Because of the tremendous impact AIDS has had on the continent, I have spent the last decade studying response to AIDS in Africa. My new book, “Doomed Interventions,” examines some of the challenges faced by donors, policymakers and citizens.
The most important thing I learned through my research was the global misalignment in prioritizing AIDS. Analyzing data on foreign aid and public opinion polls, I show that while the international community highly prioritizes AIDS, ordinary Africans give relatively lower priority to AIDS.
How the international community prioritizes AIDS
AIDS has been increasingly important to donors over time. Political scientist Jeremy Shiffman points out annual funding to address HIV/AIDS in low- and middle-income countries increased 28-fold between 1996 and 2006. In 2006, donors committed $2.5 billion to fighting AIDS in Africa; by 2015, that number doubled.
Data on donor spending suggests AIDS is exceptional, especially if you compare AIDS to other health issues. Though malaria is just as deadly as AIDS in Africa (and in some years, more deadly), AIDS funding far outpaces malaria funding.
AIDS does not just eclipse other diseases; funding for AIDS has also overshadowed support for health generally. For example, in 2003, Rwanda received $187 million earmarked for AIDS programs from three major international donors — PEPFAR, Global Fund and World Bank — which was more than five times the government’s annual budget ($37 million) for health.
Donor funding for AIDS has also outpaced donor funding for other development interventions in Africa. From 2003 to 2011, donor funding for AIDS was greater than that for agriculture and for water supply and sanitation initiatives. From 2007 to 2011, donor funding for AIDS even outpaced donor funding for education.
While this AIDS exceptionalism is characteristic of donors, citizens navigating the AIDS epidemic prioritized other issues.
How citizens prioritize AIDS
To study citizens’ priorities, I examined public opinion data collected by Afrobarometer, a Pan-African series of public attitude surveys now being conducted in more than 35 African countries.
I expected AIDS would be a priority in Africa, the region hardest hit by AIDS. I also expected countries with more significant AIDS epidemics would have more citizens prioritizing AIDS. The data showed otherwise.
In 2005, fewer than half of Afrobarometer’s 24,000 respondents thought their governments should devote more resources to combating AIDS. Particularly surprising were the African countries with high HIV prevalence (e.g., Botswana, Zimbabwe, Namibia, and Zambia), where a majority of respondents said resources should be devoted to problems other than AIDS.
These findings were consistent with scholarship analyzing data from early waves of Afrobarometer that showed AIDS failed to register high on the public agenda, even in high-prevalence countries. Analysis of later waves of Afrobarometer continued to show AIDS was a relatively low priority among African citizens. Consistently outranking AIDS (and health care more generally), unemployment is the issue citizens give the highest priority.
To understand citizen priorities more deeply, my research took me to Malawi, which had the ninth-highest HIV rate in the world. Villagers we surveyed across Malawi ranked HIV/AIDS as the lowest of five development priorities; AIDS fell behind access to clean water, agricultural development, education and general health services. Our study HIV-tested research participants, and even the HIV-positive Malawians in our study gave greater priority to clean water and agricultural development over AIDS interventions.
The relatively low priority Malawians give to AIDS is not because they’re unconcerned or unaware of AIDS. For the last two decades, Malawians have talked about AIDS in public and with strangers. During conversations at funerals, drinking sessions or rides on public transport, Malawians share ideas about AIDS, its origins and how it is transmitted — debating how much behavior change can prevent infection.
Malawians are really knowledgeable about AIDS — probably more knowledgeable than the average American. The 2004 Malawi Demographic and Health Survey reported 82 percent of women and 90 percent of men know HIV infection is not transmitted by food. Compare that to the 51 percent of Americans surveyed by the Kaiser Family Foundation in 2009 who stated they would be uncomfortable having their food prepared by an HIV-positive person.
Whose awareness could be raised on World AIDS Day?
Advocates urge the world to focus attention on areas heavily affected by AIDS and to make substantial resources available to fight AIDS. But as I show in my book, interventions against AIDS rarely seek insights from the people to whom AIDS interventions are targeted.
In many African countries, it has become increasingly easy to learn citizen’s opinions, thanks largely to Afrobarometer asking people what issues are important to them.
While many in the United States and elsewhere in the West imagine Africa as a place suffering from AIDS, this World AIDS Day could be an opportunity to raise our collective awareness about the issues citizens in Africa actually prioritize.