The authors, Dr Murugi Micheni and Cyphrene Wasike
For
those old enough to remember, or who experienced the height of the HIV epidemic
in the late 1990s and early 2000s, the memories remain vivid and deeply
traumatic. Few families, communities, schools, workplaces, or places of worship
were left untouched by the scale of illness, loss, and uncertainty that defined
that era.
Hospital wards were filled with young
adults. Funeral announcements became a routine feature of daily life. Children
were orphaned overnight. Entire communities grappled with fear, silence, and
stigma. At a time when treatment options were limited and access even more so,
an HIV diagnosis was often perceived as a death sentence and, for many, it was.
A generation later, the face of HIV has
changed dramatically.
Globally, and particularly in countries
such as Kenya, where free-to-use HIV treatment programs were rolled out early
and expanded rapidly, remarkable progress has been achieved over the past two
decades. Aids related deaths have declined significantly. New HIV infections
have fallen substantially. Millions of people who would once have died are now
living long, productive lives because of access to antiretroviral therapy. In
Kenya, HIV prevalence has declined from 5.6 percent in 2010 to approximately
three percent today, while annual new infections have fallen by more than half
over the past decade.
This success, however, presents a new
challenge. HIV no longer looks the way it once did.
The public image of HIV remains frozen
in the epidemic of the 1990s and early 2000s. Yet today, most people living
with HIV are healthy, working, raising families, and leading a normal life.
Increasingly, HIV is being managed as a chronic condition rather than an acute
fatal illness. Many young people have never witnessed the devastation that HIV
once caused and therefore assess their personal risk through a very different
lens.
Paradoxically, this success may
contribute to complacency. When HIV becomes less visible, the perceived urgency
of prevention declines. The absence of visible illness can create the illusion
that the epidemic is over, even when transmission continues. In Kenya,
thousands of new infections still occur each year, with adolescents, young
women, and certain vulnerable populations continuing to bear a disproportionate
burden.
At the same time, the epidemiology of
HIV is changing. The epidemic increasingly intersects with other health and
social challenges. HIV rarely exists in isolation. It overlaps with
tuberculosis, sexually transmitted infections, viral hepatitis, mental health conditions,
non-communicable diseases, substance use disorders, gender-based violence, and
broader social determinants of health. This is the essence of a syndemic:
multiple interacting epidemics that reinforce one another and are shaped by
shared structural and social drivers.
The reality is that a young woman
experiencing gender-based violence may simultaneously face heightened risks of
HIV acquisition, unintended pregnancy, mental health challenges, and
interrupted access to care. A person living with HIV may also be managing
hypertension, diabetes, depression, or chronic liver disease. Addressing one
condition while ignoring others no longer reflects the realities faced by
communities.
This recognition is driving a
fundamental shift in how countries respond.
For decades, HIV programs were built as
vertical systems. Dedicated clinics, dedicated funding streams, dedicated
staff, and dedicated reporting systems were necessary because the epidemic
demanded an emergency response. These investments saved millions of lives. Yet
they also created parallel structures that are increasingly difficult to
sustain in a changing health and financing environment.
Today, countries are moving towards
integration. In Kenya, the Kenya AIDS Integration Strategic Framework (KAISF)
reflects this transition. The objective is not to diminish the importance of
HIV, but rather to situate it within stronger, people-centred health systems
that address the full spectrum of health needs across the course of life.
Integration means that prevention, treatment, reproductive health, mental
health, tuberculosis, non-communicable diseases, and social support systems are
planned and delivered in a coordinated manner rather than as isolated programs.
This shift is occurring alongside
another major transformation: the changing donor landscape.
The global HIV response was built
through unprecedented international solidarity. Programs such as PEPFAR and the
Global Fund transformed access to treatment and prevention across Africa.
However, the financing environment is evolving. Donor resources are
increasingly constrained, priorities are shifting, and countries are being
called upon to assume greater responsibility for financing and sustaining their
responses.
This does not signal the end of the HIV
response. Rather, it signals a transition from emergency dependence towards
sustainability. Countries must now invest not only in commodities and services,
but also in resilient health systems capable of responding to HIV and other
emerging health challenges simultaneously.
Perhaps the most profound symbol of
progress is that people are now ageing with HIV.
A generation ago, the notion of older
adults living with HIV would have seemed unimaginable. Today, growing numbers
of people living with HIV are entering their fifties, sixties, and beyond.
Their needs extend far beyond viral suppression. They require integrated care
for cardiovascular disease, cancer, diabetes, mental health, and healthy ageing.
HIV programs must evolve accordingly.
Yet amid all these changes, one
challenge remains stubbornly familiar: stigma.
Although treatment has transformed
outcomes, stigma continues to discourage testing, delay care-seeking, undermine
adherence, and isolate individuals and families. In many settings, HIV remains
associated with judgement, shame, and misinformation. The persistence of stigma
reflects a disconnect between public perceptions of HIV and the reality of what
HIV has become.
The future of the HIV response
therefore requires a delicate balance. We must preserve the gains achieved
through decades of investment while adapting to a world in which HIV is no
longer the sole defining health challenge. We must continue preventing new
infections while supporting those ageing with HIV. We must sustain political
commitment while embracing integration. We must remember the lessons of the
past without becoming trapped by them.
Most importantly, we must ensure that
younger generations understand both the progress achieved and the risks that
remain. Many have grown up in a world where HIV is treatable and often
invisible. What they may not have seen is the human cost that made this
progress necessary in the first place.
The face of HIV has changed. The
response must change with it.
Dr Micheni is a
Public Health Physician and Epidemiologist. Cyphrene Wasike is a Development
Communication Specialist.