Thirty years ago, the CDC reported the first cases of HIV/AIDS in New York and Los Angeles. Initially thought to be a disease of gay white men, AIDS is now a global epidemic. Thirty-three million people worldwide were living with AIDS in 2010, with sub-Saharan Africa bearing the brunt.
Since the beginning of the epidemic, over 600,000 people have died of AIDS in the United States, and 1.2 million people are currently living with HIV. About a fifth of them are unaware of their infection and pose a risk of onward transmission. Estimates indicate an infection rate of approximately 56,000 a year in the United States.
AIDS in Africa
It is thought that a strain of Simian Immunodeficiency Virus (SIV) in a number of chimpanzee colonies in Cameroon was the viral ancestor of HIV-1, which causes AIDS in humans. The assertion that HIV originated in Africa is politically sensitive, with some believing that the western scientists have falsely blamed Africa for a disease that really began in the United States.
Whatever its origins, HIV/AIDS became a severe epidemic in East Africa in the 1980s. In Nairobi, Kenya, HIV prevalence among sex workers rose 15-fold between 1981 and 1985. African doctors were facing a disease with signs and symptoms similar to those observed in gay white American men, but 80 percent of cases in Africa were due to heterosexual activity, with a higher prevalence in women.
The initial response by African governments to the AIDS crisis was inadequate, and in some cases absent. In South Africa, where the epidemic has become the largest in the world with over 5 million HIV-infected people, white leaders refused to implement an AIDS education program. They did not begin to consider the danger of a large-scale heterosexual HIV/AIDS epidemic until the end of the 1980s.
The World Health Organization initially regarded HIV/AIDS in Africa as relatively unimportant compared with malaria, but by 1993—when an estimated 9 million sub-Saharan African people were HIV-positive—it was clear that this was a massive crisis. By the late 1990s, triple combination therapy with antiretroviral drugs (ARVs) was clearly making a difference in western countries, but the cost to an African would be an impossible $10,000-15,000 per person annually. South Africa began to lobby intransigent multibillion-dollar pharmaceutical companies to allow the drugs to be produced locally. In December 1999, President Bill Clinton announced to the embattled World Trade Organization conference in Seattle that the United States would seek flexibility in the patent laws that were keeping drug prices high.
In the 2000s, the cost of ARVs decreased. However, doubts were expressed that Africans would be able to adhere to multi-dose ARV regimens. In a statement that would be widely criticized, USAID Administrator Andrew Natsios stated in an interview with the Boston Globe that ”Africans don’t know what Western time is. … Many people in Africa have never seen a clock or a watch their entire lives.”
In 2003, President George W. Bush announced the unprecedented President’s Emergency Plan For AIDS Relief (PEPFAR), the goal of which was to help save the lives of those suffering from HIV/AIDS around the world. With PEPFAR and greater availability of ARVs, AIDS-related mortality began to decline in sub-Saharan Africa in 2005. In the past 10 years, the number of new HIV infections has dropped by more than 25 percent in 22 countries in the region, including some with the largest number of cases.
AIDS in Black America
While the number of new HIV infections has substantially dropped in sub-Saharan Africa, it has changed very little in the United States, especially in African-American communities. Indeed, although black Americans represent just 13 percent of the U.S. population, they account for almost 50 percent of Americans living with HIV/AIDS and 40 percent of total deaths to date. The estimated lifetime risk of becoming HIV-infected is 1 in 16 for black males, 1 in 30 for black females, 1 in 104 for white males, and 1 in 588 for white females.
Phill Wilson, founder and executive director of the Black AIDS Institute, points out that if black America were a country, it would rank 16th in the world for HIV infection. In Washington, D.C., where three-quarters of those infected are black and the infection rate doubled for black women between 2008 and 2010, HIV prevalence stands at almost 3 percent—a higher rate than the Democratic Republic of Congo, Ghana, Guinea, Liberia, and several other sub-Saharan countries.
In the PBS program “Endgame: AIDS in Black America,” Gregorio Millett, a senior policy adviser to the Office of National AIDS Policy, says, “We’ve been running in place in many ways…we have spent 30 years with a completely uncoordinated response for HIV. Even though we were requiring other countries that we were funding to have a national HIV/AIDS strategy, the U.S. never had a national HIV/AIDS strategy ourselves.”
PEPFAR’s goal was to share with the world the best practices established in the United States during the first 20 years of the HIV/AIDS epidemic. However, as PEPFAR approaches the end of its first decade, the program can now do the reverse: apply best practices from abroad to the United States, particularly in poor, black populations.
Concrete examples bear this out. Notwithstanding Natsios’ declaration, studies in sub-Saharan Africa have shown ARV adherence rates of greater than 90 percent, while adherence to HIV medications stands at only 60-70 percent in the United States. The African success appears to be due to several factors, among them the use of effective peer-to-peer counseling and systems that are community-based rather than individually focused. The PEPFAR approach, although not perfect, strongly suggests that such approaches would be beneficial in poverty-stricken areas of cities such as Washington, D.C.
PEPFAR advocates shifting responsibility for HIV testing and counseling away from overwhelmed healthcare providers to community and lay health workers. In PEPFAR programs, the wide availability of patient counseling through community health networks and strong family-based support are integral to achieving medication adherence.Counseling is provided in the community at several levels of the health network, including nurses, pharmacists, and other providers, and individuals are connected to peer support networks of other people living with HIV/AIDS.
In the United States, HIV infection is often seen only through a medical prism, but PEPFAR has shown that social support is a vital part of rendering care to people living with the disease. For example, low-income populations in urban areas must wrestle with issues such as homelessness and drug use, which complicate adherence to treatment.
Distant Africa may seem to have little relevance to the United States, but now the “Dark Continent” is shining a light on a way out of the worst epidemic in history.