The construction of a comparative analysis of AIDS public policy in Africa

Drawing on American and French anthropology, I propose several notions that capture the different types of responses, the dissimilar political contexts in which they were modified, and the successes and failures of social and political mobilisation against AIDS in Africa more generally. I begin by examining the importance of international guidelines promulgated by WHO and later by UNAIDS, which are often standardised despite differences among local contexts. The diversity of local and regional epidemiological dynamics and the plurality of political responses to the magnitude of AIDS in Africa led me to the idea of "political cultures”. This dynamic notion allows me to take into account the in-depth history and trajectory that has shaped each State’s political response to the AIDS pandemic.

Generalised access to ARVs marked a turning point in the response to the pandemic. By exploring both diachronic (before-and-after) and synchronic dimensions, I have been able to show the political processes that responded to the pandemic’s emergence in Africa. This further clarifies how different African States responded to the dynamics captured by the epidemiology of HIV/AIDS, from the beginning of the epidemic to the policy on access to combination antiretroviral therapy. Before the discovery of ARVs, the National AIDS Programs (PNLS/

NCA)¹ established according to guidelines emitted by the Global Programme on AIDS (GPA) constituted the foundation of AIDS public policy. The availability of access to ARV treatment later modified political attitudes, international mobilisation, and even the role of associations. To elucidate the responses of African States, I draw on a typology of three models of State action: “active participation”, the activist State”, and “passive adhesion”. Before embarking on the comparative analysis of the interactions of national and international actors, it is necessary to provide a historical overview for each model. This will also allow us to better grasp the confluence of socio-medical and political dynamics that preceded access to ARVs.

International frameworks or national convergences? International guidelines and Africa’s national AIDS programs (PNLS/NAC)

During 1986 to 1996 and from 1996 to the present, African States have responded to international development and cooperation in different ways. This timeline is punctuated by the therapeutic, political, and symbolic changes introduced by the discovery of antiretroviral molecules, first announced at the Vancouver AIDS Conference in 1996. Access to ARVs became synonymous with the workings of the PNLS/NACs. In some African contexts, that dynamic led to the State opting out, by default, of the now obsolete vertical Global Programme on AIDS (GPA). This WHO programme was replaced by various international efforts as well as by the Joint United Nations Programme on HIV/AIDS (UNAIDS) which coordinates international public action against AIDS (Nay, 2009, 2010a).

After the first AIDS case was discovered in the U.S. in 1981 and the HIV virus was formally isolated in 1983, the AIDS epidemic intensified on the African continent. Two obstacles slowed down the institutional response. The first was the problem of how to assess the epidemiological situation. Diagnostic tools only became available in most countries from 1985 on, with few exceptions, such as Rwanda and ex-Zaire, where international NGOs had already provided them. A second obstacle was the slowness with which some heads of state and governments acknowledged the presence of the disease on their soil. Their hesitancy stemmed from real or perceived racist prejudice that surrounds AIDS and the sensitivity about sexuality, the key mode of AIDS transmission in Africa (Dozon and Fassin, 1989, 2001).

After the first HIV screening test, ELISA (Early Linked Sorbent Assay),² became available in some countries, numerous committees, groups, and networks were set up to discuss prevention and therapeutic responses to HIV. Despite scant resources, doctors in Africa joined networks and interacted with their European and American colleagues. In 1986, Jonathan Mann founded the Global Programme on AIDS (GPA) at the WHO in Geneva. The agency’s goal was to provide an international response to the danger AIDS posed for countries of the South, especially in sub-Saharan Africa, where the pandemic’s epicentre was located. The GPA recommended that individual States, especially African ones,

International policy response in Africa 21 create National AIDS Councils or Committees (PNLS/NAC). These programmes were to develop mechanisms for epidemiological data-collection and monitoring, implement prevention programs for target groups, and, with the support of the European Union, ensure blood transfusion security (Keroudan and Eboko, 1999).

Table 1.2 presents the timeline of the establishment of the PNLS/NAC in selected African countries, as reported in the first major social science comparative study (unpublished) of African States and AIDS. The study was conducted under Gruenais's direction by an interdisciplinary team representing anthropology, sociology, political science, and contemporary history. Its goal was to understand how African States were implementing the guidelines set by international organisations, in particular the WHO’s GPA. The same methodology focussed on actors and institutions was applied to each of the study’s five countries, which represented Central Africa (Cameroon and Congo-Brazzaville), West Africa (Cote d’Ivoire and Senegal), and East Africa (Kenya). Data on international institutions (the GPA and the other international institutions present in each of the countries) provided the basis for an empirical sequence analysis that took into account the processes leading to each countiy’s implementation of their national aids commission, known as the Programme national de hitte contre le sida (PNLS) in the Francophone countries and the National AIDS Committee (NAC) in Kenya, the one Anglophone country in their study. Next, the relationships between State actors and international actors and the role of associations and international NGOs (later grouped under ‘‘civil society”) were identified at the national level. “Civil society” was redefined as “organisations of civil society”, a move supported by international organisations themselves when they were called on intermediary social groups, located between the State and society, to participate in public action against AIDS.

Table 1.2 Chronology of the implementation of National AIDS Programs (NAPs) in selected African countries.

Source Gruénais M.-E. (ed), 1999

Notes: * NAC - National AIDS Committee. ** PNLS - Programme Nationale de Lutte Contre le Sida.

Although Gruénais was not primarily influenced by PPA research and even less so by the comparative literature in this area, his study can nevertheless - if not paradoxically - be considered the first comparative sequential analysis model of AIDS in Africa. Like one of his most knowledgeable contemporaries in the area of international comparisons, the political scientist Patrick Hassenteufel (2000, 2005), Gruénais managed to avoid the major pitfalls of comparison. And as both advocates and critics of sequential analysis might note, he retained only four of seven "classic” sequences of PPA. The collective research Gruénais directed can be read against the following methodological questions posed by Patrick Hassenteufel.