Key Points

  • Africa accounts for 70% of all HIV/AIDS cases in the world although it represents only 10% of the global population. More than 25 million Africans live with HIV/AIDS, and 17 million have already died.
  • The response of the international community has been slow and largely ineffective.
  • The UN estimates that Africa will need $3 billion just for basic treatment and prevention programs, yet the U.S. and other Western countries donated only $300 million in assistance in 2000.

According to the UN Agency for HIV/AIDS (UNAIDS), 25.3 million Africans live with the virus or are dying of AIDS. Barring a miracle or a major change in international attention to the scourge, these Africans will die within the next decade.

Despite the horrors of the pandemic, the international response has been limited and only recently have most African governments begun to publicly address the problem. African governments are hobbled by poverty, cultural taboos about sex, and misperceptions about the cause and seriousness of AIDS. They also fear disruption of precious tourism and investment dollars from the West and have failed to warn their citizens about the dangers of AIDS. Western nations, including the U.S., have largely ignored the dangers and international repercussions of widespread infection in Africa. The United States in 2000 spent only $300 million for basic AIDS care and prevention programs in Africa—far short of the $3 billion regarded as necessary to slow down the pandemic.

The HIV/AIDS crisis in Africa is of the gravest magnitude. Every day, 6,700 families lose a loved one to the disease; the construction and sale of coffins is one of the fastest growing occupations in southern Africa. Sixteen African countries have one-tenth or more of their population infected with HIV, and Africa is home to 95% of all mother-to-child transmissions of HIV. In these countries, almost 80% of all deaths of young adults aged 25-45 will be directly linked to AIDS.

In six countries of southern Africa, by the year 2005, AIDS will claim the lives of between 8 and 25% of today’s active physicians. Women are affected more by this dreaded disease; in Africa, 12 women have HIV/AIDS for every 10 men. African women account for 85% of all global female infections. In southern Africa, one in four women aged 15-49 live with HIV/AIDS. In some countries, between 10 and 20% of teen-age girls are already infected. Infected girls are more likely than boys to drop out of school, reversing decades of slow but steady progress in female education. The much-vaunted African extended family system is faltering, as the number of orphans living without the care of extended families rises. By the year 2010, the projected number of orphans may exceed 40 million in Africa.

Africa’s hard-won health and education gains in the 1960s and 1970s were undermined by debt and by externally dictated structural adjustment policies in the 1980s and 1990s. Today, however, social services and economies are imploding from the deadly consequences of AIDS. In the coming decades, the continent will record significantly sharper declines in life expectancy rates and shrinkage of national economies from the effects of the epidemic.

Africans living with HIV/AIDS have limited or no access to lifesaving anti-retroviral medicines that have changed the course and management of AIDS in Western countries. Less than one-tenth of one percent of Africans living with AIDS have access to AIDS drugs. The World Bank estimates that half of all Africans live on $0.65 cents per day. The economic resources of African governments are equally meager, and they are burdened by $20 billion in annual foreign debt payments. With the rudimentary healthcare infrastructure of African countries, the strain of long-term hospitalization of AIDS patients is taking a heavy toll.

Economic underdevelopment and Africa’s impoverished conditions have created a wide-open gateway for HIV infection, tuberculosis (TB), and sexually transmitted diseases (STDs). According to the World Health Organization, an estimated 30-50% of all TB patients in Africa are also infected with HIV/AIDS. Africa has the highest rates of STDs in the world. STDs facilitate the spread of HIV infection, especially among women.

Political instability and violent conflicts keep many African governments from focusing on the AIDS crisis. Twenty of the continent’s 53 countries are involved in intrastate or interstate conflicts, which lead to having the world’s largest regional concentration of refugees. Another important factor in the deepening crisis is the high rate of AIDS within Africa’s armed forces—15-20% of the members of the military in some countries have AIDS. Mobility of the African male populations—through military operations, migrant labor such as mine workers, and shifts from rural to urban centers—exacerbates the spread of HIV/AIDS. As the HIV/AIDS pandemic continues, political and social instability will likely intensify as AIDS gobbles up scarce human and economic resources.

Problems with Current U.S. Policy

Key Problems

  • The U.S. has not provided global leadership on access to AIDS drugs for Africa and has not supported Africa?s demand to purchase or produce generic drugs.
  • The U.S. 2001 budget for fighting AIDS in Africa is about $460 million, but much more is needed.
  • The U.S. has yet to assert its influence at the World Bank and the IMF to put more resources in Africa and to cancel external debts.

Whether someone lives or dies of AIDS depends largely on where she or he lives. Despite the availability of drugs to treat AIDS, millions of Africans will die because they do not have access to AIDS drugs. In the U.S. and other Western nations, such drugs have helped AIDS to become a disease that can be managed and for which effective care is available.

Confronting the AIDS emergency, African governments are demanding that pharmaceutical companies directly provide AIDS drugs at deep discounts, or at the very least not oppose compulsory licensing and parallel import arrangements. Compulsory licensing is an international trade mechanism by which countries can instruct a patent holder to license the right to use this patent to any national company or government agency. Parallel importing describes a practice whereby a country imports goods for resale without authorization from the original seller. (See Robert Weissman, “Facilitating Access to Essential Medicines,” FPIF, February 2001.) This struggle became heated with the court battle between the government of South Africa and 39 drug companies. The companies contended that a new law would allow the South African government to ignore international patent law.

Under mounting international pressure, the pharmaceutical industry dropped its suit, and has promised to facilitate the flow of low-priced AIDS-treatment pharmaceuticals. But this issue will not go away, because even lower priced drugs will still be out of reach for most Africans, and the pharmaceutical industry remains committed to strong international patent protection and to staving off the production of generic medicines for the treatment of AIDS and other illnesses.

The U.S and its Western allies have failed to provide significant funds to fight AIDS in Africa. In 2001, the wealthiest nation on earth is spending only $460 million dollars to fight the biggest medical and humanitarian emergency of our time. The United Nations estimates that at least $10 billion will be needed to fight AIDS in Africa. A group of Harvard researchers, economists, and scientists recommended that, at bare minimum, the U.S. should spend $1.5 billion a year to fight AIDS in Africa.

Fortunately, U.S. policymakers are responding to such public pressure with increased allocations. The U.S. Senate, for example, recently approved a $700 million increase in proposed spending over the next two years to fight AIDS in poor countries. However, much more needs to be done.

In another major issue confronting Africa, U.S policymakers have not squared up to their responsibility. Africa owes foreign banks and governments about $350 billion. These debts are controversial and a major hindrance to an adequate African response to AIDS. Every year, Africa spends roughly $20 billion on debt repayment—more than the combined continental outlay for healthcare and education. At least 23 African countries spend more money on debt repayment than they spend for healthcare. The International Monetary Fund (IMF) and the World Bank have yet to effect significant debt cancellation for African nations despite widespread pressure from international citizen movements and from the G8, the forum of the world’s wealthiest nations. The U.S., which is the largest shareholder in these two international financial institutions, has yet to demand debt cancellation for Africa.

The policy problems that contribute to the AIDS crisis in Africa extend beyond Washington and other international donors. Until recently, African leaders have largely ignored the pandemic. Even today, very few African nations match their AIDS rhetoric with commensurate budget allocations. Uganda and Senegal are prominent exceptions.

Senegal, through a combination of political will, prudent budget allocations, and massive mobilization has kept its rate of infection to less than one percent. Ugandan President Yoweri Musuveni, recognizing the gravity of the AIDS pandemic, mobilized his people to modify risky behaviors and to come forward for testing and counseling. The rate of AIDS in Uganda is down to about 8%, from a high of 16% in the early 1990s.

Despite the laudable efforts of Uganda and Senegal, corruption and the squandering of scarce national resources continue. Government spending on wars, white elephant projects, and persecution of political and economic opponents is still rife across the continent.

Toward a New Foreign Policy

Key Recommendations

  • The U.S should lead other rich nations in supplying essential medicines to Africans living with AIDS, and devote significantly more resources to fighting AIDS in Africa.
  • The U.S should lead the fight for debt relief for African nations and ensure that the savings go into AIDS relief and other healthcare programs.
  • The U.S and other rich nations should work with African governments to create an environment conducive to AIDS relief on the continent.

The immediate goal of a reinvigorated U.S policy should be the dismantling of all legal and logistic obstacles to the provision of affordable drugs to all Africans living with AIDS. The developed nations, led by the U.S., should rise in unison and make a simple pledge: No African Man, Woman, Child, or Infant Should Be Denied Access to Lifesaving AIDS Drugs, by December 2002.

As the leading global democracy, the U.S. should democratize access to essential AIDS medicines for poor nations. We commend the Bush administration for maintaining President Clinton’s executive order on flexible access to AIDS drugs for poor nations. However, the U.S. needs to do more. The U.S. should ensure that the World Trade Organization (WTO) implements a flexible interpretation of the Trade-Related Intellectual Property Rights Agreement (TRIPS), thereby allowing poor nations facing the AIDS emergency to provide cheap AIDS drugs to their citizens. The U.S. and its allies should also ensure that all WTO rulings reflect a sound public health framework to ensure that the goal of unencumbered trade does not create adverse health consequences in poor nations.

The U.S. government should work more closely with the pharmaceutical companies to ensure that all obstacles to speedy and effective delivery of AIDS medicines to poor nations are eliminated. These obstacles include: (1) the concerns of pharmaceutical companies about possible parallel imports of cheap AIDS drugs into the lucrative Western markets by poor nations; (2) the concerns of citizen advocates and AIDS activists that access to AIDS drugs should not come under the purview of market forces and restrictive patent laws; and, (3) the concerns of African governments that they should have the exclusive prerogative to determine national emergencies and possible remedial actions. Washington should also work to persuade U.S. multinational companies doing business in Africa to provide AIDS prevention and treatment programs for their workers and family members.

The U.S. should devote more resources to fighting AIDS in Africa. America has always responded to major humanitarian needs, whether in Europe, Asia, or Latin America. It is time to spend readily available resources to stop AIDS in Africa. Harvard researchers estimated that a scaled-up U.S. response of $1.5 billion would cost about $5 a year per American. Doubling such a commitment would cost each American about $10 a year—a commitment well worth making, considering the magnitude of the crisis and its long-term implications for global peace and development.

It is not likely that other rich nations will spend significantly more money on AIDS without a serious commitment from the United States. The Constituency for Africa (CFA), under the leadership of former Congressman Ron Dellums, proposed a HIV/AIDS Marshall Plan for Africa with significant public- and private-sector funds to fight the disease. As a result, Congress, in August 2000, passed Public Law 106-264, the Global AIDS and Tuberculosis Relief Act of 2000, sponsored by Jim Leach, R-Iowa and Barbara Lee, D-California, that earmarked $150 million dollars for each of the fiscal years 2001 and 2002, for a Trust Fund. The Trust Fund will be used to leverage funds from multilateral development banks like the World Bank and to encourage similar commitments from other Western donors. The Trust Fund will also fund the implementation of specific HIV/AIDS programs in Africa. President Clinton signed the bill into law, as a modest start to what promises to be a long journey.

The U.S. should use its significant leverage in the G8, the IMF, and the World Bank to provide debt relief for African nations. The U.S. has the excellent opportunity at the G8 summit, in July 2001, to persuade its allies to forgive the debt of African nations, on the condition that African governments plow back such savings into verifiable investments in AIDS prevention and treatment programs and other healthcare services. The U.S. government is not the major holder of African debt—it is owed about $360 million out of the estimated $350 billion in controversial debts—but the U.S. has the moral, economic, and political leverage to advance a genuine debt relief agenda among its allies. Washington should also work with African leaders and their peoples to ensure a concerted and consistent focus on the AIDS epidemic. Without dictating their actions, the U.S should work with African governments to ensure movement in the following areas: (1) allocation of more money by African nations to fight AIDS; (2) sustained political reforms to encourage pluralistic political and multi-sector campaigns against AIDS; (3) end corrupt practices that siphon foreign aid and investments; and, (4) encourage the emergence of more civil society involvement in politics and non-government programs at community levels.

The international community led by the U.S. should not turn its back on 25 million Africans living under a death sentence. The international cooperation that has fought against oppression and tyranny since World War II should not permit the AIDS killing fields to continue in Africa. A strong case can be made that the AIDS pandemic in Africa represents a direct threat to U.S. national interests and national security because of associated political instability, economic downturn, and the intercontinental spread of infectious diseases. In the end, however, U.S. citizens and U.S. policymakers face a moral imperative and should ask: Have we done all we can to save 25 million fellow human beings from an avoidable death?

Disproportionate Impact of HIV/AIDS
Indicator Africa Outside Africa
% world population (2000) 10% 90%
% adults living with HIV infection (2000) 70% 30%
% children living with HIV/AIDS infections (2000) 80% 20%
% females living with HIV infections (2000) 85% 15%
% dead of AIDS (since early 1980s) 79% 21%
% maternal-to-infant transmission (since early 1980s) 95% 5%

% AIDS orphans (since early 1980s)



AIDS Epidemic Update: December 2000 (Geneva: UNAIDS and World Health Organization, 2000); Special Session of the General Assembly on HIV/AIDS. Report of the Secretary-General. February 16, 2001 (New York: United Nations General Assembly, 2001).
, Melvin Foote is President/CEO of the Constituency for Africa (CFA), a Washington, DC advocacy organization. CFA is promoting an AIDS Marshall Plan for Africa. Chinua Akukwe is a board member of Constituency for Africa, and Adjunct Professor at George Washington University School of Public Health.