Reflections on the HIV and AIDS pandemic over 22 years of publishing <i>AJAR</i>

The first issue of the African Journal of AIDS Research (AJAR) was published in 2002.In southern Africa, where this journal was conceptualised and created, the HIV and AIDS pandemic had already been massively impactful by then, owing to high prevalence and mortality, as well as dire social and economic consequences.In South Africa, specifically, the government of the time was stubbornly recalcitrant about the scope of the problems caused by HIV and AIDS.President Thabo Mbeki, aided and abetted by his Minister of Health Manto Tsabalala-Msimang, vacillated between denying the existence of the disease entirely and blaming others for the epidemiology.He bewildered the scientific community when he set out three questions to frame the first meeting of the Presidential AIDS Advisory Panel in May 2000: "What causes the immune deficiency that leads to death from AIDS?What is the most efficacious response to this cause or causes?Why is HIV in sub-Saharan Africa heterosexually transmitted while in the Western world it is said to be largely homosexually transmitted?" 1 The panel's report was published in March 2001, 1 not long after the 13th International AIDS Conference had met for the first time on African soil in July 2000.Despite the government's resistance to formulating appropriate HIV and AIDS responses, the panel's May 2000 meeting did provide an opportunity for scientists and activists to unite in their determination to assist the government in devising strategies.Participants, however, were somewhat offended at being characterised as "mainstream" while miscellaneous dissenters espoused a variety of bizarre opinions.It was eye-opening to watch the eminent paediatrician, Hoosen Mahomed "Jerry" Coovadia, lose his temper and confront naysayers who doubted the extent of the disease or the accuracy of the data.Coovadia's work in paediatric HIV and AIDS included groundbreaking research on mother-to-child transmission of HIV.He was a humanitarian and a leader in the struggle against apartheid.We pay tribute to Dr Coovadia, who passed away in October 2023 at the age of 83.In the context of my (AW) primary areas of research since 1990 -the social and economic causes and consequences of HIV and AIDS -I got to know the research economist, Markus Haacker.In the early 2000s, he warned the International Monetary Fund of the serious macroeconomic impact that AIDS could have.Haacker was a novel thinker and wrote extensively on health policy and was a member of many research groups.He died much too young in August 2023 and will be greatly missed.We also pay tribute to him.AJAR was launched into an environment where epidemiologists and infectious disease specialists in Africa were not yet sure how severe and wide-reaching the epidemic would be.Furthermore, although highly active antiretroviral therapy (HAART) had been developed by 1996, the drugs were still expensive and complex to administer; consequently, treatment was beyond the reach of most patients, most of whom lived in the poorer countries of the world.By 2000, it was apparent that the worst epidemics would be in African countries, and specifically in southern Africa.AJAR has published numerous articles speculating on reasons for this, yet it is still not definitively clear why the region has been so badly affected.There have been innovative and satisfying achievements.For instance, the inaugural issue of AJAR included an article coauthored by myself (AW) that tried to assess AIDS mortalities by looking at the photographs that were routinely included with obituaries in a major daily newspaper in Swaziland. 2 The argument was simple: if HIV-related mortality was rising and shifting by age and gender, we should be able to find innovative sources of evidence.This could be critical in settings where there is no vital registration of births and deaths.In Swaziland, however, most death notices included photographs of the deceased.In contrast, we have been fortunate to have relatively good data from much of southern Africa.For example, in South Africa, the national HIV and syphilis antenatal sero-prevalence surveys showed that in 1990 just 0.7% of women attending antenatal clinics were HIV-positive, whereas this was documented at 22.4% by 2000, and reached 30% by 2011.Similar prevalence levels were recorded across most of southern Africa, with slightly higher estimates in Botswana, Lesotho and Eswatini.The new standard of HIV care available by 1996 remained beyond the reach of most Africans diagnosed with HIV infection.Thanks to generous international financing, such as through the US President's Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund to Fight AIDS, Tuberculosis and Malaria, it was possible to launch extensive treatment programmes.One problem not adequately addressed, however, is that many countries failed to mobilise sufficient domestic funding, creating an imbalance in health programme funding in Africa, which remains largely unchanged.AJAR's research articles have helped to document the emerging circumstances of the pandemic in Africa while special issues have focused on particular topics.Initially, the journal produced two issues each year; by 2004 there were three and by 2009, four.This quarterly output has been maintained.The first special issue in 2009 looked at "anthropological perspectives," followed in 2011 by "HIV prevention and the world of work; resilience and coping strategies of HIV-affected children in sub-Saharan Africa".Subsequently, the journal has typically produced one special issue per year.Notably, in 2016, AJAR worked with the Health Economics and HIV and AIDS Research Division (HEARD) at the University of KwaZulu-Natal, together with the Swedish International Development Cooperation Agency (Sida), to produce a special issue on "Fast-tracking HIV prevention: scientific advances and implementation challenges". 3Another noteworthy special issue was "What the world

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