A Fragile Victory: How New Threats and Old Inequalities Jeopardise Africa's Progress towards HIV Control
Introduction
In 2024, the global fight against HIV reached a pivotal moment. According to UNAIDS, the world saw an estimated 1.3 million new infections. The epicentre of the pandemic, however, remains Eastern and Southern Africa, which accounted for 490,000 of these cases. This figure underscores a critical crossroads: the region has achieved monumental successes, yet these gains are increasingly fragile. Decades of progress are now threatened by a confluence of emerging threats, including rising drug resistance, severe funding cuts, and persistent, unaddressed inequalities. Additionally, uneven progress has left behind adolescent girls, young women, and key populations who face the dual burden of the virus and systemic marginalisation. The central challenge is no longer just medical; it is about sustaining momentum in the face of these compounding pressures. The question is whether the region can harness innovative tools and rebuild resilient systems to protect its hard-won victories and finally end the epidemic as a public health threat.
Successes and Gains
The HIV response in eastern and southern Africa is a public health success story. Over the past decade, the region has achieved a staggering 59% reduction in annual new HIV infections, from 1.1 million in 2010 to 450,000 in 2023. This dramatic decline is directly linked to a parallel 57% drop in AIDS-related deaths, saving millions of lives. The cornerstone of this achievement has been the massive scale-up of testing and treatment, measured by the global 95-95-95 targets. These targets aim for 95% of people living with HIV to know their status, 95% of those who know their status to be on treatment, and 95% of those on treatment to be virally suppressed. An estimated 84% of the more than 20 million people living with HIV aged 15 and over are now receiving antiretroviral therapy, and among those on treatment, an impressive 94% have achieved viral suppression, meaning they cannot transmit the virus. Countries like Botswana, Eswatini, Kenya, Malawi, Rwanda, Zambia, and Zimbabwe already reaching the ambitious 95-95-95 target for the general population. The good news for East Africa is that HIV prevalence has decreased when compared to earlier findings; however, significant challenges remain, as evidenced by the fact that many women in the region still report very discriminatory attitudes towards people living with HIV.
The prevention landscape is undergoing a revolutionary shift with the introduction of long-acting injectable pre-exposure prophylaxis (PrEP) options that move beyond daily pills. The World Health Organisation (WHO) now recommends long-acting injectable cabotegravir (CAB-LA), an injection administered every two months that reduces HIV risk by 79% compared to oral PrEP. This addresses a critical adherence challenge for many individuals. Even more promising is the breakthrough drug lenacapavir, a twice-yearly injectable PrEP. In Ugandan trials, participants experienced 100% protection from HIV infection. Through a landmark Global Fund agreement, Uganda is set to be among the first countriesto access this game-changing tool, which is particularly suited for populations like adolescent girls and young women who face stigma and logistical barriers to daily medication. A coalition of global health partners is working to accelerate the rollout of these options, emphasising the importance of providing a range of choices, including the dapivirine vaginal ring, to meet diverse needs. This coalition includes key institutions such as The Global Fund, WHO, UNAIDS, and Unitaid, who are collaborating on financing, guidelines, and implementation to ensure these new tools reach the communities that need them.
Emerging Threats and Challenges
A silent but formidable threat to treatment gains is the rise of HIV drug resistance (HIVDR). The WHO reports a growing global trend, with Africa facing an acute risk. Surveillance data shows pre-treatment drug resistance exceeding 10% to common first-line drugs in countries like Cameroon, Eswatini, Namibia, and Uganda. This means one in ten people starting treatment may already be infected with a resistant virus. The situation is dire for children; in nine African countries(Cameroon, Eswatini, Malawi, Mozambique, Nigeria, South Africa, Togo, Uganda and Zimbabwe), one in two newly diagnosed infants had resistance to the most common drugs before treatment even began. Evidence from Northern Uganda is alarming, revealing a 73.9% prevalence of HIVDR mutations among people with unsuppressed viral loads. Even the robust first-line drug dolutegravir (DTG) is not immune. Research from Kenya indicates that the risk of DTG resistance escalates dramatically depending on the companion drugs used, creating a specific vulnerability for children who often require regimens that increase this risk.
Despite impressive progress, the HIV response is stalling. Critical gaps persist, with half of all people globally who need but are not receiving treatment living in sub-Saharan Africa. Coverage for children, men, and key populations continues to lag. This fragile situation has been severely exacerbated by funding disruptions. Recent cuts to United States HIV funding have had a seismic impact, revealing the region's dangerous aid dependency. PEPFAR, the largest single funder of HIV prevention in 15 countries, saw its support curtailed, leading to thousands of health worker retrenchments, the closure of essential programs like DREAMS for adolescent girls, and the collapse of community outreach. Surveys report that 62% of respondents now face difficulty accessing PrEP, and 46% of people living with HIV have experienced treatment disruptions. This dismantling of the community health infrastructure threatens to reverse decades of progress and lead to a preventable rise in mortality.
The epidemic continues to be shaped by stark demographic disparities. In sub-Saharan Africa, women and girls accounted for 63% of all new HIV infections in 2024. Globally, 4,000 adolescent girls and young women are infected every week, a disparity driven by deep-seated social and economic inequalities. Key populations including gay men, transgender people, people who inject drugs, and sex workers also bear a disproportionate burden, with HIV prevalence estimates of 7.6%, 8.5%, and 7.1% respectively. These groups remain severely marginalised, their access to lifesaving services blocked by stigma, discrimination, and the criminalisation of same-sex relations, sex work, and drug use in many countries. This systemic exclusion not only fuels the epidemic but highlights the critical failure to address the structural barriers that underpin vulnerability.
Innovation & Forward-Looking Solutions
Innovation offers a path forward. For prevention, the rollout of long-acting injectables like CAB-LA and the upcoming arrival of lenacapavir promise to reduce the burden of daily pill-taking. For treatment, injectable options are proving transformative for individuals struggling with adherence. The IMPALA study in Kenya, Uganda, and South Africa found that long-acting cabotegravir and rilpivirine (CAB/RPV) injected every two months was as effective as standard oral regimens, with 91% of participants achieving viral suppression. Ugandan trial participants experienced 100% protection from HIV infection, offering a discreet and easier to adhere to option for populations. This option is particularly valuable for the up to 1.5 million people in the region with HIV. Participants overwhelmingly preferred the injectable due to the privacy it offered, directly reducing the stigma associated with daily medication. The WHO has now recommended CAB/RPV, paving the way for its inclusion in national guidelines.
Bridging the inequality gap requires tailored approaches. Expanding access to PrEP, both oral and long acting, for adolescent girls and young women is a critical priority. Similarly, service delivery must be redesigned for marginalised groups to address stigma and legal barriers. Tools like the dapivirine vaginal ring, a discreet, female-initiated method that does not require daily adherence, empower women who are unable to negotiate safer sex. However, the slow rollout of such innovations underscores a broader problem: the reliance on unpredictable international funding. Advocates insist that governments must prioritise these proven tools in national budgets, arguing that the cost of prevention pales in comparison to the lifelong expense of treatment, especially for countries that contributed to the research behind these innovations.
Conclusion
The HIV response in eastern and southern Africa is a testament to what is possible with sustained investment and global solidarity, yet it stands on the precipice of a dangerous reversal. The remarkable declines in infections and deaths are now undermined by the rise of drug resistance, the collapse of vital funding, and the unyielding grip of inequality on the most vulnerable. The arrival of revolutionary tools like long-acting injectable PrEP and treatment provides a beacon of hope, offering unprecedented protection and convenience. However, these innovations will fail to deliver on their promise if they remain inaccessible due to cost and inadequate health systems. The essential takeaway is that the medical battle is only half-won. The path forward demands an urgent course correction: a move toward sustainable domestic financing, the integration of HIV services into primary healthcare, and a relentless commitment to dismantling the stigma and discriminatory laws that fuel the epidemic. The future depends on building a response that is not only medically advanced but also equitable, resilient, and community-led, ensuring that the hard-fought gains of the past are not lost but instead form the foundation for a final victory.
