By Chinua Akukwe

The Perspective
Atlanta, Georgia

August 31, 2004

Africa continues to be the epicenter of the HIV/AIDS pandemic with more than 25 million Africans living with the condition. Africa accounts for two-thirds of all HIV/AIDS cases in the world, nearly 80% of all deaths, at least 90% of maternal-child birth transmissions, and 90% of all children who have lost one or both parents to AIDS. However, in the last few years, HIV/AIDS has become a growing concern in Asia and Central Europe. A runaway epidemic in Asia and Central Europe will have major implications for Africa. I discuss these implications.

According to the United Nations organization coordinating the global response to the pandemic (UNAIDS), about 7.4 million Asians are currently living with HIV/AIDS. For the first time, more than one million new infections occurred in Asia in 2003. As a region that accounts for 60% of humanity, an explosion in new infections will affect a large number of people. Four populous nations in Asia account for the increasing rates of HIV transmission: China, India, Indonesia and Vietnam. In India, at least 5 million individuals live with HIV/AIDS. Growing rates of HIV transmission will be a major headache for industrialized nations that have targeted them for major economic investments. An upsurge in HIV transmission is ongoing in Russian Federation and the former Soviet-bloc countries of Ukraine, Estonia and Latvia. The number of people living with HIV in Eastern Europe rose from 160,000 in 1995 to 1.3 million today. Most of the infected are less than 30 years of age.

Today, bilateral and multilateral agencies routinely refer to Asia and Eastern Europe as regions with the "fastest" rates of HIV transmission. These agencies citing the huge population at risk are now openly discussing the "global implications" of an "unchecked" epidemic in these regions. For anybody familiar with international development and policy making, these descriptions suggest an impending shift in priorities and strategies.

Specifically for Africa, what are the implications of a shift in HIV/AIDS remedial strategy towards Asia and Eastern Europe?

The first implication is a potential diversion of fiscal resources. Africa, according to UNAIDS, relies on external donors to cover up to 80% of the financial outlay for HIV/AIDS remedial efforts. If resources increasingly move to Asia and Eastern Europe, then, Africa's response to the epidemic will suffer, accordingly. Furthermore, UNAIDS's projection that Africa will account for 43% of a global HIV/AIDS expenditure of US$20 billion by 2007 may not necessarily materialize if global attention shifts to Asia and Eastern Europe. Virtually every Africa country including influential South Africa and Nigeria require sustained external support to meet the needs of individuals infected and affected by HIV/AIDS.

The second implication is that ongoing and largely successful effort to implement access to life saving HIV/AIDS medicines in Africa may falter. As scarce resources move to Asia and Eastern Europe. In addition, recent estimates by UNAIDS that 77% of HIV/AIDS expenditure in Asia by 2007 (compared to 35% in Africa) will go toward preventive programs may prove attractive to external donors looking for ways to stretch their resources.

The third implication is that many African nations that are just turning the corner on HIV/AIDS remedial efforts may be stranded. The much-heralded success stories in Uganda and Senegal depend on continuous policy and program vigilance that requires fiscal and technical resources. Countries that are turning the corner on HIV/AIDS such as Zambia and Tanzania require strong support to maintain the momentum.

The fourth, and perhaps gravest implication, is a slow down of preventive programs in Africa. Lack of fiscal and technical resources to implement information, education and communication campaigns against HIV will have major repercussions. A slow down in support for preventive programs may further drive away high risk behaving individuals. It may also force economic-driven at risk populations such as commercial sex workers and their patrons to go underground. Pregnant women may also never know their HIV status and can transmit HIV to their newborn.

Fifth, the army of advocacy organizations and civil society active in the West on accelerated AIDS remedial efforts in Africa may be hard pressed to make a case if China with more than 1 billion people or India not far behind continue to record high rates of new infections. The sheer numbers of infected individuals will likely hold the attention of policy makers in the West.

What should African leaders do now to plan for a potential shift of international policy attention to Asia and Eastern Europe as the HIV/AIDS pandemic unfolds? In this regard, time is of the essence. I suggest critical strategic steps.

The key first step is to determine Africa's HIV/AIDS priorities, goals and objectives. I have written in the past on this issue. Africa's HIV/AIDS remedial effort is largely driven by the policy prescriptions of bilateral and multilateral agencies. To overcome this strategic handicap, the African Union (AU), the African Development Bank (ADB) and the United Nations Economic Commission in Africa (ECA) should jointly develop an African response to HIV/AIDS. Under this arrangement, AU will provide the political and enabling environment for a strong African response. ADB will provide expertise on project management and also lend its considerable financial muscle. ECA will come to the table with its widely recognized expertise on policy and operations research. A major outcome of this unprecedented collaboration should be a streamlining of external support for HIV/AIDS in Africa to avoid duplication of functions and services.

Another step is to develop a continental blueprint on how to link accelerated debt relief to verifiable investments on HIV/AIDS and other socio-economic development programs. The current World Bank/IMF Heavily Indebted Poor Countries (HIPC) Initiative on debt relief is yet to have significant impact on Africa's debt burden. According to latest data from the World Bank, Africa owes US$295 billion to Western creditors. Africa's total external debt per capita is US$358 in a continent where many nations are hard pressed to spend US$4 per capita on healthcare. In developing this blueprint, the experiences of various African countries participating in HIPC should be utilized in developing an Africa Debt Relief-HIV/AIDS Swap initiative. This initiative in return for accelerated debt relief or outright forgiveness will commit African nations to verifiable investments on HIV/AIDS remedial efforts, infrastructure development (health, education and other social programs) and good governance.

Another step is to strengthen the capacity of national governments to respond to HIV/AIDS. The key is to develop regional pools of technical experts and make them available to national governments where expertise is lacking. For example, the Economic Commission for West African states (ECOWAS) should have a pool of technical experts that should assist member states, as and when due. External donors may also support development of regional expertise on HIV/AIDS.

A critical step is also to mobilize the private sector to provide HIV/AIDS preventive and clinical management services to their workers and immediate families. I once visited a major manufacturing facility in South Africa and came away hugely impressed by this organization's comprehensive HIV/AIDS program and its outreach services to the local community. The managers of this facility made it clear that it made economic sense to implement a comprehensive remedial effort against HIV/AIDS. The private sector is an untapped resource in HIV/AIDS remedial efforts in Africa.

Finally, the need to revamp or develop community-based health systems in Africa. Today, most internationally directed HIV/AIDS remedial efforts in Africa have very little effect on individuals and families infected or affected by HIV/AIDS. Africa needs to have functional, sustainable community-based health systems that reflect local realities, mobilize target populations, and encourage at-risk groups to come forward for assessment and care. Civil society organizations, especially religious and community entities are critical partners in this regard. The foundation of HIV/AIDS remedial efforts in Africa should be at the community level where most Africans live and die.

In conclusion, it is only a matter of time before the attention of the international community turns towards Asia and Eastern Europe regarding HIV/AIDS. Africa needs to be prepared for this shift. African leaders should take immediate strategic steps to improve the capacity of the continent to respond to the long-term effects of this deadly epidemic. Africa should provide leadership on HIV/AIDS in the continent, even if the epicenter of the pandemic moves to Asia and Eastern Europe.