HIV is not what it used to be—and that changes everything

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.