International political commitment and subsequent financing for HIV programmes in low- and middle-income countries have been a result of determined pursuits from multiple channels and the reframing of the narrative around HIV as more than a health condition to a global political, economic – and, to some degree, security – concern. Efforts to finance the HIV response in low- and middle-income countries were the product of a unique era of collaborative thinking and partnerships.
Disease caused by what would soon be recognized as HIV infection was first reported in the US in 1981, among men who have sex with men. At that time, the US had the highest number of people living with HIV among developed nations. There was little public understanding of the disease, and it was not regarded by politicians as a priority. A combination of political denial, fear-mongering and inadequate funding for research impeded the early response. It took strong civic action, pressure from scientific institutions and bipartisan support before steps were finally taken towards recognizing and responding to HIV in the US. While other high-income countries also began reporting cases of HIV, there was an initial delay in official oversight among health ministries until 1986–87.
Civil society, affected communities and charitable foundations played a significant role in defining country responses to the HIV epidemic. One of the salient features of the US national response was the early mobilization of directly affected groups and their allies in shaping the response. Those groups in particular were concerned about the stigma and discrimination surrounding the epidemic, and adopted a human rights-based approach that combined political activism with visible involvement in the decision-making process. Hence, the response to the HIV epidemic went beyond the traditional public health approach to interventions. However, although this approach contained the epidemic and the general public in high-income countries eventually felt less threatened by HIV, money did not immediately flow to low- and middle-income countries to fund a similar approach. Indeed, recognition of the exceptional nature of the HIV epidemic slowly started to lose salience in North America and Europe with the increased availability of medicines.
In the late 1980s, when the HIV epidemic was first acknowledged by political leaders in Africa, international concern and resources to address the epidemic in that continent were slow to develop. The World Health Organization (WHO) estimated that, in 1987, close to 2.5 million people in Africa were living with HIV; this figure doubled over the following two years. By the late 1990s, the HIV epidemic was having a visible economic impact across the continent, reducing the average national growth rate of African countries by 2–4 per cent a year. While prevention programmes to tackle the HIV epidemic in Africa were prevalent in the late 1980s to early 1990s, low- and middle-income countries (which included the majority of African countries) received only 6 per cent of the total global spending for HIV prevention programmes in 1990–91. The HIV epidemic in Africa gained significant global recognition only after the establishment of the Joint UN Programme on HIV/AIDS (UNAIDS) in 1994.
