Africa must take ownership of its HIV response, write Izukanji Sikazwe and Magda Robalo, co-chairs of the African-led HIV Control Working Group.
The sense of urgency around HIV has waned as it competes with other global crises for attention and funding, leading to a dangerous setback in the HIV response.
Twenty-three years after it first featured in the global agenda at the United Nations General Assembly (UNGA), leading HIV experts in Sub-Saharan Africa reflect on the diminished priority of the ongoing HIV epidemic, which continues to impact millions across Africa, with new cases and deaths each year.
While global targets provide an important common goal to work towards, we must not let the numbers obscure the lives and experiences at the heart of the HIV epidemic.
In 2001, UNGA held its first Special Session on AIDS, galvanising global commitment and solidarity.
Since then, the global HIV response has seen remarkable progress and the successes are to be celebrated.
In the last two decades, Africa has expanded access to lifesaving antiretroviral therapy, reduced AIDS-related deaths, and witnessed huge declines in annual new HIV infections. It saw a 59 per cent reduction in eastern and southern Africa and 46 per cent in western and central Africa between 2010 and 2023.
Five African countries have already reached the UNAIDS 95-95-95 targets, and eight more from Sub-Saharan Africa are on track.
Despite these strides, 23 years later, HIV/AIDS remains a public health threat, and Africa still bears the largest share of the global burden of HIV.
Critical questions to address now to create the needed changes for a sustainable HIV response for the next decades include: Will Africa remain dependent on external support to survive global challenges or become independent, self-sustaining, and able to manage its challenges using its own resources?
Africa must become independent for its continental health security and health sovereignty. What must happen now to ensure that objective? And more importantly, what can we do currently in partnership with global stakeholders to ensure independence becomes Africa's reality?
HIV funding, leadership
As of the end of 2023, 65 per cent of people living with HIV are in the African region. And almost half of the approximately 9.3 million people living with HIV without treatment, as well as 86 per cent of children living with HIV globally, are in Sub-Saharan Africa.
Despite this, African voices are not at the forefront of shaping the global HIV response. Over the past three decades, the HIV response in Africa has been led and resourced by the international community.
African countries have devolved financial, technical, and political leadership of the HIV response to external partners and funders. The challenge with this is that countries adapted global strategies and programmes to fit country contexts instead of letting country priorities and local contexts drive the HIV response.
As the 2025 UNAIDS targets loom closer, we stand at a critical juncture in determining the future of the HIV response on the continent.
Continued reliance on imported models and external funding jeopardises the sustainability of our response. Trends indicate that global funding is stagnating, leaving us at risk of losing, or even reversing, the progress that has been made so far.
Low- and middle-income countries across the world are facing a rising deficit in HIV funding. In Western and Central Africa, the amount of funding available for HIV programmes in 2023 was 16 per cent short of the funding needed to meet the 2025 UNAIDS target.
And in Eastern and Southern Africa, funding allocations are largely on track with global targets, although only a handful of countries (Botswana, Kenya, and South Africa) account for a large portion of the funding.
If we are to secure and sustain our hard-won gains, we must ramp up domestic resource mobilisation.
Africa-led HIV response
The HIV response must also evolve in line with the changing global economic landscape and demographic composition. We need a truly African-owned and led HIV response that is sustainable and in tune with local needs, priorities, and contexts.
For it to be truly African-owned and led, we must lead from the front, financing and driving the agenda in our HIV response.
Today, one of the biggest setbacks to the HIV response is chronic underinvestment from African nations themselves.
In the face of rising debt distress across the continent, advocating for African governments to prioritise and take ownership of HIV financing is not an easy ask.
We need to be both practical and innovative about how African countries prioritise HIV financing and can look to innovative financing solutions such as strategic taxes, diaspora bonds, co-financing mechanisms, and debt restructuring.
Regional cooperation and coordination, such as the creation of an African-owned regional fund, could also serve as a vital step towards achieving financial independence, fostering resilience, and ensuring that Africa's health outcomes are determined by Africans.
HIV research and innovation
It is not just funding that Africa is reliant on global countries for, but also HIV commodities and innovations.
While HIV medical innovations have progressed greatly in the last two decades at a global level, cost and access prevent them from fully serving the continent.
There are large gaps between the continent's healthcare needs and manufacturing capacity - Africa imports 95 per cent of its medicines and 99 per cent of its vaccines.
The design and development of most innovations are far removed from the communities they are intended to serve, making them less culturally relevant, and less likely to be effective.
People living with HIV on the continent need to be equal partners in setting priorities, shaping research and innovation, and implementing programmes.
While Africa is the world's source of HIV research data, Africans are rarely in the role of principal investigator.
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Extending African ownership to research, manufacturing, and innovation will help us close the large gaps between the continent's healthcare needs and the solutions to address them.
We must enhance Africa's local manufacturing, and re-think intellectual property regulations to ensure greater equity and access.
We need an ecosystem where African researchers can thrive, supporting regional collaborations, standardisation and coordination, and transforming global research partnerships to be more equitable and accountable.
We must also ensure African sovereignty over its health data so that research benefits the continent's needs.
While global targets provide an important common goal to work towards, we must not let the numbers obscure the lives and experiences at the heart of the HIV epidemic, the people of our beautiful continent.
With the 79th UNGA having drawn to a close, we must hail the successes of global solidarity, but also use this moment to reflect on the power dynamics that continue to underlie global health.
Izukanji Sikazwe is the chief executive officer of the Centre for Infectious Disease Research in Zambia, and Magda Robalo is president and co-founder of The Institute for Global Health and Development of Guinea-Bissau.
They also co-chair the African-led HIV Control Working Group, an independent group working towards building a sustainable, Africa-led HIV response.
This piece was produced by SciDev.Net's Sub-Saharan Africa English desk
