Until the Global Fund for AIDS, TB, and Malaria was created in 2002, if you were diagnosed with HIV, your fortunes were largely dependent upon where you were born. If you were born poor in Africa, you almost certainly were going to die. Access to ARV drugs was determined by market prices and your ability to pay. By contrast, if you were HIV+ in an advanced industrialized country, chances are that, by the late 1990s, you could get access to ARVs through national health systems or private insurance. Even the United States, which lacked a national insurance health scheme, provided poor Americans access to ARVs through programs like the AIDS Drug Assistance Programs, which came into being when the Ryan White CARE Act was passed in 1990.

Of course, rich and middle-income countries did not develop these programs overnight in pragmatic response to the AIDS pandemic. With AIDS initially viewed by the “mainstream” as a disease of the deviant, the community most immediately threatened by it had to mobilize to help create the political momentum for extending access to AIDS drugs to all who needed them. However, in most of the leading countries, the market and medical institutions required to diagnose, counsel, procure, dispense, treat, and pay for this access were already present and extensive. While many programs to test and treat the disease were new or even experimental, the broader edifice of health systems was in place.