As the world marks the 30th year of the HIV/AIDS, Africa remains at the epicenter of the global epidemic. In the last 30 years, at least 25 million Africans have died of AIDS and more than 50 million have been infected with HIV. Despite representing 10% of the global population, Africa accounts for 68% of global HIV infections and 75% of all women living with HIV/AIDS. More than 90% of all maternal transmission of HIV to newborns occurs in Africa. Nine of every ten AIDS orphans around the world are African children. Nearly two thirds of individuals qualified to receive HIV medicines are unable to have access. This year, at least 1.5 million Africans will contract HIV and up to 1.2 million will die of AIDS.

Despite the extraordinary impact of HIV/AIDS, UNAIDS reports that steady gains have been made against the epidemic in the continent.  In seven years, the proportion of individuals on AIDS lifesaving medicines increased from 2% to nearly 37 percent. Botswana has an AIDS treatment coverage rate of more than 90 percent. AIDS deaths decreased by 20% between 2004 and 2009. The proportion of pregnant women receiving HIV prophylactic medicine to reduce maternal transmission to newborns grew from 15% in 2005 to 54% in 2009. In four countries-Botswana, Swaziland, Namibia and South Africa-80% of all pregnant mothers received HIV prophylactic medicine before giving birth.

Other impressive gains in the last decade include a reduction of 32% in the number of newly infected children less than 15 years of age in southern Africa as well as 26% decrease in AIDS-related deaths. Average HIV infection rates remain low and stable in West and Central Africa, at about 2 percent. Four of the five countries with the highest burden of HIV in Africa -Ethiopia, Zambia, South Africa and Zimbabwe- averaged an impressive reduction rate of 25% in new infections between 2001 and 2009. South Africa recently rolled out the most comprehensive, coordinated AIDS response in history.

Although the HIV/AIDS epidemic appears to be slowing down in many parts of Africa, the continent continues to face significant challenges that can inflict severe damage to the much vaunted African renaissance of the 21st century. First, nearly 7 million Africans that qualify for AIDS lifesaving medicines are yet to be on treatment.  These nearly 7 million individuals will die if they are unable to receive treatment. Second, ten countries in southern Africa currently account for 34% of all global HIV infections. South Africa, the richest economy in the continent has the highest number of individuals living with HIV worldwide, 5.6 million, according to the UNAIDS. How long can the economy of South Africa remain robust if AIDS continues to account for the largest proportion of maternal deaths and is also responsible for 35% mortality among children under 5 years of age?  Swaziland has the highest prevalence rate of HIV among adults in the world at nearly 26 percent.

Third, the feminization of AIDS in Africa is alive and well. In, 2011, Africa women are at the receiving end of HIV/AIDS and respite appears a long way off. Women and girls not only remain disproportionately at risk of HIV transmission, they are also less likely empowered to prevent new infections. I am not aware of any significant, sustained, comprehensive and coordinated effort in Africa to address social and cultural mores that may increase the risk of HIV transmission among women. The rate of HIV infection among couples where one partner is initially infected (mostly males) is very high, sometimes as high as 85 percent. The UNAIDS estimates 60% of new HIV infections in Zambia may have been contracted within marriage or in cohabitation arrangements. The UNAIDS estimates 50-65% new HIV infections in Swaziland, 35-62% in Lesotho and 44% in Kenya may have been similarly contracted. Although a recent research trial in Africa and Asia suggest access to medicine by a HIV positive individual can reduce transmission to an uninfected partner by up to 96%, field implementation is unlikely in the near term due to lack of funds and the fact that more than 90% of individuals living with HIV in Africa are unaware of their status.

Fourth, AIDS continues to stalk Africa in a tightly-knitted quadrangle that includes chronic poverty, tuberculosis and untreated sexually transmitted diseases (STDs).  Already in Africa, TB, an ancient but eminently preventable and treatable disease, may be responsible for as much as half of all AIDS deaths. Poverty remains a way of life in the continent. Cultural taboos, inability to pay for treatment and lack of functional health facilities remain impediments to timely care of STDs. The future does not look bright regarding the prospects of breaking the back of the formidable AIDS Quadrangle in Africa.

What does the future portend for Africa in the fight AIDS?

The honest answer is not so good at this time. Perhaps in the future, the situation may change. Should Africa wring its hand and await the consequences? The answer is a resounding no.

Specific steps should be taken immediately by African governments to accelerate a coordinated effort against the HIV/AIDS menace. I briefly discuss these steps.

Africa should never celebrate modest victories in the fight against AIDS as long as nearly 7 million Africans are living on an AIDS death sentence that can be easily mitigated by available lifesaving medicines.

Africa should never accept the death of one individual due to lack of access to available lifesaving medicines. Neither North America nor Europe will accept such a scenario. The African Union needs to articulate the financial, technical and logistics cost of providing lifesaving medicines to all Africans in need; raise some portion of required resources within the continent; and, negotiate specific assistance from rich nations, multilateral agencies, foundations and high net worth well wisher individuals to meet the treatment needs of individuals qualified for care.  No excuse is acceptable. Africa now needs to plan and lead the fight against AIDS in the continent. No external organization or nation will lead this fight for Africa. Africa needs a continent specific AIDS Operational Plan that matches rhetoric with action. The bold Africa AIDS Operational Plan should complement the recently adopted United Nations General Assembly pledge to ensure that all babies are born free of HIV by 2015 and that their mothers live long enough to raise them to adulthood. The specific Africa AIDS Operational Plan should also complement the bold vision of UNAIDS of a future of zero new HIV infections, zero discrimination and zero AIDS-related deaths.

African governments need to implement comprehensive HIV prevention programs, with efforts to address all known risk factors on the table.

Gender equity issues, sexuality issues, male circumcision issues, poverty, cultural norms and practices that may increase risk of HIV transmission, lack of access to health and education services, limited financial resources, political instability and conflict/post conflict situations should be on the table as continental leaders craft effective information, education and communication campaigns against HIV transmission. This dialogue needs to occur at the highest political, economic, social, religious and traditional levels to ensure the adoption of credible preventive programs. Africa should spearhead the global HIV prevention revolution suggested by the United Nations. A coordinated HIV prevention revolution will be the strong foundation for effective testing/counseling, treatment, supportive and rehabilitative services throughout the continent.  

Africa now needs to begin a coordinated, comprehensive care and support initiative for its nearly 15 million AIDS orphans.

Since the early 1990s when the issue of AIDS orphans became apparent in Africa, especially in eastern and southern Africa, no concerted effort has being made at national,  regional and continental levels to address the plight of AIDS orphans.  The combination of unprecedented deaths of young adults from AIDS and the rising incidence of AIDS orphans put tremendous strain on the much vaunted extended family system in many parts of the continent. As noted in a book I had written with another colleague, AIDS orphans are often likely to eke out meager existence under the watchful gaze of increasingly infirm grandparents. I remain puzzled on why the plight of AIDS orphans in Africa has not ignited a coordinated regional or continental operational response. 

Until new HIV infection dwindles to negligible proportions in Africa, a young woman or man newly diagnosed with HIV can live an additional 50 years due to uninterrupted access to lifesaving medicines and supportive care, a HIV positive pregnant woman lives long enough to see her newborn live to adulthood and AIDS orphans grow up to become responsible members of the society, the fight against AIDS in Africa remains a matter of life and death. The future of Africa may depend on the bold moves it makes today to wage a fight to the finish against AIDS. The fight against AIDS in Africa will be won one family, one neighborhood and one community at a time, led by dedicated teams of Africans refusing to back down against tremendous odds and difficulties.  

By Dr. Chinua Akukwe

The author is the former Chairman of the Technical Advisory Board of the Africa Center for Health and Human Security at the George Washington University, Washington, DC. He has written extensively on health and development issues.