In the prescient bestselling book The Coming Plague, published over 20 years ago, an epidemiologist is quoted saying: “AIDS is trying to teach us a lesson. The lesson is that a health problem in any part of the world can rapidly become a health threat to many or all” (1). This warning wasn’t a lone cry in the wilderness. In the last twenty years, alarm bells have been ringing out in the public health community prophesying that sooner or later there would be a global pandemic for which we are not ready. Multiple studies echoed these warnings: our systems of disease surveillance and response are outdated, slow, and lack coordination (2). Any hot spot of disease on our planet has the potential to rage out of control, they all warned.

As if following a script COVID-19 exploded out of Wuhan, China in likely the most reported and closely observed spread in modern medical history. In spite of this almost real time surveillance, it still managed to infiltrate every single populated continent on Earth within six weeks. As health system after health system struggled under the weight of the ravaged lungs of sufferers, a messy retreat was attempted. Countries shut down and shut out possible vectors of disease, mostly to little avail. Like all plagues before, COVID-19 reaped its greatest butcher’s bill among the most fragile members of our society: the sick, the elderly, the marginalized, and the poor (3).

The public health community’s eyes naturally turned to Africa, a beleaguered continent still struggling with the destructive legacies of colonialism, war, and poverty, where so often pandemics wrought their greatest destruction. The fear of what could happen when the disease that had defeated the first world hospitals of Bologna and New York City reached the overcrowded slums of Lagos and Kinshasa was palpable (12). Would we see the massive death tolls and healthcare collapses that would dwarf those we were witnessing in the West?

And what of the multiple comorbidities afflicting so many Africans at that same time? Tuberculosis, malaria and a host of tropical diseases still hold their grip on the population of many Sub-Saharan countries (11). What would happen in this deadly mix when the coronavirus joined forces with all these scourges? Thoughts of course then turned to HIV/AIDS, that familiar enemy, whose hallmark is precisely the nightmare of anyone fighting a virus with a ravenous hunger for impaired biological barriers: a collapse of the immune system. Would we see a terrifying combination of immunosuppressed African patients succumbing to COVID-19 in massive numbers?

However, as the pandemic raged on in the Northern Hemisphere and fueled desperate isolation and quarantine attempts as well as civil and political strife, African countries remained relatively untouched by the COVID-19 spread. Even accounting for the dearth of reporting and doubts over the accuracy of disease counts, it seemed an unlikely turn of events was occurring. The virus was largely sparing Africa. As of September 2020, the African continent still marks the second lowest case counts of any continent at 1.4 million, 6.6 times lower than Asia and 11.1 times lower than the Americas (4).

Cases per 100,000 population in Africa and Europe as of 10/3/2020, based on data from Johns Hopkins University.

COVID-19 is a ravenous disease that not only consumes breath, but also consumes resources. The acute respiratory distress that is the hallmark of severe COVID-19 infection requires extensive care and it stretches the capabilities of even the most well-equipped hospitals and intensive care units. Throughout North America and Europe entire health systems and hospitals have pushed everything else aside in order to devote resources on those afflicted with this new virus. Logistics groaned under the weight of the demand.

Even as the specter of a massive COVID-19 explosion south of the Sahel subsided, a new fear emerged: would African health systems, in an attempt to shore up their defenses for a coming coronavirus invasion, neglect the intricate logistics of providing lifesaving medication to its HIV positive patients? What happens when limited dollars are taken away from antiretroviral therapy distribution and put towards disease surveillance and potential respirator acquisitions? Would we see an explosion in uncontrolled HIV viral loads and deepening immunosuppression again? Would efforts to defend against one enemy resurrect another?

Recent modeling spoke to a nightmare scenario where a six-month disruption in HIV treatment pipelines could cause more than 500,000 deaths in Sub-Saharan Africa over the next 12 months, with even a modest interruption causing upwards to 110,000 excessive deaths (5).

While we do not have concrete answers as to the causative effects yet, that worst case scenario does not seem to be taking place. HIV mortality rates across Sub-Saharan Africa have largely remained stable throughout the pandemic. The compliance of patients with antiretroviral therapy also seems to not have taken a significant drop. Could these twin observations be indirect evidence that supply chains for distributing HIV/AIDS chronic therapy remain unbroken?

Another interesting possibility is that the very same antiretroviral therapies used to prevent HIV viral replication are also exhibiting a protective effect in those taking them daily, since previous studies have shown combination treatments used to treat HIV are effective against other coronaviruses such as SARS and MERS (8).

If indeed the steadfastness of antiretroviral therapy distribution is proven to be correct, this is to be commended of course. The feasibility of providing constant chronic therapy to millions of patients dispersed across a large landmass has long been questioned by those who feel that it’s only a matter of time until resources are exhausted, and this medical largesse cannot be continued (9). It should indeed be a source of satisfaction to be wrong about this dire prediction and applaud our African partners for continuing the effort to maintain the health of their HIV positive populations even in the face of a pandemic.

Pelebox, created in 2019, is a solution to automate and simplify the distribution of medication in South Africa. Previous to Pelebox, medication distribution was a staff intensive process that routinely involved patients waiting at clinical sites for 3 or more hours. The Pelebox solution involves the use of smart lockers placed in high traffic areas such as retail outlets and shopping malls – freeing up clinics for patient care. When the medication for a specific enrolled patient is available, health clinic staff can load it into a smart locker for that patient who then receives a text message alerting them their medication is ready for pickup. No waiting involved. Pelebox has reached over 3,000 patients and plans to establish an additional 30 smart locker locations in South Africa.

These congratulations have significant caveats of course for the future remains uncertain. The COVID-19 pandemic still holds the globe in its grip, showing only few signs of abatement. Multinational efforts continue as of this writing to create a vaccine that will end what has become the first true public health challenge of the 21st Century (10). We still don’t know what is protecting Africa from the disease that has laid low so many in the developed and developing world. And until we know, we cannot be sure of its perpetuity. The factors that are keeping COVID-19 mortality to a fraction of that of the Global North could vanish just as easily and mysteriously as they appeared.

It’s important to maintain our vigilance and continue studying the factors behind the African experience with this disease so that we know how to maintain what looks to be now a favorable situation. Beyond maintenance, the knowledge would serve the Global community as we all struggle to shore up defenses and continue devoting resources to fighting this disease.


1. Garrett, Laurie (1994). The Coming Plague. 1st Ed, New York City, NY: Penguin Books

2. Pike, Jamison, Jason F. Shogren, David Aadland, W. Kip Viscusi, David Finnoff, Alexandre Skiba and Pete Daszak (2020). “Catastrophic Risk: Waking Up to the Reality of Pandemic?”, Eco Health. Vol. 17, p, 217-221. Retrieved online (09/28/2020):

3. Centers for Disease Control and Prevention (2020), “Health Equity Considerations and Racial and Ethnic
Minority Groups”, Coronavirus Disease 2019, National Center for Emerging and Zoonotic Diseases (NCEZID) (Covid-19). Retrieved online (09/28/2020):

4. Anna, Cari, (2020, September 22) “As US struggles, Africa’s COVID-19 response is praised”, Associated Press, retrieved online:

5. UNAids Global Report (2020), “Seizing the moment: tackling entrenched inequalities to end epidemics”, retrieved online:

6. Saunders, M. J., & Evans, C. A. (2020). COVID-19, tuberculosis and poverty: preventing a perfect storm. The European respiratory journal, 56(1), 2001348.

7. Millett, G. A., Jones, A. T., Benkeser, D., Baral, S., Mercer, L., Beyrer, C., Honermann, B., Lankiewicz, E., Mena, L., Crowley, J. S., Sherwood, J., & Sullivan, P. S. (2020). Assessing differential impacts of COVID-19 on black communities. Annals of epidemiology, 47, 37–44.

8. Advisory Board (2020), “Can drugs meant for HIV treat the new coronavirus?”. Retrieved online:

9. Atun, R. Chang, Angela Y Chang, Osondu Ogbuoji, Sachin Silva, Stephen Resch, Jan Hontelez and Till Barnighausen (2016), “Long-term financing needs for HIV control in sub-Saharan Africa in 2015-2050: a modelling study”, BMJ Open, Vol. 6, Issue 3. retrieved online:

10. Branswell, Helen (2020, March 18), “WHO to launch multinational trial to jumpstart search for coronavirus drugs”, Stat News. Retrieved online: