In 2011, there were 34.2 million people living with HIV. In some 15 African countries, between 5-25 percent of the population has HIV. But Africa is by no means homogeneous and regions vary greatly. While the disease currently affects southern Africa severely, West Africa faces much lower rates of infection, with countries averaging between less than 1 to 4 percent, and North Africa averaging less than 0.1 percent.
Some of the difference in infection rates can be attributed to how countries responded to the epidemic in the 1980s, when the disease began to emerge in full force. Returned Peace Corps volunteer Gary Engelberg was in Senegal at the time, where he now runs Africa Consultants International, a nongovernmental organization focused on health-care advocacy, study-abroad programs, and cultural orientations.
After his volunteer service from 1965-67, Engelberg was Peace Corps associate country director for Senegal from 1967-69, then was a regional training officer for west and central Africa from 1969-72.
He started ACI in 1983 with another returned Peace Corps volunteer, Lillian Baer, who served in Cote d'Ivoire from 1966-68, along with a staff of about five. Today, ACI's 40-person staff consults with nongovernmental organizations on HIV/AIDS issues in Benin, Burkina Faso, Cote d'Ivoire, Ghana, Guinea, Mali, Niger, and Togo.
"ACI began health work in the 1980s - family planning and maternal health," Engelberg said. "Then the United Nations Development Program HIV in 1990 invited us to help them develop a response for HIV and development: The U.N. understood what the development impact would be.
"In the beginning, it was a lot of work," said Engelberg. "In the 1990s, this was still a fairly new phenomenon. We were trying to get civil and religious society to be aware of how this would impact the country."
Essentially, ACI worked with NGOs already operating in Senegal to incorporate HIV-prevention education and care into their existing structures.
"After that year of consultation [with UNDP], we moved our organization to face that," he said. "We had a good reputation in terms of advocacy and training, and we continued to work in the field. Across the country, we worked as advisers to medical people, mobilizing civil society, and organizations, adding an AIDS program to whatever they were doing - grafting it on to the existing network.
"In the beginning, there was this idea to have a separate network - to create a whole new network - which wouldn't have the reach. Instead, we had this network of NGOs and we got them to add on a mobilizing component. Basically, in Senegal, there are hundreds of organizations that provide HIV support: We don't have specialized organizations for the support [and] we can't afford to create a whole new network."
The result is that Senegal has integrated care and support for people living with HIV and sexual minorities, unlike other countries such as the United States, where early prejudice forced activists to initiate a parallel system of care when primary doctors refused to accept or treat HIV patients.
Engelberg noted several other differences in Senegal, including the early activism of Catholics and, later, Muslims, which is a stark contrast to some East African countries where religious leaders discourage the use of condoms, encourage HIV-positive people to discontinue their treatments to let God heal them and speculate that HIV/AIDS is God's judgment for immoral behavior.
"The Catholic Church is very progressive here," Engelberg said. "We worked with a wonderful nun who was here at the beginning of the epidemic. She mobilized all aspects of the Catholic community for care and support groups for people with HIV and prevention. And she gradually convinced the hierarchy to get involved with the response to HIV/AIDS."
Specifically, the church cared for the people who were suffering, carving that out as its niche in the response to HIV: According to Engelberg, the first free, voluntary, anonymous testing center was created by the Catholic AIDS Association, not the government.
Over the years, Engelberg said ACI's work has evolved, moving from prevention education to advocacy, then care and treatment.
"As time went on, we got more involved with advocacy, working with the media to create a more favorable environment," he said. Then, ACI began working with associations of people living with HIV/AIDS and men who have sex with men (MSM).
"Most recently - the past two-three years - we've been working with sexual minorities, MSM in particular," Engelberg said. His group now helps facilitate a national organization for MSM to develop a strategic plan to advocate for the rights of sexual minorities.
"In Senegal, a wave of homophobia has destroyed a lot of the HIV/AIDS work" of the last decades, he said.
On a recent Islamic holiday, Engelberg said many of the Muslim leaders' sermons condemned homosexuality.
"There's still an awful lot of religious prejudice," he said. "We have to find a way of neutralizing that message. Hopefully, they can be warned that the pot is starting to boil before it boils over. It's important for them to understand the relationship between oppression of gay people and their role to provide prevention and care."
Engelberg said the religious homophobia could be "counterproductive and very dangerous."
"The young gay community is particularly at risk because they are not careful," he said. "I wouldn't be surprised if we had a regression."
As part of a subcommittee created to work on sexual-minority issues - same-sex sexual activities are illegal in Senegal - Engelberg has trained MSM to be advocates for themselves, "to give them a voice so they can actually talk about their perceptions."
Another recent challenge Engelberg noted in the fight against HIV/AIDS in Africa is a return to family planning as a major international aid focus.
"Funding for AIDS is waning; it's more difficult to maintain the HIV/AIDS work," he said, adding that the shift in funding makes sense as family planning can incorporate HIV prevention.
"But on another level, there are still millions of people who need care and support," Engelberg said. "There are still areas in Africa where people don't have access to antivirals. There are many places in Africa where AIDS remains shameful. There's stigma."
"It's better, but a lot of people are still suffering."