HIV and the Global South:
Inequality, Access, and the Fight for Treatment

The phrase "global HIV epidemic" can make it easy to picture an abstraction — statistics, percentages, maps with colored regions. But behind every data point is a person in a specific place trying to do what people everywhere with HIV are trying to do: access care, stay on treatment, and live their life.

Two-thirds of those people live in sub-Saharan Africa. Understanding why, and what has been done to address it, is essential to understanding the HIV epidemic as a whole — and why decisions made in Washington, Geneva, and pharmaceutical boardrooms have life-and-death consequences for millions of people who will never interact with those institutions directly.

The disproportionate burden

Sub-Saharan Africa has approximately 14% of the world's population. It carries approximately 67% of the global HIV burden1. Eastern and southern Africa alone — a subregion comprising countries like South Africa, Zimbabwe, Zambia, Mozambique, Uganda, Kenya, and Tanzania — account for more than half of all people living with HIV in the entire world.

In some countries, HIV prevalence among adults exceeds 20%. In Eswatini (formerly Swaziland), roughly one in four adults is living with HIV. These are not statistics from the 1990s. They are current2.

Why sub-Saharan Africa carries this burden

The disproportionate HIV burden in sub-Saharan Africa is not an accident or an inevitability. It is the result of specific historical, structural, and political conditions that made the epidemic both more severe and harder to address.

Poverty and health system capacity

HIV is not only a disease of poverty, but poverty dramatically worsens every aspect of the epidemic — access to testing, ability to adhere to treatment, nutritional support that affects treatment outcomes, and the capacity of health systems to deliver care at the scale needed. Countries with the highest HIV burdens often have the weakest health infrastructure, a legacy of colonialism, structural adjustment policies, and chronic underfunding of public health.

The mode of transmission

Unlike most of Eastern Europe, Asia, and Latin America — where the epidemic is concentrated among specific key populations — sub-Saharan Africa's epidemic is largely generalized, meaning it has spread through heterosexual transmission into the general population. This makes it both harder to target prevention efforts and more broadly distributed across communities.

Gender inequality as a structural driver

In sub-Saharan Africa, women and girls accounted for 63% of all new HIV infections in 20244. Every week, 3,300 adolescent girls and young women in the region became infected with HIV. This is not primarily a behavioral pattern. It is a structural one: gender-based violence, economic dependence on male partners, limited access to education and income, and cultural norms that restrict women's ability to negotiate safer sex all drive disproportionate HIV risk for women and girls.

Women and girls: the epidemic within the epidemic

The feminization of the HIV epidemic in sub-Saharan Africa is one of its most critical and underreported features. Globally, 45% of all new HIV infections are among women and girls. In sub-Saharan Africa that figure rises to 63%. Among adolescent girls and young women aged 15-24, the disproportion is even more stark: they account for a share of new infections vastly exceeding their share of the population.

Addressing this requires more than HIV services. It requires addressing the structural determinants of women's vulnerability: legal frameworks that protect women from violence, economic empowerment, access to education, and the dismantling of gender norms that limit women's autonomy. HIV programs that ignore these structural factors consistently underperform.

The fight for generic drugs: a history that still matters

In the late 1990s, antiretroviral therapy had transformed HIV in wealthy countries from a death sentence to a manageable condition. The drugs worked. They were patented and expensive — more than $10,000 per patient per year at a time when per capita GDP in many African countries was under $500.

What followed was one of the most consequential fights in modern public health history. South Africa, under Nelson Mandela, attempted to pass legislation allowing the compulsory licensing of generic antiretrovirals. A coalition of pharmaceutical companies sued the South African government. International advocacy — led by groups including MSF, ACT UP, and the Treatment Action Campaign — turned the lawsuit into a global scandal. The companies eventually withdrew.

The Doha Declaration on TRIPS and Public Health in 2001 established that countries could override pharmaceutical patents in public health emergencies5. PEPFAR, created in 2003, initially required the use of branded drugs — a provision eventually changed under advocacy pressure to allow generic purchases. The Global Fund and UNITAID have since leveraged massive purchasing power to drive down prices further.

Today, first-line antiretroviral therapy can be produced and delivered for less than $100 per patient per year in many settings6. That transformation — from $10,000 to under $100 — was not a market miracle. It was the result of sustained advocacy, compulsory licensing, generic manufacturing (primarily in India and Brazil), and international funding pressure.

Community health workers: the backbone of the response

One of the most important and least celebrated elements of the HIV response in sub-Saharan Africa is the community health worker network — trained community members who provide testing, treatment support, adherence counseling, and basic health services in communities that formal health systems cannot reach at scale.

In countries like Ethiopia, Malawi, and Mozambique, community health workers are the primary point of contact between the health system and people living with HIV in rural areas. They know their communities. They speak the languages. They have earned trust that a clinic 40 miles away cannot replicate.

When the 2025 funding crisis hit, UNAIDS documented what happened: in Ethiopia, when formal systems broke down, young volunteers formed WhatsApp groups to check on peers, mothers banded together to support children's treatment, and youth collectives used community radio to share health information. Community resilience is real — but it should not be the primary safety net when funding systems fail.

What PEPFAR built in the Global South

PEPFAR's contribution to the HIV response in sub-Saharan Africa is genuinely difficult to overstate. Since 2003, it has supported HIV treatment for more than 20 million people, funded prevention of mother-to-child transmission programs that have dramatically reduced pediatric HIV, and built health infrastructure that extends far beyond HIV7.

Equally important is what PEPFAR did to the economics of the response. By committing to purchase antiretrovirals at scale, it created demand that justified generic manufacturing investment. By funding programs that demonstrated treatment delivery was feasible at population scale in low-income settings, it demolished the argument that ART rollout in Africa was logistically impossible.

The 2025 crisis and what it means for the Global South

The abrupt reduction in US HIV assistance in early 2025 fell hardest on the countries least able to absorb the shock. Countries where international assistance accounts for 80% or more of HIV prevention programming9. Countries where the health systems PEPFAR helped build cannot yet sustain themselves without external support.

UNAIDS modelling suggests that if the funding gap becomes permanent, an additional 6 million HIV infections and 4 million AIDS-related deaths could occur by 2029. Those are not projections about the distant future. They are projections about people who are alive right now, who are on or approaching ART, whose supply chains are stressed or broken.

The longer-term question the crisis has forced is one of sustainability: the global HIV response cannot depend indefinitely on the political decisions of a single donor country. The transition to nationally-led, domestically-financed responses is the right direction — but it requires time, capacity building, and continued external support during the transition. Abrupt withdrawal is not a managed transition. It is abandonment.

What community resilience looks like

Against the backdrop of crisis, the stories of community response deserve to be named. In Ethiopia, peer networks maintained treatment adherence when supply chains broke. In Kenya, community-led organizations rerouted medication deliveries when PEPFAR-funded programs stalled. In Zimbabwe, mothers' groups maintained pediatric HIV treatment when clinic capacity was overwhelmed.

These are not heartwarming footnotes. They are evidence that the communities most affected by HIV in the Global South are also the most capable of leading their own responses — when given resources, authority, and respect. The future of the global HIV response depends on that recognition becoming structural rather than incidental.