‘The time has come’: Crafting a sustainable, African-led HIV response

Global finance for fighting HIV in Africa exists on shaky grounds — much of it at the whims of American politicians who have the power to sever support for the U.S. President's Emergency Plan For AIDS Relief, which has invested billions into the continent’s HIV response. But a group of experts from across Africa are working to craft a road map for a new kind of HIV response — drawing on the diversity of the continent and its resources, including human capital. The two co-chairs of the African-led HIV Control Working Group gave Devex a preview of the shape it’s taking. This includes Dr. Magda Robalo, president and co-founder of the Institute for Global Health and Development of Guinea-Bissau, and Dr. Izukanji Sikazwe, chief executive officer of the Centre for Infectious Disease Research in Zambia. “The time has come for an epidemic that is essentially African — because the majority of cases and deaths are in Africa — to be driven by the continent,” Robalo said. This is all part of a broader movement on the continent to increase the health security of its population by ensuring stronger systems exist locally. Crafting a vision The working group was established in May 2023 to create a framework for an African-led and financed response to the HIV epidemic, cognizant of the epidemic’s nuances across the continent, Sikazwe said. This included bringing together experts with diverse areas of expertise. They established thematic groups including on prevention, control, governance, sustainability, and community response. Other members of the working group include Dr. Michel Sidibé, African Union special envoy for the African Medicines Agency; Yvette Raphael, executive director of Advocacy for Prevention of HIV in Africa; and Dr. Yogan Pillay, director of HIV & TB delivery program at the Gates Foundation — which is funding this work. “We believe that Africa cannot take leadership and ownership of the response if the financing continues to come from external sources.” -- — Dr. Magda Robalo, president and co-founder, Institute for Global Health and Development of Guinea-Bissau They’re currently engaging with stakeholders such as governments and communities of people living with HIV to craft position papers on what a genuinely African response to HIV should look like in the lead-up to 2030, Sikazwe said. This is the year the world’s committed to ending the epidemic. They hope they will “put on the table options for our leaders to consider going forward,” Robalo said. In the past, strategies around tackling HIV in Africa have been globally defined, Robalo said. Even though much of the HIV research has been conducted on the continent, “the voices of African experts are not dominant in the definitions of the strategies,” she said. “We want to see more Africans on the forefront.” People over commodities Africa’s HIV response is heavily reliant on external funding, with the U.S. government bearing the brunt of it, Sikazwe said. PEPFAR is the largest commitment by a nation to address a single disease — committing some $120 billion globally. African countries currently make up about half of PEPFAR-supported countries. In addition to PEPFAR, the U.S. government contributes significantly to multilateral funding mechanisms to support African’s HIV response through The Global Fund to Fight AIDS, Tuberculosis and Malaria, among other efforts. This year, the U.S. Congress provided short-term reauthorization of PEPFAR until March 2025 — but it’s unclear what happens next. Historically, the program was reauthorized by Congress for five-year periods. “This clearly leaves Africa in a precarious position as we are heavily reliant on external funding to support services to more than 25.6 million people living with HIV on the continent,” Sikazwe said. Ensuring African governments provide more domestic financing is key. However, this isn’t a simple task as governments are operating under limited fiscal space with heavy debt burdens. Robalo said their work will include defining financing strategies. She pointed to Zimbabwe as an example of an approach, where there’s a tax levy to fund HIV programming. The experts are also mulling over creating a new African fund for health sovereignty. “We believe that Africa cannot take leadership and ownership of the response if the financing continues to come from external sources,” she said. “We are pushing for integration and moving away from siloed, vertical, and disease specific funding or approaches.” --— Dr. Magda Robalo The HIV response has long been anchored around getting health commodities such as medicine and tests to people. But Robalo said there’s a need to shift the focus to communities and people in a holistic way. “People are more important than commodities and taking into account the full need of communities — the full needs of people,” she said. One example, she said, is insufficient systems around diagnosing and treating cervical cancer. Women living with HIV are six times more at risk of contracting cervical cancer. “Despite the investment in [antiretroviral therapy] that we are putting those people on in order for them to live longer and healthier lives, they will end up dying of cervical cancer because the systems are not integrated enough to take care of non-HIV diseases,” she said. Ensuring gender inequities are tackled is also important to an African-led response, Robalo said, as new infections continue to affect young girls at higher rates than young boys. “HIV is a feminine disease in Africa,” she said. What could have been Over the past two decades of PEPFAR and Global Fund support, not enough was done to ensure this money worked to broadly strengthen health systems, Robalo said. “The billions that have been poured into African health systems to respond to HIV, TB, and malaria, could have done much better to strengthen systems,” she said. One issue is supply chains have been created in vertical ways, she said. They’re strong for bringing in HIV medicines, for example, and vaccines supplied by vaccine alliance Gavi, but to bring in many other commodities, parallel systems need to be established, she said. “We are not saying that what was done wasn't good enough,” Robalo said. “At the beginning, we definitely needed that vertical approach to be able to curtail the number of deaths. But we got to a point where we could have gone more integrated with the broader health system into perspective — and that did not happen.” “We are pushing for integration and moving away from siloed, vertical, and disease specific funding or approaches,” she added. Within this vision, there’s still a role for the international community, she said. The Lusaka Agenda, launched a year ago, presented five shifts needed to better coordinate and strengthen the contribution of global health initiatives. This “creates an enabling environment for donors and global health initiatives to align behind nationally defined priorities,” she said. The next phase Africa is in a challenging new phase of the HIV epidemic. Often when diseases reach the final stretch of cases, there’s a need for more targeted strategies and stronger surveillance systems to diagnose and treat cases, Robalo said. And the younger generation needs to be continually educated because they largely don’t grasp the magnitude of the devastation AIDS caused in the past. “They don't have the historic background that people my age do. They have not seen people dying like flies [because] of HIV,” she said. “HIV is not a problem for them. They don't see it as we see it.” Prevention is currently underfunded in the continent’s response, with more of a focus on treatment, Sikazwe said. But changing that will be an important part of the new vision, she said. For example, mother-to-child transmission of HIV persists — as high as 10% or more in certain geographies and sub-populations, Sikazwe said. “Why is this still the case, when we know how to stop this?” she asked. There’s also a need to ensure health innovations become accessible and affordable — such as the new long-acting injectable lenacapavir, which is used as a preexposure prophylaxis, or PrEP. “We can't afford to be putting more and more people on treatment. We need to close the tap. We need to invest in prevention so that we reduce the number of new infections,” Robalo said.