In less than a generation, HIV has become one of the leading killers on the African continent, but its long-term impacts on the continent’s already fragile development capacity threatens to be particularly devastating. In both men and women, the virus is impacting heaviest on the most productive sectors of African economies – prime-aged adults – robbing these already besieged economies of scarce skills, children of their parents and a continent of a generation in the prime of their working lives (Poku 2002; Whiteside 2002). Crucially, these losses – in both human capital and intergeneration knowledge – are taking place against a background of declining economic capabilities with its related structural indebtedness; weak states with their deteriorating infrastructures; and societies already reeling from two decades of adjustment pressures. Herein lies Africa’s predicament: on the one hand, how to respond effectively to the multiple demands of HIV/AIDS, whilst on the other, struggling with a debt overhang which is undermining investments in social welfare. In what follows, I will argue that any effective engagement with HIV/AIDS in Africa must simultaneously engage with the continent’s economic decline, if it is to be effective and sustainable.