Curbing HIV/AIDS in sub-Saharan Africa through political leadership

December 2, 2016 by Dr. Abraar Karan And Dr. Tom Coates, Public Library of Science

The HIV/AIDS epidemic is now almost through its fourth decade since becoming established as a major public health concern in the early 1980s. The global health community has made immense progress in understanding the biologic basis of the virus; the epidemiology behind its spread through populations; treatments that are effective in suppressing the virus; and the social and cultural factors that have influenced how individuals are living with the disease. However, there is a dearth of information regarding the role of political leadership, and how it can successfully or detrimentally affect populations as it relates to the HIV epidemic, and other diseases more generally.

On World AIDS Day 2016, we are calling for a renewed commitment by in Sub-Saharan Africa to commit to accurate and de-stigmatizing public communications that will greatly benefit HIV prevention, diagnosis, and treatment efforts.

Sub-Saharan Africa, the region with over two-thirds (estimated 25.5 million out of 36.7 million globally) of HIV/AIDS in the world, is an important focal point in examining how political leadership can influence people's behaviors. HIV prevention has primarily focused on individual decision-making as it relates to sexual behaviors, and leaders have the potential to effect such change through passionate, motivational rhetoric. Beyond prevention, however, both testing and treatment are equally important factors that have met substantial roadblocks due to misinformation and stigma, and herein lays an important opportunity for political will and influence.

African political leaders' responses to HIV over the last several decades have been varied, with some leaders demonstrating exemplary approaches, while others have been unfortunately harmful. The political infrastructure in most Sub-Saharan African countries is hierarchical, but the levels of public influence do not necessarily follow in that hierarchy. In a Gallup poll from 2014, African leaders had a wide range in their public approval ratings, and this is likely to affect the ultimate efficacy of their messages. There is even fewer data with regard to the public approval of specific health leaders, such as Ministers of Health, but one would expect a similar disconnect between public popularity and the power of public narrative. This highlights an opportunity at the intersection of health and politics not only for the HIV epidemic, but other diseases as well, including Ebola and Zika, both which have also worsened because of political inaction and instability.

One particular aspect of that has been of pivotal importance is the role of public demonstrations. These include speeches, rallies, and health-related events, such as HIV testing and male circumcision campaigns that many African governments have used to influence their public. Generally speaking, these have traditionally aimed to provide health information about HIV, reduce associated disease stigma, increase HIV testing rates, reduce sexual multiplicity, delay the age of sexual debut, encourage use of condoms, and motivate populations to unite against the epidemic.

In most Sub-Saharan African nations, Presidents, Vice Presidents, First Ladies, Ministers of Health, Prime Ministers, and international Ambassadors have played critical roles in local health movements around the HIV epidemic. In a number of countries, these officials have directly spearheaded campaigns and ensured public involvement to better connect with people in civil society. Others have utilized directed and technical public health messaging—such as the uptake of Option B+ in Uganda for prevention of mother to child transmission—that is explicit but avoids stigmatization or undermining risk. Involvement of First Ladies through cross-border initiatives, such as the Organization of African First Ladies against HIV/AIDS, has also been essential in creating momentum around new campaigns.

As new HIV therapy regimens and public health strategies are introduced into the market, the need for proper communication, especially in countries in which health literacy is low, will become essential. Creative efforts to de-stigmatize HIV testing have been of particular importance in this effort. In some countries, for instance, public health officials and even Presidents have undergone public testing for HIV as a means for public engagement. There have been parallel efforts in the circumcision movement as well, notably in Zimbabwe among Members of Parliament. Moreover, effective stigma reduction must permeate through all ranks of society. To this extent, African leaders in the past decade have become more open with personal stories, including how HIV had affected members of their own families and administrations, a stark contrast to the previous AIDS denialism.

Politicians have also stood in the way of progress, with the most notable and detrimental examples being speeches that bolster stigmatization, and false science. The President of Uganda, Yoweri Museveni, has been notorious for particularly stigmatizing assertions in recent years, and South African President Jacob Zuma has made comments, including reducing HIV risk from showering, that are baseless and harmful. Before President Zuma, President Mbeki of South Africa questioned the relationship between HIV and AIDS and the benefits of anti-retroviral medication. The challenge of communication surrounding health issues such as HIV is that wrong information, or stigma-inducing rhetoric, is far more detrimental than the benefit of correct information, largely because farfetched myths tend to stick in people's minds. This highlights the essential need for smart, thoughtful, and careful framing of messages by political elite. Many studies have illustrated the existence of numerous myths regarding HIV transmission and cure both globally and in the Sub-Saharan African context. We must ensure that political leaders serve to dispel rather than contribute to this growing body of folklore.

Aside from using stigmatizing language, there are numerous countries in which high-level political leaders, such as the President, have promoted legal frameworks that marginalize vulnerable groups. One such example is the criminalization of same-sex activity in the country of Zambia among many others in Sub-Saharan Africa. Uganda has also gained notoriety for blatant homophobia, with President Museveni supporting such sentiment with comments describing homosexuals as "disgusting" and also passing anti-gay bills into law. It is immensely challenging to create national movements that support people living with HIV/AIDS when country leaders remain fundamentally opposed to the beliefs of certain groups that are highly affected by the epidemic.

We need to establish a much stronger research base to demonstrate how the actions of political leaders in Sub-Saharan Africa have correlated with shifts in HIV prevalence, self-reported behavior change, and other traditional metrics assessing the growth of the epidemic. Ecological study models may begin to provide a first glance at this. Nonetheless, there needs to be a stronger emphasis on unified messaging around HIV/AIDS, and on a more serious avoidance of harmful messaging as highlighted.

While the fields of epidemiology, global health, medicine, and economics have contributed significantly to curbing the HIV epidemic, the efforts from the political side of the equation have been relatively weaker with regard to organization and execution. An immense potential remains for political leaders to take the helm of the epidemic, and to steer their countries toward large-scale behavioral and cultural change. While political support will in no way be enough on its own, it is equally unlikely for the epidemic to be curtailed without concerted efforts from governmental leaders.

Importantly, the relationship between governments and civil societies must be deliberately strengthened. The tumultuous histories of political violence and unrest in many of the countries in Sub-Saharan Africa have created large divides that have serious implications for epidemic control for HIV and other infectious diseases. Through civil society partnerships, advice from public health research agencies, including the Center for Disease Control (where author AK worked as part of a team advising strategy for the US Ambassador and the Mozambican President, Armando Guebuza, in 2013) and Johns Hopkins Center for Communication Programs (which focuses specifically on the role of communication in public health), and by leveraging political good will and sound scientific understanding, leaders in Sub-Saharan Africa can help create a more robust response to HIV control and eradication.

We must not allow the opportunity to pass. The dangers of weak leadership are many fold and have already proven consequential in the past and present. The future must be different for those living with HIV/AIDS, and those who are at risk of contracting the virus. A partnership between politics and science is greatly needed if the global HIV community is going to continue attempting large-scale behavior-change, destigmatization, testing, or treatment campaigns. We believe that time must be now.

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