Lessons Africa has learnt in 15 years of responding to HIV/AIDS - Executive summary

HIV, the virus that causes AIDS, started spreading in various corners of the globe just over two decades ago. Today, Africa is by far the most severely-affected continent. Africa is home to 70% of the adults and 80% of the children living with HIV in the world, most of whom still have inadequate access to even basic health care. Millions more are still falling prey to the virus every year. Africa has buried three-quarters of the more than 20 million people worldwide who have died of AIDS since the epidemic began. As children lose their parents and teachers, and hospitals, farms and factories their workers, the epidemic has become a full-blown development crisis.

Paradoxically, though, Africa already possesses most of the "tools" – if not all the resources – needed to change the course of the epidemic. As this paper illustrates, communities and countries across the continent have pioneered, developed and tested many successful responses to HIV and AIDS. There is an impressive range of best practice in Africa, proof that the continent is not powerless against the epidemic.

The goal of this paper is to draw out the precious lessons learnt and share them with Africa’s leadership at all levels of society. The main lessons have been summarised under just seven headings, as shown below, and each has been illustrated with examples of best practice from countries across Africa.

Readers will note that this report cites a great deal of best practice implemented outside the health sector. There is a good reason for this. AIDS is an epidemic with special features that call for a special response. With no vaccine available against HIV, prevention hinges on informing people, motivating them and empowering them to protect themselves, their partners and their newborn infants. Likewise, though the health sector is the mainstay of health care for those infected, it can do little to alleviate the poverty that afflicts many AIDS-affected households, ease the plight of orphaned children, or safeguard a country’s development achievements.

Instead, the response to HIV/AIDS demands strong and creative leadership from all sectors and parts of society as much as increased community ownership of the problem and of its solution. Having analysed the impact of the epidemic, ministries of planning and finance must help ensure financing of crucial interventions for prevention and care –the two reinforce each other -- and devise ways to alleviate the epidemic’s toll on households, agriculture, mining and other sectors. Respected community leaders need to encourage people to take the invisible HIV threat seriously and, where necessary, change local attitudes and traditions that make people unnecessarily vulnerable to HIV or to the impact of AIDS. Schools have a responsibility to inform children about HIV before they become sexually active and risk exposure, and teach them the skills they need to navigate safely through life. Religious leaders need to combat the blame and rejection associated with AIDS and encourage a "social contract" between the affected and the as-yet-unaffected. In places where the AIDS stigma is diminished, individuals living with HIV will feel freer to give the epidemic a human face and make their full contribution to combating it.

The "social contract"

With over 24.5 million Africans already infected with HIV, it is important to avoid social division – an "us" versus "them" mentality – and instead encourage a social contract promoting mutual tolerance and shared rights and responsibilities among all persons: those who know they have HIV, those who have tested negative, and the vast majority who do not know their infection status. By "signing on" to such a contract, people can become joint stakeholders in a society of solidarity and sexual precaution that fortifies them against HIV and unnecessary suffering from AIDS.

Examples of best practice:

In Botswana, President Festus Mogae provides an example of a national leader who has understood and accepted the challenge of building a national response that covers all sides of the social contract.

In Malawi, South Africa and Zambia, a United Nations Volunteer programme shows how persons living with HIV/AIDS can contribute to national HIV/AIDS responses.

In Burundi, the National Association for Support of Persons living with HIV/AIDS runs a centre staffed by infected and affected persons which offers prevention activities, voluntary counselling and testing, medical and psycho-social support.

In Zimbabwe, Chirumhanzu Home-Based Care Project provides prevention and home care activities in a poor rural area, fortifying health system resources with those of families, communities and persons living with HIV/AIDS.

In South Africa, the Bambisanani programme combines the efforts of government, NGOs and the private sector to provide services to the social, economic and health needs of the infected, affected and vulnerable populations.

Getting the AIDS message out to broad populations – and following up with action

In the absence of a vaccine or cure, preventing unsafe sexual behaviour is still the most cost-effective way of saving lives. In places where denial and ignorance flourish, citizens have little defence against the silent spread of HIV. However, even in countries where the level of basic knowledge is very high among certain populations, significant behavioural change does not always follow. Merely getting the HIV/AIDS message out is not enough: action aimed at reducing stigma, teaching skills and helping people to change behaviour is crucial.

Examples of best practice:

In Senegal, Muslim and Christian leaders have become advocates for HIV/AIDS prevention and care.

In Ghana, social marketing of the female condom has gone from pilot project to national programme.

In Tanzania, traditional healers help dispel incorrect information about AIDS, reach people distrustful of medical systems, and distribute condoms.

Mutual reinforcement of AIDS care and prevention

Care and prevention programmes can be described as the " social contract" in action. Over and above their direct benefits to those infected and AIDS-affected families, these programmes have important spin-offs for the rest of the community. They make the epidemic more visible and hence help uninfected people to take the HIV threat more seriously as well as strengthen efforts in HIV prevention among those infected, affected and the ret of the population.

Examples of best practice:

Uganda’s AIDS Information Centre provides same-day confidential counselling and HIV testing. Counselling and testing helps empower people to access care, if infected, and take steps to protect themselves and/or their partners from infection.

In Côte d’Ivoire, the Centre for Socio-Medical Assistance (Centre d'Assistance socio-médicale), working in a poor urban setting, has used its prevention awareness work to build support for its clinical and home care activities.

In Zimbabwe, the Commercial Farmers Union combines peer education and condom distribution with home care for rural populations.

In Uganda, creative social marketing of a treatment kit for common sexually transmitted infections (STIs) in males simultaneously provides an entry-point for HIV/STI prevention.

In Uganda, trials of antiretroviral nevirapine have excellent potential for scaling up due to low drug cost and low complexity of treatment.

Something for all, and special measures for those at greater risk

Unprotected sex continues to fuel the HIV epidemic. Therefore, broad prevention campaigns aimed at the general public are still necessary. At the same time, it makes strategic sense to focus strongly on populations at greater risk and geographic areas where rapid HIV spread has become an emergency.

Examples of best practice:

In Senegal, AIDS education and condom use programming has successfully reduced transmission of HIV among sex workers and their clients.

In Cote d’Ivoire the Programme for STI/AIDS Care and Prevention among Female Sex Workers and their Partners have drawn the participation of three main groups: sex workers (both professional and non-professional); their clients and sex partners; and the owners and operators of locations where the sex trade occurs.

Making people less vulnerable to HIV infection

An individual or a community’s vulnerability to HIV is a measure of their ability to control the risk of infection. Personal factors, factors affecting access to relevant information and services, and societal factors may either mitigate or exacerbate vulnerability. For example, a person who is discriminated against with respect to education or employment on the basis of race, gender, sexual orientation or other characteristics is also more vulnerable to HIV infection. Similarly, a young person who can not access condoms is more vulnerable to HIV than other young people.

In many settings, women – and in particular young women – are especially vulnerable to HIV infection. They may be less able than men to avoid non-consensual or coercive sexual relations.

Rural communities may be vulnerable because of lower levels of literacy and less access to information and services.

Examples of best practice:

In Kenya, Mathare Youth Sports Association brings life skills and awareness of the HIV risk and prevention to young people before they become sexually active.

In Ethiopia, the Save Your Generation Association (SYGA) was implemented by a group of young men who wanted to do something about the rising impact of AIDS on young, out-of-school Ethiopians.

In Tanzania, careful planning for HIV prevention activities among migrant and local labour was carried out before construction began at the hydroelectric project at Kihansi Falls. Programming covered both the estimated 2,000 migrant workers and the 40,000 people already living near the dam site.

The Society for Women and AIDS in Africa (SWAA) was formed in 1988 to provide a platform for women to address HIV/AIDS and the socio-economic conditions which make them vulnerable to the epidemic. Today it has 28 country branches doing advocacy, prevention and many other activities.

Tanzania’s Female Guardians at Schools programme protects primary school girls against sexual harassment and exploitation, and assists them in dealing with social and reproductive health problems.

Reducing HIV/AIDS impact on people

What should be done when AIDS strikes an individual, family or community? Practices range from palliating painful symptoms of AIDS to outlawing discrimination based on HIV status and improving HIV-affected families’ ability to generate income.

Examples of best practice:

In Uganda, Mildmay Clinic provides specialized palliative care to people living with HIV/AIDS, reducing their suffering and pain, and to die without physical discomfort.

In Zimbabwe, the Zambezi Valley Organic Cotton Project helps many AIDS-affected agricultural smallholder families (particularly those headed by widows) by equipping them to grow a cash crop while reducing their need for expensive inputs and labour.

In the capital city of Kenya, the Kariobangi Community-Based Home Care Programme provides a good example of how to serve the children "left behind" by the AIDS epidemic.

Implementing Expanded Reponses

So far the Best Practices we have discussed have dealt with the implementation of specific programmatic and technical approaches to tackling the epidemic. However, ultimately a single comprehensive framework for planning and programming is needed by joining together the building blocks we have discussed.

Experience with such a framework is building up in Africa, and two additional building blocks would include strategic planning on a national level, and support to local responses in the field.

The development of a national strategic plan begins with an analysis of the situation and the response to HIV/AIDS, including risk behaviour and vulnerability factors, and using the resulting data to set priorities and focus initial action. Consensus is required from a wide range of actors including government, civil society, people living with and affected by HIV/AIDS, private sector and supported by the UN Theme Group and donors.

National strategic plans have been completed in 30 countries to date and are close to completion in another 14.

Examples of best practice:

The process of creating Malawi’s National HIV/AIDS Strategic Framework 2000-2004 shows how a broad-based national consensus can be built around a strategic planning process. It informed a wide range of groups and institutions about AIDS as an issue, built a sense of ownership among these groups and institutions and gave political leaders a high-profile document to commit to, with clear goals and principles.

In Cote d’Ivoire, which is currently experiencing serious political instability, the interaction of Cote d'Ivoire’s UN Theme Group on HIV/AIDS and national AIDS officials provides important lessons for coping with such instability and moving the response ahead.

In Malawi, clear national policy guidelines have shaped the evolution of planning and programming for the country’s growing number of orphans. The guidelines are simple and brief, and over the years have provided planning guidance for groups interested in developing orphan care programmes.

The development of Uganda’s 2000-2005 National Strategic Framework for HIV/AIDS Activities illustrates the decisive role that must sometimes be played by national political leadership. President Museveni took personal charge of Uganda’s HIV/AIDS planning process after it had lost momentum, and forced it back on track.

Support to local responses to HIV/AIDS is based on the empowerment of communities through the development of local partnerships consisting of social groups, service providers and facilitators. United in these local partnerships, people are gradually building socially acceptable actions that enable them to respond adequately to the epidemic.

Such support can only be based on decentralisation of the overall management of national responses.

The District Response Initiative is now underway in about 15 countries, which represents 50% of countries with national strategic plans.

Examples of best practice:

In Gaoua: In Burkina Faso the struggle against AIDS involves existing organisations and different administrative sectors. These partners, with the support of Gaoua authorities, have designed a common plan, agreed on shared objectives, and mobilised their own resources.

In Tanzania, the Kyela District Council has passed a ground-breaking by-law; aimed at addressing local behaviours that increase vulnerability to HIV/AIDS.