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.

About 64% of people with HIV live in sub-Saharan Africa, using the combined UNAIDS eastern/southern and western/central Africa estimates for 2025. Decisions about access and funding affect their ability to obtain care, as they do elsewhere in the Global South.^[1]

The disproportionate burden

UNAIDS estimated 21.1 million people living with HIV in eastern and southern Africa and 5.2 million in western and central Africa in 2025. Together, 26.3 million is about 64% of the global 41 million. Eastern and southern Africa alone accounted for just over half. These are rounded estimates with uncertainty ranges, not exact counts.1

Some countries have particularly high prevalence. Eswatini’s national prevention roadmap cites the 2021 SHIMS 3 survey estimate of 24.8% among adults aged 15 and older. That is a dated survey estimate, not a claim that exactly one in four adults has HIV today.2

Why sub-Saharan Africa carries this burden

The distribution of HIV reflects interacting biological, social, economic and historical factors. Access to prevention and care, gender inequality and health-system resources matter, but no single explanation describes every country or community.^[4]

Poverty and health system capacity

Financial hardship can make transport, appointments, food and medication access more difficult. National health systems also face staffing and funding constraints. These barriers deserve attention without treating poverty as an explanation for every infection or assuming that countries with high prevalence have uniformly weak services.^[4]

The mode of transmission

Transmission patterns vary within and between regions. Several southern African countries have high prevalence across the wider adult population, while key populations also face substantial risk and barriers to care. Prevention needs both broad access and services designed with the communities most affected.^[4]

Gender inequality as a structural driver

UNAIDS’s 2025 report estimated that women and girls accounted for 63% of new infections in sub-Saharan Africa in 2024, with about 3,300 acquisitions each week among adolescent girls and young women aged 15–24. These historical figures illustrate unequal risk; they do not establish the cause of any individual infection. Violence, economic dependence and restricted access to prevention can contribute.4

Women and girls: the epidemic within the epidemic

Women and girls accounted for 44% of new HIV acquisitions globally in 2025. The 63% sub-Saharan Africa figure above comes from the previous reporting year. Keeping those dates separate avoids implying that the two estimates describe the same dataset.^[1]

HIV prevention for women and girls should connect clinical services with protection from violence, education, economic opportunity and meaningful choices about sex and health. These needs are described in UNAIDS’s analysis; they do not mean every programme lacking a particular component has been shown to fail.^[4]

The fight for generic drugs: a history that still matters

Combination ART transformed HIV treatment, but high medicine prices blocked access for many people. MSF’s historical account records Cipla’s 2001 offer of a three-drug regimen for $350 per person per year as a major challenge to prevailing prices. Historical drug prices should not be confused with the full cost of delivering care.^[11]

Thirty-nine pharmaceutical companies challenged South Africa’s Medicines and Related Substances Control Amendment Act, which sought to improve affordability through measures including parallel imports, generic substitution and price controls. They withdrew the lawsuit on April 19, 2001, following extensive South African and international advocacy. The dispute was broader than a law simply allowing compulsory licences for antiretrovirals.^[12]

The 2001 Doha Declaration clarified that the TRIPS Agreement supports governments’ right to protect public health, including compulsory licensing. An emergency is not required to issue a compulsory licence; urgency affects whether prior negotiation with the patent holder is required. Separately, FDA approval or tentative approval enables quality-assured generic antiretrovirals to be purchased for PEPFAR, even when patents or exclusivities prevent U.S. marketing.^[13]5

In August 2023, the Global Fund announced procurement agreements offering TLD medicine for under $45 per person per year. That is a drug procurement price, not the total cost of clinical visits, laboratory monitoring, distribution and care. Generic competition, licensing and pooled purchasing helped lower prices; continued delivery still requires a functioning health system.6

Community health workers: the backbone of the response

Community workers and peer organizations can help people find testing, navigate services and stay connected to care. Their roles and training vary, and they complement rather than replace clinical teams. UNAIDS’s reporting from Ethiopia gives a concrete example of that work.^[14]

In Bahir Dar, Ethiopia, UNAIDS described community networks supporting people facing conflict, displacement and financial hardship. Local knowledge and trust can help services reach people, but the report does not establish that community workers are the main healthcare contact throughout Ethiopia, Malawi and Mozambique.^[14]

UNAIDS’s August 2025 Ethiopia account describes young volunteers using WhatsApp groups, mothers supporting children’s treatment and youth groups sharing health information through community radio. It also describes serious unmet needs. These efforts show adaptation under pressure, not proof that every interruption was prevented.^[14]

What PEPFAR built in the Global South

PEPFAR’s December 2024 results sheet reported support for 20.6 million people receiving HIV treatment as of September 30, 2024 across 55 partner countries. This is a treatment-support snapshot, not a cumulative count since 2003 and not a sub-Saharan-Africa-only total.7

Large purchasing programmes and quality-assured generics helped make treatment more affordable. FDA’s PEPFAR review process assesses medicines for safety, effectiveness and quality, while pooled procurement creates opportunities to negotiate lower prices. Medicines still need staff, testing, supply chains and community support to reach patients.^[13][6]

The 2025 crisis and what it means for the Global South

International funding disruptions exposed dependence on external support. UNAIDS’s July 2026 account reports that international aid supplied about 80% of HIV prevention funding in sub-Saharan Africa. That regional share should not be treated as the exact proportion for every country or every HIV service.9

In July 2025, UNAIDS projected 6 million additional HIV infections and 4 million additional AIDS-related deaths during 2025–2029 if U.S.-supported HIV services collapsed entirely. This is a conditional model, not a count of events already observed or an unavoidable forecast.^[10]

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

The Ethiopia example shows what community response can look like: peer check-ins, support for children’s treatment and locally shared health information. These documented actions deserve support. The report also describes unmet needs that require reliable funding and clinical services.^[14]

Communities affected by HIV bring knowledge that should shape prevention and care. Supporting that leadership means resources, authority and respect. Community resilience should strengthen reliable services, rather than become an excuse to withdraw them.^[14]