AIDS is not over

Four years ago optimism was high that AIDS was in retreat, and could ultimately be eradicated. Back then the Joint United Nations Program on HIV/AIDS (UNAIDS) was boldly predicting “the end of AIDS by 2030.” Nobody is feeling so optimistic now.

New HIV infections, after dropping steadily for the ten years to 2005, more or less stabilized at 2 million a year in the last decade, and the annual death toll from AIDS has also stabilized, at about 1.5 million a year.

But the future looks grimmer than the present.

Two-thirds of all HIV-positive people (24 out of 36 million) are in Africa, and an even higher proportion of the AIDS deaths happen there. If it were not for Africa, the predictions of four years ago would still sound plausible. So what’s wrong with Africa? Two things: It is poor, and there are “cultural practices” that facilitate the spread of the HIV virus.
 
The great achievement of the International AIDS Conference that was held in Durban sixteen years ago was to break the grip of the big pharmaceutical companies on the key drugs that were already making HIV-positive status a lifelong nuisance rather than a death sentence in other parts of the world. Unfortunately, the drugs were so expensive that the vast majority of Africans simply could not afford them – so they died instead.

In a diplomatic and media battle that lasted for almost a decade in the late 1990s and early 2000s, African countries managed to shame the big pharmaceutical countries into accepting the importation of much cheaper “generic” versions of the main anti-retroviral drugs, mainly from Brazil, India and Thailand, for use in poor African countries.

The Western drug companies not only dropped their collective lawsuit against the South African government in defense of their patents. Some of them even began providing their own patent drugs to the African market at one-tenth or even one-twentieth of the price they charged elsewhere. A widely used course of treatment that cost $10,000 a year in the US at the time became available to Africans at a price of about $100 a year.
Many HIV-positive Africans could not even afford that amount, but Western governments and private foundations also began providing major funding for anti-HIV programs in Africa: $8.6 billion in 2014. (80 percent of the money comes from the United States and the United Kingdom)

Even today half of Africa’s HIV-positive population is not using the basic cocktail of anti-retroviral drugs on a regular basis. There is still a stigma attached to having the virus, and many of the non-users who have been diagnosed as positive don’t go the clinics to collect their drugs because it involves standing in line and being seen by people they know.

The continent’s death rate from AIDS went into a temporary steep decline, but it is now heading back up for a number of reasons. The main one is that resistance to the standard mix of drugs has grown into a major problem.

The second-line treatment, using newer drugs that are still available at the “African discount”, costs $300 per person per year – and resistance is also apparent in 30 percent of those cases. The third-line or “salvage” treatment costs $1,900 a year even in Africa. The governments can’t afford it, and very few Africans have medical insurance.

Drug resistance has been growing in the developed world too, of course, but the solution there is to move HIV-positive people onto newer combinations of drugs that are far more expensive. The cost of treatment in the US today can be higher than $20,000 a year, and not one African in a thousand can afford that.

African governments will probably have to wage another long diplomatic and media battle to access generic or cut-rate versions of the best new drugs. In the meantime, a great many people will die. And this is happening just as the amount of funding from Western sources for anti-HIV programs in Africa has gone into decline: Donations last year were down by almost one billion dollars. 

The other specific reason for sub-Saharan Africa’s much higher rate of HIV infections is “cultural”. What that means, in plain English, is that sexual traditions are different there: pre-marital and extra-marital sex is commonplace. Moreover, older men often exploit their relative wealth and power to have unprotected sex with many young women and girls.

This may explain why in southern Africa, uniquely in the world, 60 percent of new HIV infections are among young women. And it is striking that HIV infection rates are far lower in those parts of the continent that have been Muslim for many centuries – or Christian for many centuries, like Ethiopia – and where the sexual rules of engagement are therefore much stricter.

The situation in sub-Saharan Africa is almost bound to get worse, not better, because the 15-24 age group, the most likely to become infected, is growing explosively fast. They number about 200 million now, but that will double to 400 million by 2040. Africa has long been the world capital of HIV and AIDS, and it will remain so for the foreseeable future.