Before the development of antiretroviral (ARV) therapy, HIV infection meant that most people would die of AIDS within a decade. But access to ARVs meant that, for some, HIV was rendered a chronic disease, comparable with diabetes and hypertension. The drugs were initially regarded as too complex to be rolled out in Southern Africa, but pilot studies conducted by Médecins Sans Frontières and other organisations proved that patients adhered excellently when they were well-informed about HIV and its treatment.

The cost of ARVs also decreased in the late 1990s, as generically manufactured drugs were developed and pharmaceutical corporations lowered their prices in response to pressure from civil society.

The Southern African Development Community (SADC), representing 15 Southern African states, has committed to a host of declarations to ensure better access to HIV treatment and prevention services. Among these are the Millennium Development Goals (MDGs), which include the goals of universal HIV treatment by 2010 and a halt and reversal of the epidemic by 2015.

In the South African context, the struggle of the Treatment Action Campaign (TAC) for public access to ARV treatment in the late 1990s drew international attention to the health and human rights violations of people living with HIV as a result of states' failures to provide life-saving medicines and services.

But at the end of 2008, the global mood has changed. HIV activists are facing a backlash based on the growing perception that the rollout of ARV therapy is plundering resources from other health and humanitarian programmes and that ARV regimens are ultimately unsustainable in developing countries. Exhaustive evidence which proves that the rollout of ARV programmes strengthens health systems through capacitating healthcare workers, establishing new distribution networks and improving the quality of life of patients who require less inpatient care because of the immune-boosting effects of the drugs, is consistently ignored by these critics.

As a recession looms, funding for healthcare initiatives is becoming more and more sparse. The MDG of halting and reversing the incidence of major diseases, including malaria, by 2015, appears delusional in light of the recent outbreak of cholera in Zimbabwe and of the rising prevalence of multi-drug resistant and extremely drug-resistant tuberculosis in Southern Africa.

However, as the 2008 'Treatment Barometer' of the Southern African Treatment Access Movement (SATAMO) shows, remarkable gains have been made with regard HIV treatment access for Southern Africans, despite the persistent shortages in healthcare workers, essential medicines and diagnostics equipment.

In Namibia, where the country's vast geography means that people on ARVs often have to travel over a hundred kilometers to access medicines, ARV coverage is 88%. This is the highest in sub-Saharan Africa and puts Namibia in line with other developing nation success stories in public ARV access, Brasil being the foremost example with ARV coverage of 95%.

Botswana also has high ARV penetration, with 79% coverage, although sources argue that stigma against HIV-positive people remains rampant including among the ranks of healthcare workers.

SATAMO's 'Treatment Barometer' documents how stigma around visiting HIV clinics remains a major deterrent to treatment access in numerous SADC states, including Lesotho. The heightened incidence of TB/HIV co-infection in Lesotho also means that patients must travel long distances to separate clinics to access treatment. The integration of TB/HIV services is critical, and the implementation of a single TB/HIV infection card for patients is one simple means of merging the treatment and care of these co-epidemics.

The integration of TB/HIV services in South Africa is one of the TAC's primary campaigns from 2009 and beyond. TB/HIV are inseparable in South Africa, where approximately 53% of South Africans with TB are also HIV-positive, with dual infection rates of up to 80% in some communities.

Much has been written about the 'feminisation' of HIV in Southern Africa, in which HIV-infection is more prevalent among women. In 2007, for example, approximately 2.8 million South African women were HIV-positive, compared to 2.3 million South African men. This discrepancy in infection rates is attributable to the region's culture of gender inequality. In contexts in which women are less able to control sexual encounters and less able to access means of HIV prevention, they are more prone to sexually transmitted infections.

Interestingly, the 'Treatment Barometer' shows that, in many Southern African states, more women than men are accessing ARVs. In Malawi, 61% of the 146,000 Malawians on ARVs are women. In Mozambique, 62% of the 96,613 ARV recipients are women. The social, epidemiological and economic circumstances that ensure higher HIV prevalence among women, and lower uptake rates of ARVs among men, must be addressed if the HIV MDGs are ever to be achieved.

Southern Africa has made remarkable gains in treating HIV, but the halt and reversal of the epidemic, called for in the MDGs, requires the massive and sustained commitment of states, funders and citizens. We cannot allow the downturn in markets to derail the healthcare programmes on which millions of Southern African lives depend.