tag:theconversation.com,2011:/au/topics/pepfar-25384/articlesPEPFAR – The Conversation2023-01-24T13:23:01Ztag:theconversation.com,2011:article/1949082023-01-24T13:23:01Z2023-01-24T13:23:01ZGrassroots AIDS activists fought for and won affordable HIV treatments around the world – but PEPFAR didn’t change governments and pharma<figure><img src="https://images.theconversation.com/files/505231/original/file-20230118-18-a5un95.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C645&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">AIDS activists have used protests to demand access to treatment.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/people-from-africa-action-mark-world-aids-day-with-a-rally-news-photo/78178017">Jim Watson/AFP via Getty Images</a></span></figcaption></figure><p>The <a href="https://www.kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency-plan-for-aids-relief-pepfar/">President’s Emergency Program for AIDS Relief, or PEPFAR</a>, has revolutionized the fight against global AIDS over the last 20 years. <a href="https://www.state.gov/wp-content/uploads/2021/12/PEPFAR-Latest-Global-Results.pdf">In that time</a>, the U.S. program has brought antiretroviral treatment to nearly 19 million people living with HIV, the virus that causes AIDS; prevented mother-to-child transmission of HIV for 2.8 million babies; and brought HIV testing and prevention services to millions of others. </p>
<p>But this program would not be so successful – and might not even exist – without the work of grassroots AIDS activists around the world.</p>
<p>As a <a href="https://scholar.google.com/citations?user=pTaBXaIAAAAJ&hl=en">historian of social movements</a>, I spent years interviewing AIDS activists, digging through their papers and scanning old websites, group email lists and message boards. These sources showed that, over the course of more than a decade, these activists challenged the status quo to demand – and deliver – HIV treatment to millions of poor people around the world.</p>
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<figcaption><span class="caption">Treatment Action Campaign activists in South Africa put pressure on drugmakers and governments for access to HIV medication.</span></figcaption>
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<h2>AIDS drugs for Africa</h2>
<p>In his <a href="https://www.washingtonpost.com/wp-srv/onpolitics/transcripts/bushtext_012803.html">2003 State of the Union address</a>, then-U.S. President George W. Bush announced the creation of PEPFAR when he called for an astounding US$15 billion in funding over five years for the fight against AIDS in Africa and the Caribbean.</p>
<p>His announcement did not come out of nowhere. By that point, AIDS activists had spent years fighting to bring treatments for HIV to low- and middle-income countries hardest hit by the epidemic. My book, “<a href="https://uncpress.org/book/9781469661339/to-make-the-wounded-whole">To Make the Wounded Whole</a>,” describes how members of the AIDS Coalition to Unleash Power (ACT UP) Philadelphia linked their own struggles for affordable, quality health care for poor people with AIDS in the U.S. to similar struggles around the world.</p>
<p>This fight began in earnest in the late 1990s when highly effective antiretrovirals to treat HIV became available, giving a new lease on life to those who could access them. But the new drugs were expensive, and activists saw that their high cost would <a href="https://actupny.org/Vancouver/sawyerspeech.html">put them out of reach for most who needed them</a>.</p>
<p>Some low- and middle-income countries took their own steps to make life-saving antiretrovirals available. In 1997, South Africa, in the midst of a rapidly growing HIV epidemic, passed the <a href="https://www.jstor.org/stable/24115724">Medicines and Related Substances Act</a>, allowing the government to produce or acquire less-expensive generic versions of the drugs. Meanwhile, <a href="https://doi.org/10.1016/s0140-6736(02)11775-2">domestically produced generics</a> were a cornerstone of Brazil’s program to provide access to free antiretrovirals for people living with HIV/AIDS in the country.</p>
<p><a href="https://web.archive.org/web/20000524182434/http://www.aegis.com:80/news/ct/1999/ct990404.html">Pharmaceutical companies opposed these efforts</a>, with a representative of the Pharmaceutical Research and Manufacturers Association (PhRMA) claiming that countries that produced generics committed “a form of patent piracy.” So, too, did the Clinton administration, claiming that South Africa and Brazil violated intellectual property agreements under the World Trade Organization. In particular, former Vice President Al Gore, acting as chair of the U.S.-South Africa Binational Commission, and Charlene Barshefsky, the U.S. Trade Representative, <a href="http://www.cptech.org/ip/health/sa/stdept-feb51999.html">pressured their South African counterparts</a> to change the law in 1999.</p>
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<a href="https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Activists marching with signs reading 'Europe! Hands off our medicine'" src="https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/505233/original/file-20230118-15-abvp33.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">AIDS activists in Nairobi, Kenya, protested against a free trade agreement between the European Union and India that would have phased out generic AIDS drugs.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/KenyaAIDS/a45c66d0b20044878765422e1f099f09">Khalil Senosi/AP Photo</a></span>
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<p>Activists fought back against both the pharmaceutical industry and the policymakers who put intellectual property rules, and the corporate profits they protected, ahead of saving people’s lives. Members of ACT UP Philadelphia, along with others, <a href="https://actupny.org/actions/gorezaps.html">hounded Gore on the presidential campaign trail</a>, chanting, “Gore is killing Africans – AIDS drugs now,” and <a href="https://www.democracynow.org/1999/11/19/act_up_activists_storm_office_of">occupied Barshefsky’s office in Washington</a>. They also participated in a massive demonstration at the 2000 International AIDS Conference in Durban, South Africa, with thousands of marchers from around the world crying “<a href="https://actupny.org/reports/durban-march.html">Phansi, Pfizer, phansi!</a>” (“phansi” is Zulu for “down”) to demand a reduction in the drug company’s AIDS treatment prices.</p>
<p>All of this agitation worked. Clinton <a href="https://www.sfgate.com/health/article/Poor-Nations-Given-Hope-on-AIDS-Drugs-New-2892857.php">curbed his administration’s pressure campaign</a> against South Africa. Thanks in part to the wider availability of generics, the average cost of antiretrovirals <a href="https://www.msf.org/patents-prices-patients-example-hivaids">fell dramatically</a>. And the <a href="https://www.wto.org/english/thewto_e/minist_e/min01_e/mindecl_trips_e.htm">2001 World Trade Organization Ministerial Conference in Doha, Qatar</a>, affirmed that public health and “access to medicines for all” would be paramount in the fight against HIV/AIDS and other epidemics.</p>
<p>Having succeeded in making antiretrovirals more affordable, activists pressed for an international program to purchase and distribute them. According to journalist Emily Bass, <a href="https://www.publicaffairsbooks.com/titles/emily-bass/to-end-a-plague/9781541762459/">external pressure from grassroots activists</a> gave global health advocates within the Bush administration, including National Institute of Allergy and Infectious Diseases Director and chief medical advisor Anthony Fauci, the opportunity to push forward their proposal for a massive effort by the U.S. to treat AIDS in Africa. That proposal quickly evolved into PEPFAR.</p>
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<figcaption><span class="caption">John Robert Engole was the first patient to receive HIV treatment under PEPFAR.</span></figcaption>
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<p>Activists continued to shape PEPFAR as the program came together. They advocated for people with AIDS to be treated with generic antiretrovirals, which allowed more people to be treated than would otherwise be possible with patented drugs. And when it came time to renew PEPFAR in 2008, they <a href="https://healthgap.org/wp-content/uploads/2018/11/Bird-dogging-101.pdf">extracted promises from presidential candidates</a> to <a href="https://fpif.org/how_to_stop_aids_now/">reauthorize the program at $50 billion</a>, over three times Bush’s initial pledge.</p>
<p>Today, PEPFAR <a href="https://www.state.gov/where-we-work-pepfar/">works in over 50 countries</a>, including in Central and South America, Southeast Asia and the former Soviet Union. Since 2003, the program has injected <a href="https://www.kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency-plan-for-aids-relief-pepfar/">over $100 billion</a> into the fight against global AIDS, although <a href="https://www.kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency-plan-for-aids-relief-pepfar/#endnote_link_559116-23">annual funding levels have been flat for most of that time</a>. Yet despite stagnant funds, PEPFAR has brought treatment to an increasing number of people in need. That it has done so is in no small part thanks to the AIDS activists who fought to make generic antiretrovirals available, allowing the program to treat many more people than would otherwise be possible.</p>
<h2>Lessons unlearned</h2>
<p>To be sure, the Bush administration had its own reasons to address AIDS in Africa. National security experts at the U.S. State Department had <a href="https://uncpress.org/book/9780807872116/infectious-ideas/">long worried that AIDS would destabilize the continent</a>, as historian Jennifer Brier has shown, and PEPFAR burnished the president’s commitment to “<a href="https://newrepublic.com/article/86075/compassionate-conservative-hiv-pepfar-bush-gop-budget">compassionate conservatism” and faith-based social programs</a>. </p>
<p>But by the time of Bush’s announcement, grassroots activists had already spent years arguing in public that treating AIDS in Africa was not only possible but imperative. And their advocacy for low-cost generic antiretrovirals paved the way for global AIDS treatment on a scale that had once been thought impossible.</p>
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<a href="https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Protestors holding a black coffin, wearing paper skull masks and signs reading 'I died on an ADAP waiting list' and 'Gilead gouges gov' AIDS dollars'" src="https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/505646/original/file-20230120-4485-zn9j4t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">AIDS protestors called upon pharmaceutical companies to lower drug pricing to affordable levels.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AIDSHealthcareFoundationProtestatGileadSciences/3937be37fe0b45339e1518d5ad3c48b2">Alison Yin/AP Images for AIDS Healthcare Foundation</a></span>
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<p>Unfortunately, U.S. responses to recent viral epidemics have not shown evidence that the nation has learned from the PEPFAR example. The <a href="https://doi.org/10.1038/d41586-022-03529-3">hoarding of COVID-19 vaccines</a> by the U.S. and other wealthy nations shows the same persistent disregard for human life that was evident in attempts to block generic medicines from reaching people who needed them. At the same time, millions of doses of a highly effective vaccine against mpox in the U.S. national vaccine stockpile were <a href="https://www.nytimes.com/2022/08/01/nyregion/monkeypox-vaccine-jynneos-us.html">allowed to expire</a> while outbreaks of the virus <a href="https://doi.org/10.1038/d41586-022-01686-z">raged in West and Central Africa</a> in 2022. And early 2023 announcements that Pfizer and Moderna may both price their COVID-19 vaccines at <a href="https://arstechnica.com/science/2023/01/moderna-may-match-pfizers-400-price-hike-on-covid-vaccines-report-says/">well over $100 per dose</a> in the U.S. recalls the exorbitant drug prices that aroused activist fury in the fight against AIDS.</p>
<p>PEPFAR has saved millions of lives, in no small part because activists thought big and fought hard for justice in the U.S. response to global AIDS. Although the program is far from perfect, it serves as a reminder of what is possible when solidarity guides responses to humanity’s biggest challenges, and the power of grassroots organizing in turning principles into policy.</p><img src="https://counter.theconversation.com/content/194908/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dan Royles has received funding from the National Endowment for the Humanities and the National Park Service. He is affiliated with the Miami-Dade Democratic Party. </span></em></p>The US PEPFAR initiative has brought HIV medication to millions of people globally. Behind this progress are the activists that pressured politicians and companies to put patients over patents.Dan Royles, Associate Professor of History, Florida International UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1945392022-11-15T14:00:44Z2022-11-15T14:00:44ZUS midterm elections deserve Africa’s attention – but not for reasons of foreign policy<figure><img src="https://images.theconversation.com/files/495070/original/file-20221114-18-wfiqzj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Americans vote In the 2022 midterm elections on 8 November. </span> <span class="attribution"><span class="source">Drew Angerer/Getty Images</span></span></figcaption></figure><p>Africans normally pay little attention to American elections when the presidency is not at stake. But the midterm polls – such as the <a href="https://edition.cnn.com/politics/live-news/midterm-election-results-livestream-voting-11-08-2022/index.html">8 November 2022</a> one – deserve Africa’s attention. </p>
<p>During midterms, US voters elect 435 members of the House of Representatives for a two-year term and one-third of the senators, the 100-member upper house, who serve for six years. The two houses are collectively known as the <a href="https://www.visitthecapitol.gov/about-congress">US Congress</a>. Some governors, and other officials, including those responsible for elections of the 50 states, also seek a mandate during this period. </p>
<p>Midterm elections take place halfway into the president’s term of office. Typically, they are taken as a judgement on his performance. President Joe Biden’s national approval rating on the day before the midterms was <a href="https://www.reuters.com/world/us/biden-approval-ticks-lower-democrats-brace-midterm-losses-reutersipsos-2022-11-07/">only 39%</a>. This suggested there would be another big win for the opposition Republicans. Instead, the Senate <a href="https://www.bbc.com/news/world-us-canada-63613264">remains narrowly Democratic</a> and the House likely will have a slim Republican majority when all votes are finally counted. </p>
<p>America is still deeply divided. I believe, however, that the electioneering showed democracy’s resilience, which should be a boost for democracy advocates across Africa. </p>
<p>The “wild card” in this election was the role of Donald Trump. He and his supporters managed to get their candidates nominated in many states. Most promoted his false claim that the 2020 presidential election had been “stolen” and Biden was an illegitimate president. They also favoured the Supreme Court’s decision to overturn a woman’s right to an abortion. Both issues, electoral integrity and human rights, are of concern to democrats everywhere, including Africa.</p>
<h2>Foreign policy was not an issue</h2>
<p>Voters understand that foreign policy is rarely an issue in midterm elections. Presidents retain wide discretion in foreign policy. </p>
<p>Current <a href="https://www.whitehouse.gov/wp-content/uploads/2022/08/U.S.-Strategy-Toward-Sub-Saharan-Africa-FINAL.pdf">US strategy towards sub-Saharan Africa</a> will continue to frame US foreign policy at least until 20 January 2025, when the next administration is inaugurated. But African governments and their citizens have many other interests and values at stake in relations with America.</p>
<p>What matters to African countries are the social forces at work in the US that may affect the long term relations between the US and Africa. America is becoming more pluralistic. The African diaspora is becoming more integrated. A backlash from those Whites fearful of losing status seems inevitable. Whether and how Americans manage this peacefully and democratically should interest the world’s most diverse continent. </p>
<p>I recall, for example, how the <a href="https://blacklivesmatter.com/">Black Lives Matter</a> campaign <a href="https://www.wbur.org/hereandnow/2020/06/12/black-lives-matter-africa">resonated across Africa</a>. </p>
<h2>The Trump factor</h2>
<p>The foremost US domestic issue that should concern Africa is whether Donald Trump’s role in shaping this election will affect his own prospects of reelection in 2024. Many of his supporters ran, and <a href="https://www.theguardian.com/us-news/2022/nov/09/trump-endorsed-candidates-republicans-midterm-performance">many of them lost</a>. This could reduce his chance to be the Republican nominee <a href="https://www.brookings.edu/blog/fixgov/2022/11/09/what-do-the-2022-midterms-mean-for-2024/">in 2024</a>. </p>
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<img alt="A man wearing a suit, shirt and tie is shown speaking into a microphone." src="https://images.theconversation.com/files/495313/original/file-20221115-11-f6vr5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/495313/original/file-20221115-11-f6vr5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=449&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495313/original/file-20221115-11-f6vr5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=449&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495313/original/file-20221115-11-f6vr5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=449&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495313/original/file-20221115-11-f6vr5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495313/original/file-20221115-11-f6vr5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495313/original/file-20221115-11-f6vr5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">US President Joe Biden.</span>
<span class="attribution"><span class="source">Chip Somodevilla/via Getty Images</span></span>
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<p>Three aspects of these hotly contested races that are salient for sustainable democracy in Africa are already clear. </p>
<p>First, in highly polarised but diverse societies, close elections are to be expected, and demand nonviolent and just democratic discipline.</p>
<p>Second, electoral integrity matters and must be transparent and authoritative. Citizens need to be confident that all their votes will be counted. Trump and his allies denigrated the certified electoral results in 2020 and the <a href="https://factcheck.afp.com/doc.afp.com.32N83JF">accuracy of voting last week</a>. But voting in all 50 states went off with <a href="https://www.axios.com/2022/11/09/midterms-homeland-security-no-voter-fraud">very few glitches</a>. </p>
<p>Third, candidates must “play by the rules”. The most important of which is to concede when informed by election officials that you have lost. If candidates fail to do this, the risk of violence becomes acute, as it did in the assault on the US Capitol by Trump supporters <a href="https://www.justice.gov/usao-dc/one-year-jan-6-attack-capitol">on 6 January 2021</a>. Voters in the midterms showed that they <a href="https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2022/11/09/voters-push-back-against-election-deniers-in-key-states">rejected “electoral denialism”</a> without proof.</p>
<p>A divisive but decisive issue that motivated high turnout in several US several swing states was whether women have a human right to decide for themselves whether to have an abortion, within democratically agreed rules. </p>
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Read more:
<a href="https://theconversation.com/how-us-policy-on-abortion-affects-women-in-africa-182525">How US policy on abortion affects women in Africa</a>
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<p>Many other democracies, including South Africa, constitutionally guarantee this right. Republicans have long <a href="https://www.guttmacher.org/gpr/2013/09/abortion-restrictions-us-foreign-aid-history-and-harms-helms-amendment">imposed abortion restrictions on women’s health</a> programmes sponsored by the US Agency for International Development. During the Obama Administration they were removed, but Trump <a href="https://www.theguardian.com/world/2017/may/15/trump-abortion-rule-mexico-city-policy">reimposed them</a>. </p>
<h2>US elections and the world</h2>
<p>The 2022 US midterm election at least offers hope that constitutional or civic nationalism – not white racial nationalism – will define US democracy. The country is demographically <a href="https://academic.oup.com/book/41486/chapter/352889533%5DProf">becoming more ethnically diverse</a>, in that sense more like Africa. </p>
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<img alt="A man wearing a suit, shirt and tie appears in a pensive mood." src="https://images.theconversation.com/files/495312/original/file-20221115-23-jblmdu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/495312/original/file-20221115-23-jblmdu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495312/original/file-20221115-23-jblmdu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495312/original/file-20221115-23-jblmdu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495312/original/file-20221115-23-jblmdu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495312/original/file-20221115-23-jblmdu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495312/original/file-20221115-23-jblmdu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="source">Former US President Donald Trump. Saul Loeb/AFP via Getty Images</span></span>
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<p><a href="https://www.pewresearch.org/race-ethnicity/2022/01/20/the-caribbean-is-the-largest-origin-source-of-black-immigrants-but-fastest-growth-is-among-african-immigrants/">America has a large and growing African diaspora</a>. According to exit polls, eight in 10 black Americans voted for Democratic candidates in the 2022 midterm election, although Republicans are <a href="https://www.washingtonpost.com/nation/2022/11/11/black-asian-latino-voter-turnout/">making some inroads</a>. Many are recent immigrants from Africa who continue to maintain close family and cultural ties to their <a href="https://www.pewresearch.org/fact-tank/2022/01/27/key-findings-about-black-immigrants-in-the-u-s/">countries of origin</a>. </p>
<p>African scholars and diplomats could learn important lessons from their diaspora’s hopes and fears about America’s version of democracy and federal system. </p>
<h2>Mutual learning</h2>
<p>All African governments are collectively committed to basic democratic principles under the <a href="https://au.int/sites/default/files/pages/34873-file-constitutiveact_en.pdf">Constitutive Act of the African Union</a> and the African Charter for Democracy, Elections, and <a href="https://au.int/en/treaties/african-charter-democracy-elections-and-governance">Governance</a>. </p>
<p>The United States, the world’s oldest democratic experiment, remains vulnerable to a populist demagogue, determined to defy the first principle of sustainable democracy: the peaceful transition of power. This alone should give African scholars incentives to learn more about the internal workings of American politics and why and how this principle showed resilience in the 2022 midterm poll. </p>
<p>This could inform their debates about which version of democracy is best for their nation, and might even yield fresh insights of value to American democrats as they strive to fulfil their constitution’s promise to <a href="https://www.uscourts.gov/about-federal-courts/educational-resources/about-educational-outreach/activity-resources/us#:%7E:text=%22We%20the%20People%20of%20the,for%20the%20United%20States%20of">“form a more perfect union”</a>.</p><img src="https://counter.theconversation.com/content/194539/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John J Stremlau does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Despite America’s deep divisions, the electioneering showed democracy’s resilience. This should be a boost for democracy advocates across Africa.John J Stremlau, Honorary Professor of International Relations, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1505962020-12-17T13:29:19Z2020-12-17T13:29:19Z10 reasons why Anthony Fauci was ready to be the face of the US pandemic response<figure><img src="https://images.theconversation.com/files/374923/original/file-20201214-17-1s3m7ar.jpg?ixlib=rb-1.1.0&rect=1086%2C718%2C2874%2C1864&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Fauci is an accomplished scientist who also excels at connecting with the public.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/WashingtonIdeasForum/429cb8132c184c1fbd3ccbe28a3dc87d/photo?boardId=d7f2514f50804466b15dfb81ed00d9cd&st=boards&mediaType=audio,photo,video,graphic&sortBy=&dateRange=Anytime&totalCount=26&currentItemNo=8">AP Photo/Cliff Owen</a></span></figcaption></figure><p>His call to “Wear a mask” tops a <a href="https://apnews.com/article/joe-biden-fred-shapiro-anthony-fauci-coronavirus-pandemic-racial-injustice-e91a67237ab395eb63105d4bfb811247">list of 2020’s notable quotes</a>. Brad Pitt <a href="https://www.youtube.com/watch?v=uW56CL0pk0g">portrayed him – and praised him – on “Saturday Night Live</a>.” Time magazine <a href="https://time.com/guardians-of-the-year-2020-anthony-fauci-frontline-health-workers/">named him a 2020 guardian of the year</a>. Amazon features seven pages of T-shirts, mugs and more emblazoned with his face.</p>
<p>Longtime <a href="https://www.niaid.nih.gov/about/director">director of the National Institute of Allergy and Infectious Diseases</a> Anthony S. Fauci has been everywhere in 2020.</p>
<p>Although perhaps only recently a household name, Fauci is no Tony-come-lately. Over the past four decades he’s played prominent roles as a scientist, physician, administrator and spokesman. You know what he’s been up to over the past several months. But what of his previous nearly 80 years? And what made him the figure he has become?</p>
<h2>From Brooklyn to Washington</h2>
<p><a href="https://en.wikipedia.org/wiki/Anthony_Fauci">Fauci, son of a pharmacist</a>, was <a href="https://www.biography.com/scientist/anthony-fauci">born in Brooklyn</a> on Dec. 24, 1940. He attended Regis High, a tuition-free Jesuit boys’ school. Passionate about basketball, he captained the high school team – despite his height of 5 feet 7 inches.</p>
<p>He then attended the College of the Holy Cross, in Massachusetts, choosing a premedical major combining humanities and science. He graduated first in his class from Cornell University Medical College and went on to complete a medical residency.</p>
<p>The Vietnam War was underway, and male med school graduates were required to serve their country. One option was the U.S. Public Health Service, which includes the National Institutes of Health, based outside Washington, D.C. Fauci entered a <a href="https://history.nih.gov/download/attachments/1016824/YellowBerets.pdf">highly selective training program</a> there. He’s worked at NIH essentially ever since.</p>
<p>At NIH, Fauci initially conducted specialized research on the immune system and related rare diseases – for example, one now termed <a href="https://medlineplus.gov/granulomatosiswithpolyangiitis.html">granulomatosis with polyangiitis</a>, in which blood vessels in the respiratory system and kidneys become inflamed. His work led to effective treatment of these previously largely fatal conditions.</p>
<h2>The age of AIDS</h2>
<p>As the 1980s arrived, what came to be called AIDS emerged. Fauci soon redirected his research to focus on the new disease. <a href="https://www.washingtonpost.com/opinions/2020/07/16/anthony-fauci-built-truce-trump-is-destroying-it/?arc404=true">He accepted the directorship of NIAID in 1984</a>, in part to increase its emphasis on AIDS.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/375430/original/file-20201216-21-5fkz11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="protesters holding signs with flare smoke in background" src="https://images.theconversation.com/files/375430/original/file-20201216-21-5fkz11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/375430/original/file-20201216-21-5fkz11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/375430/original/file-20201216-21-5fkz11.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/375430/original/file-20201216-21-5fkz11.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/375430/original/file-20201216-21-5fkz11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=497&fit=crop&dpr=1 754w, https://images.theconversation.com/files/375430/original/file-20201216-21-5fkz11.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=497&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/375430/original/file-20201216-21-5fkz11.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=497&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Protesters demonstrating at the National Institutes of Health, May 21, 1990.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AIDSCrisis1990/c87a4dad94ff403b8eb5895a047ffcca/photo?boardId=d7f2514f50804466b15dfb81ed00d9cd&st=boards&mediaType=audio,photo,video,graphic&sortBy=&dateRange=Anytime&totalCount=27&currentItemNo=0">AP Photo/Bob Daugherty</a></span>
</figcaption>
</figure>
<p>While continuing research and patient care, Fauci as institute director entered other realms. He <a href="https://www.c-span.org/person/?anthonyfauci">testified repeatedly before Congress</a>. He gained visibility in the media. He was confronted by AIDS activists – and eventually <a href="https://www.newyorker.com/magazine/2020/04/20/how-anthony-fauci-became-americas-doctor">included them in setting priorities for developing treatments</a>. Doing so <a href="https://www.washingtonpost.com/history/2020/05/20/fauci-aids-nih-coronavirus/">set a precedent for involving patients</a> in decisions about research on their diseases.</p>
<p>Fauci’s leadership has expanded over the years. He was among the main architects of the President’s Emergency Plan for AIDS Relief, or <a href="https://www.state.gov/pepfar/">PEPFAR</a>, a major program <a href="https://doi.org/10.1056/NEJMp1714773">begun under President George W. Bush in 2003</a>, to <a href="https://www.hiv.gov/federal-response/pepfar-global-aids/pepfar">help control AIDS internationally</a>. He provided leadership regarding responses to <a href="https://doi.org/10.1097/01.COT.0000295196.65807.39">bioterrorism</a> and to <a href="http://dx.doi.org/10.3201/eid1104.041167">SARS</a>, <a href="https://doi.org/10.1056/NEJMp1600297">Zika</a> and <a href="https://doi.org/10.1056/NEJMp1409494">Ebola</a>. He is a member of the Trump administration’s White House Coronavirus Task Force, and he has accepted President-elect Joe Biden’s <a href="https://www.nytimes.com/2020/12/04/us/fauci-says-he-accepted-bidens-offer-to-be-chief-medical-adviser-right-on-the-spot.html">invitation to serve as chief medical adviser</a>.</p>
<h2>Prolific in publication</h2>
<p>Along the way, Fauci has <a href="https://pubmed.ncbi.nlm.nih.gov/?term=fauci+as">authored or co-authored well over 1,000 journal articles</a>, including <a href="https://pubmed.ncbi.nlm.nih.gov/?term=fauci+as&filter=subject.aids">more than 500 about AIDS</a>. Of the articles, strikingly many appeared in top journals such as Science, Proceedings of the National Academy of Sciences and the New England Journal of Medicine. Fauci also is one of the editors of <a href="https://www.mhprofessional.com/medical/harrisons-principles-of-internal-medicine">a major medical textbook</a>.</p>
<p>Over the years Fauci published on topics that attest to his readiness for the coronavirus: <a href="https://doi.org/10.1086/511989">past pandemics</a> as well as <a href="https://doi.org/10.1097/00001888-200512000-00002">emerging infectious diseases</a> and <a href="https://doi.org/10.1126/scitranslmed.3009872">how to confront them</a>, even how to <a href="https://doi.org/10.1177/1740774515618198">conduct clinical trials in the midst of an outbreak</a>.</p>
<p>A recent study <a href="http://www.webometrics.info/en/hlargerthan100">ranks Fauci as the 32nd most highly cited</a> living researcher. His papers have been <a href="https://app.webofknowledge.com/author/record/30304308">cited more than 50,000 times</a> by other publications, and his journal articles have been mentioned tens of thousands of times in social media.</p>
<h2>Sources of success</h2>
<p>Clearly, Fauci is a remarkably successful scientist and a highly visible public figure. What factors seem to have contributed? Here are 10.</p>
<ol>
<li><p>Smarts: Clearly Fauci is extraordinarily bright and knowledgeable. He has studied both science and humanities. The mix has fostered proficiency in lab and clinic, skill in communication and an ability to navigate the halls of power.</p></li>
<li><p>Integrity: “I believe I have a personal responsibility to make a positive impact on society,” he <a href="https://www.npr.org/templates/story/story.php?storyId=4761448">has stated</a>. “I’ve tried to accomplish this goal by choosing a life of public service.” Strong values have directed his choices, such as that to remain at NIAID <a href="https://www.nature.com/articles/nm0102-10">despite offers</a> to become director of NIH or take more lucrative positions elsewhere.</p></li>
<li><p>Empathy: Fauci’s values include concern for others’ well-being. Upon being confronted by AIDS activists, he said, “<a href="https://www.holycross.edu/departments/publicaffairs/hcm/summer02/features/fauci.html">I saw people who were in pain</a>.” He cared for, and about, people with AIDS even while the disease still was tremendously stigmatized.</p></li>
<li><p>Flexibility: Fauci can pivot. He redirected his work with the emergence of AIDS, contributing importantly to the understanding and treatment of the disease. Despite insults from AIDS activist Larry Kramer, he developed a <a href="https://www.nytimes.com/2020/05/27/health/larry-kramer-anthony-fauci.html">productive alliance and warm friendship</a> with him.</p></li>
<li><p>Energy: Fauci has an exceptional work ethic and is blessed with amazing energy. <a href="https://doi.org/10.1126/science.337.6091.152">Account</a> after <a href="https://www.huffpost.com/entry/anthony-fauci-fighting-covid-19_n_5fc7fed7c5b61bea2b14e3ee">account</a> details the staccato pace of his ultra-long days – rising before dawn, rushing from commitment to commitment with barely a break and answering email until late at night.</p></li>
<li><p>Trustworthiness: Fauci has earned credibility – through research and publication, impact on patient health and long service. In his communications, his values keep him focusing on the facts. An essay in the <a href="https://www.washingtonpost.com/opinions/2020/07/16/anthony-fauci-built-truce-trump-is-destroying-it/?arc404=true">Washington Post</a> terms him “the singular referee the country trusts” during the pandemic.</p></li>
<li><p>Connections: Adviser to six U.S. presidents and the current president-elect, Fauci has abundant ties in Washington among both politicians and the media. Some science reporters have covered his work since the 1980s.</p></li>
<li><p>Communication: Termed “<a href="https://www.nytimes.com/2020/03/08/health/fauci-coronavirus.html">the explainer-in-chief of the coronavirus epidemic</a>,” Fauci is a master communicator. He knows how the media function. He explains clearly. He speaks in sound bites – think “<a href="https://apnews.com/article/travel-public-health-colorado-health-anthony-fauci-45ef103e241a14e8760b6bb417fcabb3">we are likely going to see a surge upon a surge</a>” of cases after the Thanksgiving holiday – and his comments are tweetable. He is accessible to the press. He listens as well as speaks.</p></li>
<li><p>Recognizability: Fauci has a distinctive look and voice. His name is unusual yet not unwieldy.</p></li>
<li><p>Teamwork: “It’s almost impossible to do anything meaningful without either leading a team or being part of the team,” Fauci <a href="https://www.wsj.com/articles/the-mentor-who-made-dr-anthony-fauci-11587040520?page=1">has said</a>. A <a href="https://www.niaid.nih.gov/research/lab-immunoregulation">photo of Fauci’s lab group</a> shows some 80 members, including senior researchers. <a href="https://servicetoamericamedals.org/honorees/anthony-s-fauci-m-d/">Highly regarded for his mentorship</a>, Fauci even <a href="https://news.yahoo.com/fauci-read-undergraduate-thesis-now-171950882.html">made himself available to an undergrad</a> writing a thesis – and then commented extensively on the finished product.</p></li>
</ol>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/375434/original/file-20201216-23-ey0q7r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Fauci throws out a pitch at an MLB stadium" src="https://images.theconversation.com/files/375434/original/file-20201216-23-ey0q7r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/375434/original/file-20201216-23-ey0q7r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/375434/original/file-20201216-23-ey0q7r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/375434/original/file-20201216-23-ey0q7r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/375434/original/file-20201216-23-ey0q7r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/375434/original/file-20201216-23-ey0q7r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/375434/original/file-20201216-23-ey0q7r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Fauci found time to throw out the ceremonial first pitch at a Major League Baseball game in July 2020.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/YankeesNationalsBaseball/9e70a8a5d3404c358eb82083cfd8fb14/photo?boardId=d7f2514f50804466b15dfb81ed00d9cd&st=boards&mediaType=audio,photo,video,graphic&sortBy=&dateRange=Anytime&totalCount=27&currentItemNo=3">AP Photo/Andrew Harnik</a></span>
</figcaption>
</figure>
<p>In many ways, Fauci has been the face of the fight against COVID-19 in the U.S. “If we’re going to get through this, we’ve got to all pull together as a country,” Fauci <a href="https://asm.org/Articles/2020/August/Fauci-Calls-for-American-to-Pull-Together-to-Fight">has stated</a>. His blunt, evidence-based approach has helped make him famous in 2020. With any luck, he can lead the way to controlling COVID-19 in 2021.</p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p><img src="https://counter.theconversation.com/content/150596/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barbara Gastel does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Fauci turns 80 this Dec. 24 – and he’s been on the national stage for decades. Here’s more about his work before COVID-19 and why he was perfectly poised to help the US respond to the pandemic.Barbara Gastel, Professor of Veterinary Integrative Biosciences and of Humanities in Medicine, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/893162018-02-22T14:14:54Z2018-02-22T14:14:54ZBeyond donor dollars for health care: how Uganda is thinking outside the box<figure><img src="https://images.theconversation.com/files/204817/original/file-20180205-19918-k2of6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Donor funding for HIV treatment has saved millions of lives in sub Saharan Africa.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Over the last 15 years, there’s been a rapid increase in the number of patients receiving HIV treatment in sub-Saharan Africa. This has largely depended on <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445041/">foreign aid</a>, particularly from global aid organisations such as the President’s Emergency Plan for AIDS Relief <a href="https://www.pepfar.gov/">(PEPFAR)</a> and <a href="https://www.theglobalfund.org/">The Global Fund</a>.</p>
<p><a href="https://www.reuters.com/article/us-aids-pepfar/u-s-aids-program-saved-million-african-lives-study-idUSTRE5356BB20090406?feedType=RSS&feedName=worldNews">Millions of lives have been saved</a> and the quality of life of those living with HIV has been improved dramatically. </p>
<p>In recent years there have been persistent reports of a decline in the amount of international assistance that governments are getting for HIV treatment. This has happened at the same time as there’s been a <a href="http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2017/november/20171121_righttohealth_report">dramatic increase</a> in the number of people who need HIV treatment. The numbers spiked significantly after the <a href="http://www.who.int/mediacentre/news/releases/2009/world_aids_20091130/en/">World Health Organisation</a> announced in 2015 that everyone diagnosed with HIV should start treatment immediately.</p>
<p>African countries have become dependent on foreign aid to meet the escalating demand for HIV treatment. In Uganda for example, <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=kakaire+tom+2016">foreign aid accounts for 85%</a> of the national HIV response. </p>
<p>This is a dangerous place to be. <a href="https://theconversation.com/how-trumps-proposed-us-aid-cuts-will-affect-healthcare-in-africa-75865">Changes in the governments</a> of donor countries can affect foreign aid commitments. And countries receiving aid are susceptible to donors using aid as a political tool. In 2015 for example, donor aid to Uganda was <a href="https://www.reuters.com/article/us-usa-uganda-gay-announcement/u-s-cuts-aid-to-uganda-cancels-military-exercise-over-anti-gay-law-idUSKBN0EU26N20140619">temporarily halted</a> after an anti-gay law was passed in the country. </p>
<p>What’s become increasingly clear is that there’s funding gap for the scale-up of antiretroviral treatment as well as service delivery. The gap is for the ongoing services that people living with HIV need, like having their viral loads tested regularly or getting multivitamins to build their immune systems. </p>
<p>In <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5259831/">our research</a> we looked at how Uganda is attempting to plug this gap with a range of innovative approaches involving different donors and for different aspects of HIV treatment.</p>
<p>We found that the initiatives have resulted in multiple funding streams, which in turn has increased access to the support services that people on ARVs need. </p>
<h2>What’s not covered</h2>
<p>In Uganda there are about <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60658-4/fulltext">1.7 million people living with HIV</a>. More than 750 000 of them are on antiretroviral treatment. </p>
<p>As part of its national HIV and AIDS strategic plan the country has committed to enrol 80% of the people living with HIV on antiretroviral treatment by 2020. Although the government has increased its domestic spending on HIV in recent years, large international funders still finance vital components of the HIV programme such as HIV drugs. </p>
<p>But a large part of the drive requires scaling up services and there are a number of critical areas that aren’t covered. This includes, for example:</p>
<ul>
<li><p>Medication that is administered to HIV patients for the numerous opportunistic infections they can get.</p></li>
<li><p>Buying food for patients to make sure they don’t take their medication on empty stomachs. </p></li>
<li><p>Paying for multivitamins and the additional nutrition support patients need to ensure they stay healthy. </p></li>
<li><p>Funding community HIV outreach activities in all districts of Uganda without exception.</p></li>
</ul>
<p>We looked at close to 200 health facilities across Uganda that provided emergency roll-out of HIV treatment between 2004 and 2009 to see how they coped. </p>
<p>Our study shows that these gaps were funded by private individuals and foundations.</p>
<h2>How funding gap is being closed</h2>
<p>In the Masaka region of South Western Uganda the majority of HIV clinics are funded by the California-based African Health Care Foundation. But several health facilities didn’t solely depend on foreign aid. To cover their costs they introduced innovative funding strategies. </p>
<p>Some introduced ‘VIP’ clinics where higher-paying patients were treated after normal working hours. They paid what was called ‘Robin Hood’ pricing because the extra money was used to support the costs of poorer patients. </p>
<p>Some clinics had also developed a special ‘HIV’ medical insurance scheme to help patients manage costs because these can fluctuate with HIV. By expanding private insurance coverage clinics could potentially reduce the outpatient burden in public facilities by redistributing some of the patient loads. </p>
<p>Several public hospitals behaved like NGOs to source funding, and had a team of grant writers on board.</p>
<p>Most health facilities in our survey no longer depended solely on PEPFAR and The Global Fund. They had managed to attract at least two additional funders, with many having as many as five donors.</p>
<h2>Reducing dependency on donors</h2>
<p>Governments in Africa should all be moving closer to fulfilling the Abuja Declaration which commits them to spending 15% of their annual budgets on the <a href="https://www.ncbi.nlm.nih.gov/pubmed/26050375">health sector</a>. At the moment the average is no more than 5%. This would reduce the current very high levels of dependency on foreign aid.</p>
<p>And there are other alternatives that should be explored. In Zimbabwe, for example, HIV services are funded by a 2% levy on beer and soft drinks. Uganda has a similar initiative. But it hasn’t been implemented yet even though it’s been in the pipeline since 2014.</p>
<p>On top of this, as our study shows, it’s also possible to find local alternative mechanisms to improve access to HIV services.</p><img src="https://counter.theconversation.com/content/89316/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Henry Zakumumpa does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Remarkable progress is being made on HIV treatment. But African countries need to work on sustainable ways to ensure the treatment programmes are not entirely dependent on foreign aid.Henry Zakumumpa, PhD Candidate, Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/814242017-07-23T11:43:00Z2017-07-23T11:43:00ZLook to China for the main beneficiary of America’s likely retreat from Africa<figure><img src="https://images.theconversation.com/files/179204/original/file-20170721-28498-1pkuss3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Presidents of Kenya, Guinea, US and Nigeria's Vice President at the G7 Summit. </span> <span class="attribution"><span class="source">Angelo Carconi/EPA</span></span></figcaption></figure><p>Anti-terrorism and transactional relationships are likely be the main features of US President Donald Trump’s Africa policy. But if Trump’s proposed cuts to the state department hold, the US will be less and less of a presence on the continent, according to <a href="http://www.businessofgovernment.org/bio/gregory-f-treverton">Prof Gregory F Treverton</a>, who directed the US <a href="https://fas.org/irp/nic/">National Intelligence Council</a> in the Obama Administration.</p>
<p>Treverton, who is currently Professor of Practice at the <a href="https://www.usc.edu/">University of Southern California</a>, is a world authority on security and intelligence. I put a number of questions to Treverton who visited South Africa recently to deliver the keynote address at a <a href="http://www.dirco.gov.za/docs/2015/dirco0714.htm">South African Council on International Relations</a> conference on South Africa’s relations with Africa.</p>
<hr>
<p><strong>Why is Donald Trump’s foreign policy so incomprehensible?</strong></p>
<p>I wish I knew! It’s a continual struggle between, on the one hand, the true believers, the American firsters who are anti-trade and anti-engagement in what they see as an unfriendly world, and on the other more traditional conservative Republicans. </p>
<p>The pattern has been that the more traditional conservative Republicans, like the Secretaries of State and Defence, tug policy in a more familiar direction, only to have the president blow the process up with a tweet condemning the <a href="https://www.theguardian.com/environment/paris-climate-agreement">Paris climate agreement</a> or <a href="http://www.cnbc.com/2017/05/30/trumps-tweet-tirade-against-germany-could-backfire-on-us.html">labelling</a> Germany an unfair trader. The intensity of the struggle is reflected in the continuing haemorrhage of leaks, all from the very top of the administration.</p>
<p><strong>Didn’t the post-Second World War liberal international order need a shake up?</strong> </p>
<p>Yes, and perhaps in that sense we’ll end up thanking Trump, if, and this is a big if, we get through the next years without a major crisis or too much broken crockery. Some of Trump’s complaints, like (America’s Western) allies bearing too little of the burden, have been true for a long time. And the reaction by Americans to the sense that they pay too much for the “public goods” of international economics and security has been going on for a long time. </p>
<p>Polls routinely show that Americans <a href="http://www.politifact.com/global-news/statements/2016/nov/09/john-kerry/yep-most-people-clueless-us-foreign-aid-spending/">think</a> the country spends on foreign aid 20 or 30 times what it actually does. So, too, the questioning of what we all too easily call the “liberal international order” has been growing over time.</p>
<p><strong>You suggested that Russia under <a href="https://www.theguardian.com/world/vladimir-putin">Vladimir Putin</a>, is a declining power. Doesn’t the evidence point in the other direction?</strong></p>
<p>It surely is a declining power, though Putin has played a weak hand extraordinarily well. It is in demographic decline, and far from modernising the Russian economy, Putin has only deepened its dependence on hydrocarbons. My fear is that as the country declines, it will be all the more tempted to turn to what tools it retains – cyber attacks and nuclear sabre-rattling.</p>
<p><strong>How do you think Trump’s Africa policy will turn out?</strong></p>
<p>In <a href="http://foreignpolicy.com/2017/01/11/rex-tillerson-pick-for-secretary-of-state-breaks-with-trump-on-key-issues/">testifying</a> before Congress, Secretary of State <a href="http://www.bbc.com/news/world-us-canada-38281954">Rex Tillerson</a> probably was as clear as the administration could be given its disarray. Africa was in the “turning to other countries” category, and he began with the fight against terrorism. He did, though, mention the economic opportunities in Africa, mostly in the sense of business that might be done. I suspect those will continue to be the emphasis.</p>
<p><strong>So does this mean that anti-terrorism and transactional relationships will be the main features of Trump’s Africa policy?</strong></p>
<p>I think they will continue to be the main drivers, for better or worse, though not the only drivers. The country will have to respond to major humanitarian crises whether the administration wants to or not. And some of the legacy programmes of the last two administrations, like the <a href="https://agoa.info/about-agoa.html">African Growth and Opportunity Act</a>, or the <a href="https://www.pepfar.gov/">President’s Emergency Plan for AIDS Relief </a> have had bipartisan support, so we’ll see how they fare in the congressional budget process. </p>
<p><strong>And, if this is so, what are the long-term implications of this for US relations with the continent?</strong></p>
<p>If Trump’s proposed cuts to the <a href="https://www.state.gov/">State Department</a> and <a href="https://www.usaid.gov/">USAID</a> hold, the US will be less and less of a presence on the continent. The main beneficiary, diplomatically, will be China, followed by the Europeans and perhaps even Russia, though it doesn’t have much to contribute except arms sales. </p>
<p>If there is any silver lining, perhaps it will be that Africans, and particularly South Africans, will realise they have to take more initiative on their own. </p>
<p><strong>When it comes to the US itself, you raised the possibility that it might break up? Where you speaking in abstract terms, or is this a real possibility?</strong></p>
<p>I meant it mostly as a metaphor and as a touchstone for thinking about the future. I don’t think it’s likely, but it does have to be considered. </p>
<p>What is certain is that the next few years will be a kind of a guerrilla war, one mostly fought in the courts, between the US federal government and the “blue” (read Democratic Party-controlled) states, led by California, over climate change, immigration and other issues.</p>
<p><strong>What does the Trump presidency mean for these ideas?</strong></p>
<p>So far it seems bound to increase the divide in America. Trump has talked and acted entirely to please his base. He has played on fear, fanning it by portraying the country in dire straits surrounded by a hostile world. So far that base – especially older and often poorer white Americans – seems to have been satisfied by word, words they see as validating them. </p>
<p>But we’ve known from the beginning that Trump can’t deliver on his promises: those “good” low-skilled jobs in manufacturing or mining (as he has portrayed them) aren’t coming back. So we’ll see, but I expect that realisation to only deepen the anger and disaffection.</p>
<p><em>The co-hosts of the conference Treverton addressed were the <a href="https://www.uj.ac.za/faculties/humanities/JIAS">Johannesburg Institute for Advanced Study</a> (JIAS) and the <a href="https://www.wits.ac.za/wsg/">Wits School of Public Management</a>.</em></p><img src="https://counter.theconversation.com/content/81424/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Vale receives funding from the the University of Johannesburg, the Nanyang Technological University, Singapore and the National Research Foundation. </span></em></p>Under the Trump administration Africa is only likely to matter in the fight against terrorism and in providing American companies with economic opportunities.Peter Vale, Professor of Humanities and the Director of the Johannesburg Institute for Advanced Study (JIAS), University of JohannesburgLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/778382017-05-19T01:00:45Z2017-05-19T01:00:45ZTrump’s global gag order: 5 questions answered<figure><img src="https://images.theconversation.com/files/169611/original/file-20170516-11920-18ugjes.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Community health workers like these visit patients’ homes in Malawi to help prevent mother-to-child transmission of HIV. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/usaid_images/14929179975/in/photolist-fpbMUp-aQMAYZ-dCxeUD-aSur7V-b3R1Rt-b3R2oX-dEVMyy-b3R27a-dRQPAZ-6ZtchW-hgsjEG-5bwcvw-9Ew4ZB-9Ui5Dt-dAYLds-oKeX3F-dU2Dh3-qFoYn-dw9Hnp-dEBboS-fgvYov-aQMAZ6-bEyXDR-aMxvhD-fgLeJY-qbViAL-cni9zU-hHrpg9-hHqXKb-c2XNWA-aRwNcx-oERaPx-u7rF96-hHrKFM-945Zp6-fokQm2-oFmDXh-9W2YA2-4v8yRi-cE9xzJ-oKeX5K-fEQHxX-9VxEus-hHqCbR-dw9fng-cE9bkd-bmCsUq-9VuPrz-dEQncT-kXqimY/">Baylor College of Medicine Children's Foundation–Malawi/Chris Cox</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p><em>Editor’s note: President Donald Trump recently signed an executive order that media reports say could obstruct nearly US$8.8 billion the U.S. spends annually to <a href="http://khn.org/morning-breakout/trumps-abortion-gag-rule-will-block-8-8b-in-aid-to-fight-malaria-aids-and-other-diseases/">fight deadly diseases abroad</a>. Here, Maureen Miller, a Columbia University Medical Center professor and infectious disease epidemiologist with training in medical anthropology, answers five questions about this move, including what it has to do with abortion.</em></p>
<h2>1. What’s at stake?</h2>
<p>Three of the biggest killers in the developing world are AIDS, tuberculosis and malaria. Currently 36.7 million people are <a href="http://www.unaids.org/sites/default/files/media_asset/global-AIDS-update-2016_en.pdf">living with HIV/AIDS</a>, a third of the world’s population is <a href="https://www.cdc.gov/tb/statistics/">infected with tuberculosis</a> and more than one million people <a href="https://www.unicef.org/health/files/health_africamalaria.pdf">die from malaria</a> each year.</p>
<p>Trump’s executive order endangers $6.8 billion in annual funding for the <a href="https://www.pepfar.gov/funding/budget/index.htm">President’s Emergency Plan for AIDS Relief</a>. Former President George W. Bush created this initiative, known as PEPFAR, to help save the lives of people suffering from HIV/AIDS. </p>
<p>The U.S. put <a href="http://kff.org/global-health-policy/fact-sheet/u-s-federal-funding-for-hivaids-trends-over-time/">$1.35 billion</a> of that money into the the Global Fund to Fight AIDS, Tuberculosis and Malaria last year. This independent organization is the largest entity dedicated to preventing and treating these diseases. The U.S., its top donor, covers half <a href="http://kff.org/global-health-policy/fact-sheet/the-u-s-the-global-fund-to-fight-aids-tuberculosis-and-malaria/">the Global Fund’s operating costs</a>, but that represents only a quarter of what our nation spends to fight these diseases internationally. Some $600 million in family planning aid is affected, as is <a href="https://theconversation.com/will-trumps-global-family-planning-cuts-cause-side-effects-75813">other spending</a> slated for global health. </p>
<p>Although I follow these issues closely, I have been unable to find a complete breakdown of the widely reported <a href="http://khn.org/morning-breakout/trumps-abortion-gag-rule-will-block-8-8b-in-aid-to-fight-malaria-aids-and-other-diseases/">$8.8 billion affected</a>.</p>
<p>Women compose <a href="http://Aidsinfo.unaids.org">51 percent of the people living with HIV/AIDS</a> worldwide. Since 60 percent of the people with the virus in sub-Saharan Africa are women, they may bear the brunt of this move. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/169610/original/file-20170516-11945-en0mnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/169610/original/file-20170516-11945-en0mnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/169610/original/file-20170516-11945-en0mnh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/169610/original/file-20170516-11945-en0mnh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/169610/original/file-20170516-11945-en0mnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/169610/original/file-20170516-11945-en0mnh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/169610/original/file-20170516-11945-en0mnh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Eunice Adhiambo, an HIV-positive Kenyan woman, and her HIV-negative daughter Jyll.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/usaidafrica/9451379699/in/photolist-fpbMUp-aQMAYZ-dCxeUD-aSur7V-b3R1Rt-b3R2oX-dEVMyy-b3R27a-dRQPAZ-6ZtchW-hgsjEG-5bwcvw-9Ew4ZB-9Ui5Dt-dAYLds-oKeX3F-dU2Dh3-qFoYn-dw9Hnp-dEBboS-fgvYov-aQMAZ6-bEyXDR-aMxvhD-fgLeJY-qbViAL-cni9zU-hHrpg9-hHqXKb-c2XNWA-aRwNcx-oERaPx-u7rF96-hHrKFM-945Zp6-fokQm2-oFmDXh-9W2YA2-4v8yRi-cE9xzJ-oKeX5K-fEQHxX-9VxEus-hHqCbR-dw9fng-cE9bkd-bmCsUq-9VuPrz-dEQncT-kXqimY">Riccardo Gangale/USAID Kenya</a></span>
</figcaption>
</figure>
<h2>2. How does the US support global efforts to fight and treat HIV/AIDS?</h2>
<p>PEPFAR, primarily implemented through USAID, the National Institutes of Health and the Centers for Disease Control and Prevention, emphasizes improving the health of women, newborns and children. Among its biggest achievements has been integrating AIDS relief and reproductive health services, since HIV is transmitted primarily through unprotected sex. </p>
<p>Until now, PEPFAR has commanded broad bipartisan support, perhaps due to its well-documented success. For the first time since the HIV/AIDS epidemic began in the 1980s, new HIV infections in sub-Saharan Africa – which accounts for <a href="http://aidsinfo.unaids.org/">almost two-thirds</a> of all people living with HIV/AIDS – <a href="http://www.unaids.org/sites/default/files/media_asset/global-AIDS-update-2016_en.pdf">are decreasing</a>. Former President Bush, who <a href="http://www.reuters.com/article/us-africa-bush-idUSKBN1761LJ">traveled to Botswana and Namibia</a> in April, still champions the program.</p>
<h2>3. How is global health aid connected to abortion?</h2>
<p>An estimated <a href="http://kff.org/global-health-policy/fact-sheet/the-u-s-government-and-international-family-planning-reproductive-health-efforts/">303,000 women</a>, primarily in developing countries, die yearly from complications due to pregnancy, childbirth and abortion, and those are the <a href="http://www.who.int/mediacentre/news/releases/2017/yearly-adolescent-deaths/en/">leading causes of death</a> among adolescent girls globally. Approximately one-third of maternal deaths could be prevented if all women had access to effective contraception.</p>
<p>The U.S. is the <a href="http://kff.org/global-health-policy/fact-sheet/the-u-s-government-and-international-family-planning-reproductive-health-efforts/">world’s largest supporter</a> of family planning and reproductive health services. It is also one of the largest purchasers and distributors of contraceptives. <a href="http://kff.org/global-health-policy/fact-sheet/the-u-s-government-and-international-family-planning-reproductive-health-efforts/">No federal funds have paid for abortions</a>, however, since 1973 – either internationally or at home. All nongovernmental organizations receiving U.S. support must agree to this policy.</p>
<p>In 1984, the Reagan administration expanded those restrictions by denying U.S. family-planning money to entities that performed abortions or promoted the practice. Subsequent Democratic presidents lifted this restriction, known either as the “<a href="http://kff.org/global-health-policy/fact-sheet/mexico-city-policy-explainer/">Mexico City policy</a>” or the “global gag rule,” while Republican presidents reinstated it.</p>
<p>Trump framed his new order as “<a href="https://www.state.gov/r/pa/prs/ps/2017/05/270866.htm">Protecting Life in Global Health Assistance</a>,” but it’s unlikely to reduce the number of abortions performed in poor countries. A <a href="http://www.who.int/bulletin/volumes/89/12/11-091660/en/">2011 study by Stanford University researchers</a> found that abortion rates in sub-Saharan African countries rose when the standard restrictions were in force from 2001 to 2008. </p>
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<h2>4. How does Trump’s action stray from Republican precedents?</h2>
<p>The Trump administration has expanded the policy’s reach, broadening it to encompass all foreign health care providers that receive U.S. funding rather than only those that get family planning dollars. For example, any group that does sexual health education to prevent the spread of HIV and also informs women that abortion is legal where they live will <a href="https://www.statnews.com/2017/05/16/mexico-city-policy-global-health-funding/">lose their U.S. support</a>. They would have remained eligible for that money had Trump followed the pattern set by the past three Republican administrations.</p>
<p>The exact repercussions are unknown. The <a href="https://www.state.gov/r/pa/prs/ps/2017/05/270879.htm">State Department</a>, under Rex Tillerson’s leadership, plans to review the impact within six months.</p>
<h2>5. Can other donors bridge the gaps?</h2>
<p>It’s unclear which organizations will agree to these new restrictive terms or what will happen to spending. The administration says it <a href="https://www.state.gov/r/pa/prs/ps/2017/05/270879.htm">will redistribute funds</a> from organizations that refuse to comply to those that will. </p>
<p>But those other groups may not exist. As Johnathan Rucks of the <a href="https://www.nytimes.com/2017/05/15/us/politics/trump-gag-rule-abortion.html?rref=collection%2Fbyline%2Fgardiner-harris&action=click&contentCollection=undefined&region=stream&module=stream_unit&version=latest&contentPlacement=2&pgtype=collection">global health group PAI</a> told The New York Times: “It’s not like we have an influx of providers in places like West Africa.” </p>
<p>Given the limited alternatives, the number of unmet health needs will surely rise, particularly for women and children. In March, other governments and private funders announced they had raised <a href="http://www.npr.org/sections/goatsandsoda/2017/03/02/517959453/-190-million-raised-to-fill-aid-gap-left-by-trumps-abortion-rule">$190 million for international family planning</a> to narrow the anticipated gap caused by the Trump administration’s policies. Now, that’s probably just a drop in the bucket of what will be needed.</p>
<p><a href="https://www.theguardian.com/global-development/2017/feb/14/bill-and-melinda-gates-trumps-global-gag-rule-endangers-millions-women-girls-us-funding">Bill Gates</a>, a philanthropist who with his wife Melinda gives more than <a href="http://www.gatesfoundation.org/Who-We-Are/General-Information/Foundation-Factsheet">$4 billion</a> away every year, mostly to improve global health and fight poverty, told The Guardian that Trump’s expansion of the policy could “create a void that even a foundation like ours can’t fill.”</p><img src="https://counter.theconversation.com/content/77838/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maureen Miller does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>All recent Republican presidents have cut off foreign aid tied to abortion. Trump’s expansive version of those restrictions endangers billions slated for HIV/AIDS, malaria and other diseases.Maureen Miller, Adjunct Associate Professor of Epidemiology, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/551382016-03-03T04:18:32Z2016-03-03T04:18:32ZAfrica’s children need help coping with a myriad of stresses, not just HIV<figure><img src="https://images.theconversation.com/files/113378/original/image-20160301-31062-e9zy1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The call to action to address childhood vulnerability in Africa must go far beyond those children infected and affected by HIV.</span> <span class="attribution"><span class="source">Reuters/Radu Sigheti </span></span></figcaption></figure><p>HIV has exacted a terrible toll on many children in sub-Saharan Africa. Of more than <a href="http://www.avert.org/professionals/hiv-social-issues/key-affected-populations/children">17.8 million children</a> who have lost one or both parents to HIV globally, 15 million live in Africa. Another <a href="http://www.unaids.org/sites/default/files/media_asset/FactSheet_Children_en.pdf">three million</a> are infected with HIV. And each year very large numbers are made vulnerable when parents or family members become sick and are unable to work. </p>
<p>The global health community has made significant progress over the past 15 years to understand how to keep HIV-positive children alive and prevent infant infections. Between 2001 and 2013, paediatric infections decreased by <a href="http://www.who.int/hiv/topics/paediatric/hiv-paediatric-infopage/en/">58%</a>. And the number of children on antiretrovirals increased from 355,000 in 2009 to 740,000 in <a href="http://www.who.int/hiv/topics/paediatric/hiv-paediatric-infopage/en/">2013</a>. </p>
<p>Arguably, children – and their families – who are affected by HIV and receive donor assistance may be less vulnerable than their peers who have not had their lives touched by HIV, but still grow up in extreme poverty.</p>
<p>For this reason, the call to action to address childhood vulnerability in Africa must go far beyond the 17.8 million children infected and affected by HIV. </p>
<h2>A global focus on HIV</h2>
<p>The global community and the US in particular, through the <a href="http://www.pepfar.gov/">President’s Emergency Plan for AIDS Relief</a>, has invested billions of dollars in HIV programs. These investments are part of a global plan to ensure an AIDS-free generation <a href="http://www.pepfar.gov/documents/organization/201386.pdf">by 2015</a>. </p>
<p>The plan has largely centred on providing antiretroviral medication to HIV-positive people and preventing mother-to-child transmission. About <a href="http://www.unaids.org/sites/default/files/media_asset/20131219_AccessARTAfricaStatusReportProgresstowards2015Targets_en_0.pdf">one-third</a> of HIV-positive adults and children access lifesaving treatment. And more than half of infected pregnant women access medicines that protect their babies from the virus. </p>
<p>But much still has to be done, as shown in our review in the <a href="http://www.pediatric.theclinics.com/article/S0031-3955(15)00147-9/abstract">Pediatric Clinics of North America</a> journal. </p>
<p>Aside from providing lifesaving medication, donor efforts have also reduced the social and economic burden faced by HIV-affected families and children.</p>
<p>HIV-positive people not receiving treatment will inevitably become ill and will be unable to work. Their children will stop going to school to take care of them or their younger siblings. Many may not be able to afford school fees. </p>
<p>The social, emotional, and developmental health of children orphaned or otherwise affected by HIV is more difficult to measure and more difficult to address. Africa is <a href="http://www.unaids.org/sites/default/files/media_asset/20131129_stocktaking_report_children_aids_en_0.pdf">home to 85%</a> of AIDS orphans globally. </p>
<h2>More inclusive approach needed</h2>
<p>But our disease-centric focus for funding and interventions is far too limited. On a continent where millions of children are living in poverty, undernourished or struggling to stay in school and fulfil their potential, it is not enough to focus the bulk of donor funding on those affected by HIV. </p>
<p>An alternative and more inclusive approach would be to focus on adverse childhood experiences. From this broader perspective we can address the many variables influencing the health and well-being of the child. </p>
<p>Children in sub-Saharan Africa face myriad challenges which make them vulnerable. Losing a parent to HIV, being HIV positive and facing stigma and discrimination are also adverse childhood experiences. Another is growing up in extreme poverty.</p>
<p>I was working in rural, southern Kenya and I could not stop thinking about the widespread, extreme poverty unrelated to HIV. Some of the families in the largely Maasai community where I was staying may have been affected by HIV but the vast majority were not. </p>
<p>In Kenya, about 6% of the adult population has HIV. More may be at risk of becoming infected, but they are a minority. The biggest driver of vulnerability among children in this community is profound poverty exacerbated by too little food and scant water sources. Six of the 13 fastest-growing economies in the world are in Africa. Kenya is one of them. Yet <a href="http://www.worldbank.org/en/topic/poverty/overview">42% of Africans</a> still live on less than US$1.25 per day. </p>
<p>Poverty affects children’s ability to attend school. Most African countries provide <a href="http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf">universal primary school</a> education. But children can still be barred from school if they cannot pay fees for uniforms and books. Overall primary school completion for the continent is only 67%. More than <a href="http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf">22 million</a> children remain out of school.</p>
<p>In several countries hit hard by HIV, such as Cameroon, Rwanda, South Africa and Zambia, <a href="http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf">at least 90%</a> of children are enrolled in primary school. This progress is the result of large investments by governments and foreign donors in universal primary education.</p>
<p><a href="http://www.epdc.org/sites/default/files/documents/Orphans%20and%20Vulnerable%20Children.pdf">A study</a> comparing school attendance and success between orphans and non-orphans in Lesotho, Malawi, Tanzania, Uganda and Zambia found that poverty was more strongly associated with school difficulties than orphan status. This was true for both primary and secondary students, and points to a conclusion that support targeting orphans is reducing their vulnerability, at least with regard to education.</p>
<p>It also suggests that we need to broaden our approach to childhood vulnerability in contexts with a high HIV burden where government and donor support has tended to focus on children affected by HIV.</p>
<h2>Expanding our approach</h2>
<p>The US Centres for Disease Control and Prevention have been funding research on <a href="http://www.cdc.gov/violenceprevention/acestudy/index.html">adverse childhood experiences</a> in the US for a number of years. The United Nations Children’s Emergency Fund has <a href="http://www.unicef-irc.org/MODA/">developed a methodology</a> to assess the impact of multidimensional, overlapping deprivations on child vulnerability.</p>
<p>At the same time, public health researchers and child advocates have developed tools to measure and understand the sources of resilience that help some children to excel despite all odds. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22943414">Sources of resilience</a> include both internal factors such as hope for the future and self-esteem, and external factors such as access to education and financial resources. </p>
<p>We need to leverage the profound global empathy for children affected by HIV to address the needs of all vulnerable children on the continent. </p>
<p>Five months ago, the United Nations General Assembly ratified 17 new <a href="https://sustainabledevelopment.un.org/sdgs">Sustainable Development Goals</a> to replace the Millennium Development Goals. The breathtakingly ambitious goals include to “end poverty in all its forms everywhere” by 2030 and “ensure healthy lives and promote well-being for all at all ages”. </p>
<p>Some days, I am inspired by the audacity of these goals. But mostly I think about the children in Kimana, Kenya. Vulnerable? Yes. Affected by HIV? Mostly not. And I wonder what it will take to get them onto the global development agenda.</p><img src="https://counter.theconversation.com/content/55138/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Beard has received past funding from the United States Agency for International Development for HIV research. The content and views expressed here do not necessarily reflect the opinions or policies of USAID or the US government.</span></em></p>The call to action to address childhood vulnerability in Africa must go far beyond the 17.8 million children infected and affected by HIV.Jennifer Beard, Assitant Professor of Global Health, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.