil society in Africa. It is not enough in the fight against H.I.V. and AIDS to invite community-based organizations and civil society to participate in "workshops" or "seminars" or have them attend "stakeholder forums." Providing "mini-grants" to local organizations with fanfare and press coverage is also not enough since the needs of families battling AIDS cannot be met by token gestures. We are not aware of any serious effort by national, bilateral, or multilateral agencies to scale up the capacity of proven local organizations actively on H.I.V./AIDS issues.

We are also unaware of any serious, organized effort to provide sustained technical, financial, and logistic assistance to these proven local organizations. These local organizations lack the financial and technical support to increase the number of people served, to provide a comprehensive menu of services, and to train new service providers. To scale up support for local programs, it is important to conduct a comprehensive inventory of proven local organizations and their programs. It is also important for domestic and international organizations active on H.I.V./AIDS issues in Africa to implement a transparent strategy on scaling up successful programs. For example, in regards to AIDS orphans, a comprehensive remedial strategy requires the identification and scaling up of effective local programs and services already meeting the needs of these children.

Fourth, programs to fight new H.I.V. infections in Africa are inadequate and too weak to reach targeted high-risk groups effectively. Despite the horrors of the H.I.V./AIDS epidemic in Africa, it is important to note that less than 10 percent of Africans live with the condition. It is therefore surprising to find an apparent lack of urgency in the implementation of information, education, and communication (I.E.C.) campaigns against H.I.V. transmission among the at-risk populations. Credibility issues with chosen messengers, flawed messages, and limited stakeholder participation in the design of H.I.V. preventive messages are taking its toll. I.E.C. campaigns in Africa should have locally relevant content, be integrated with ongoing programs of proven local organizations, be customized to meet local needs, and should have focused outcomes, especially an increased uptake and retention of healthy practices and behaviors by at-risk populations. H.I.V. voluntary counseling and testing programs should be widely available, part of a comprehensive H.I.V. prevention strategy, and offered to at risk populations in environments that respect their privacy and avoid stigmatization. H.I.V. prevention programs should take advantage of social interaction opportunities to reach at-risk populations, from homes to neighborhoods, community events, schools, playgrounds, religious institutions, and workplaces.

Another major problem in Africa is the inadequate attention to maternal transmission of H.I.V. to newborns and the subsequent impact of AIDS in early childhood. Although AIDS remains the focus of international attention, its impact on early childhood is not receiving the same level of interest. AIDS mortality rates among African children under five years continue to grow. According to UNAIDS, less than 10 percent of pregnant women in Africa, receive offers of remedial programs that can prevent transmission of H.I.V. to their infants. In addition, prenatal care remains tenuous in many parts of Africa. Consequently, H.I.V.-positive pregnant women are not receiving the support they need to stay healthy during pregnancy, especially when pre-pregnancy or inter-pregnancy health status may not be optimal.

According to UNICEF, "AIDS is redefining the very meaning of early childhood for millions. It is depriving young children of many of their human rights to the care, love, and affection of their primary caretakers." Pediatric AIDS treatment, support, and care, and nurturing and guidance, for children 0 to 8 years old, are missing. Primarily, there is a lack of awareness, knowledge, and training on early childhood development in Africa and the deadly impact of AIDS. In addition, limited financial resources, and dilapidated health and education infrastructure, remain important impediments to effective H.I.V./AIDS remedial efforts among children in Africa.

Fifth, we have yet to see any serious effort to roll out comprehensive antiretroviral clinical programs in Africa. Ongoing government efforts in Nigeria, South Africa, and a few other African countries that have chosen to provide antiretroviral therapy to those deemed clinically qualified, deserve commendation. News reports of extremely modest programs in Uganda, Zambia, Senegal, Tanzania, and Ethiopia are also encouraging. However, the proportion of people receiving these medicines is too low to make a significant dent in these countries. Consequently, it is perplexing to note the extravagant fanfare that announces extremely modest antiretroviral programs in Africa. In fact, the overwhelming proportion of those in need may never receive assistance.

For Africa to ramp up its AIDS clinical program, bilateral and multilateral agencies should provide consistent and long-term financial support. In particular, G-8 nations, especially the United States, should significantly raise their financial support for AIDS remedial efforts in Africa. These sustained financial supports should be devoid of red tape and bureaucratic bottlenecks so that the impact is felt in the field as soon as possible. The Global Fund to fight AIDS, tuberculosis and malaria and the State Department's Office of the U.S. Global AIDS Coordinator, both have a specially mandated and humane role to play given their significant resources, technical capacity, and political leadership.

Sixth, ending the debt overhang of Africa and putting savings into good use is critical in the war against H.I.V./AIDS. That many African countries remain mired in poverty is well known. Poverty is a way of life in many African countries, especially in nations where the government is the main "industry" for able-bodied men and women. However, as long as these poor African countries continue to use scarce financial resources to make yearly debt repayments to rich nations, it would be virtually impossible to mount credible H.I.V./AIDS remedial efforts in the continent. Without belaboring this issue, it is only fair for the rich nations and multilateral agencies to reduce significantly the debt burden of African nations, especially those groaning under the burden of H.I.V./AIDS. The 2005 G-8 initiative on debt relief is a welcome development. However, the G-8 debt relief initiative did not extend to all poor countries in Africa. Attendant savings from debt relief should be used for social and welfare programs for the poor in Africa, with donor and recipient countries, and the civil society, ensuring that intended beneficiaries receive support in a timely manner and for stated needs.

Seventh, African elite must recommit to ending poverty and fighting a more effective war on AIDS. It is no secret that the gulf between the rich and the poor in Africa defies imagination. It is also no secret that despite various national and regional initiatives, African ruling elites since political independence from colonial authorities have not met the lofty expectations of their citizens. The key to Africa's renaissance lies with its elite and its people, despite the assistance of external donor countries and multilateral agencies. African elites should protect the political rights of tribal minorities, commit to fundamental human rights, including freedom of expression, and create enabling environments for private enterprise and wealth creation. Furthermore, Africans in leadership positions should enthrone due process and the rule of law, and ensure orderly political transitions.

It is heart breaking that in the midst of dire economic problems African ruling elites would allow a situation whereby donor countries and multilateral agencies spend money and effort guarding against malfeasance in externally funded programs in the continent. We call on African leaders and the elite to provide transparent, transformative leadership. The key to a transformative leadership is the implementation of governance reforms that improve service delivery to citizens, create enabling regulatory environments that encourage professional and economic activities, and convince the youth to have unflagging confidence in the future. It is also important for governance reforms to earn the confidence of indigenous civil society organizations and international development partners.

Eighth, we must find ways of getting feedback from ordinary Africans in the fight against H.I.V./AIDS. Most surveys in Africa on H.I.V./AIDS focus on sera-prevalence rates and knowledge about routes of H.I.V. transmission. However, the priorities of target populations are often not a major factor in H.I.V./AIDS programming efforts. International AIDS remedial efforts in Africa have very little built-in mechanisms for understanding perceptions of at-risk populations regarding specific remedial strategies or initiatives. Unwittingly, a situation now exists where stakeholder analysis and feedback on H.I.V./AIDS remedial efforts is an afterthought. It is critical for domestic and international AIDS remedial efforts in Africa to demonstrate that proposed strategies and activities reflect the stated priorities of target populations.

Ninth, the plight of women in Africa must take center stage in H.I.V./AIDS remedial efforts. Since African women represent at least 57 percent of all individuals living with H.I.V./AIDS in Africa, according to UNAIDS, remedial efforts should include specific strategies targeting women. African women need to be actively involved in local, national, and regional initiatives to address H.I.V./AIDS, especially in decision-making roles. Specifically, serious H.I.V./AIDS remedial efforts in Africa cannot shy away from serious discussion and action on issues that make women more vulnerable to the epidemic.

These issues include lower levels of education for girls and young women, endemic poverty, cultural taboos, limited opportunities for economic independence, sexual violence, and lack luster judicial deterrence for rape.

African girls should stay in school. African women should be empowered to strive for economic independence through micro-credit schemes and other entrepreneurial incentives. In particular, these programs should target widows with small children so they have enough income to shun the temptation of trading sex for material favors. African women need enforced legal protection against sexual violence and rape. Widows need to have legal backing to own or acquire properties. In addition, widows need to be protected from cultural taboos that prevent them from inheriting properties jointly owned with their dead spouses. In addition, African women need to become actively involved in the political, economic, professional, and civil society leadership in their countries, at all levels, from local to national governments. At community levels, traditional healers and traditional rulers have important roles to play in ending cultural practices that jeopardize the health and well-being of African women.

Tenth, youth, the future leaders of Africa, are largely absent in the fight against H.I.V. and AIDS. Young men and women whose future beckons in Africa are largely absent in the fight against this epidemic. Besides the obligatory "youth forums" or "youth summits" of international conferences, very little HIV/AIDS programming exists for the youth in Africa. Despite bearing a significant burden of the epidemic, African youth are not often at the table during the design, implementation, and monitoring and evaluation phases of H.I.V./AIDS remedial efforts. African youth, as future leaders of Africa, should become an indispensable part of domestic and international H.I.V./AIDS remedial efforts.


On the Web

XVI International AIDS Conference, Aug. 13-18, 2006, Toronto, Canada

This article shares 10 lessons the authors learned from their involvement in H.I.V./AIDS remedial efforts in Africa. This article, hopefully, should spur other colleagues with unique experiences in AIDS remedial efforts to share their insights and lessons learned so that policy makers in Africa and the international community can improve H.I.V./AIDS policies and programs in the continent. Today, 25 years into the H.I.V./AIDS epidemic, there is no doubt that African nations are locked in a battle for survival. Unfortunately, families affected and infected by H.I.V./AIDS in Africa are beyond the reach of domestic and international remedial efforts.

To reach these families, domestic and international H.I.V./AIDS remedial efforts would have to change strategy, focusing more on community-based programs and services. To make a difference at local communities where the fight against the epidemic is lost and won, African governments should re-orientate their health systems to focus on primary health programs. African policy makers should reform their health systems to become more accountable, financial, and technical, to the priorities of citizens. Governance reforms should be internally driven to meet the expectation of citizens rather than as a response to external donor pressure.

Unfortunately, primary health systems and community-based health programs have suffered years of neglect in Africa. A comprehensive community-based health system framework in Africa will require sustainable, stable, and long-term financial support from the G-8 and other industrialized nations. In this regard, the United States is indispensable, both as provider of significant financial support and as a catalyst for other nations to commit to quality community-based health systems in Africa.

What will no longer suffice is a continuation of the present status quo whereby remedial efforts have very little relevance to the needs of at-risk individuals or those living with H.I.V./AIDS. Today, more than 24 million Africans live with H.I.V./AIDS. In the past 25 years, more than 20 million have died. This year, at least 2 million Africans will likely lose their battle against AIDS. We have learned a lot in the past 25 years on AIDS remedial efforts in the continent. We now know enough about H.I.V./AIDS to minimize H.I.V. transmission, provide clinical and social support for those living with the condition, and support those affected by the epidemic in Africa.

Rhoi Wangila is the executive director of the Ark Foundation of Africa, an organization dedicated to the provision of comprehensive services to families and individuals battling H.I.V./AIDS in Africa.

Dr. Chinua Akukwe is a contributing editor of