As can be seen from the early sections of this Epidemic Update, HIV has penetrated every country across the globe. It is painfully clear that one continent is far more touched by AIDS than any other (see Regional HIV/AIDS Statistics and Features, End of 2000). Africa is home to 70% of the adults and 80% of the children living with HIV in the world, and has buried three-quarters of the more than 20 million people worldwide who have died of AIDS since the epidemic began. Over and above the personal suffering that accompanies HIV infection wherever it strikes, the virus in sub-Saharan Africa threatens to devastate whole communities, rolling back decades of progress towards a healthier and more prosperous future.
In the next few sections, we look at how AIDS affects the lives and livelihoods of the men, women and children of the hardest-hit countries, especially those in southern Africa. The information presented reveals two things. The first is that the devastation wrought by HIV is very real, whether the impact is measured in terms of children's future prospects or companies' bottom line. The second thread running through this report is that the epidemic is stimulating a new resilience. Governments, businesses, families and communities are adapting -- with more or less effort and pain -- to the new landscape being sculpted by the epidemic. This illustrates the encouraging ability of people across Africa to rise to new challenges just when the situation seems hopeless.
Households: Coping According to Their Ability
In countries that are worst affected by the epidemic, rising sickness and death often take place against a background of deteriorating public services, poor employment prospects and endemic poverty that are not directly related to the HIV epidemic, but that may be exacerbated by it. These factors not only reduce the capacity of communities to step in and help those most affected by AIDS but complicate the task of measuring the impact of AIDS at the household level. Many of the studies that look at AIDS-affected households do not simultaneously collect information from unaffected households, so they have difficulty distinguishing between the impact of sickness and death in a young adult and the impact of other shocks, such as drought, inflation, or a rise in school or health service fees. And since most household studies are conducted at a given point in time, they miss the households that have failed to cope, those that have been dissolved by AIDS, sending young people to the streets and old people to destitution and death.
What information there is available shows that households bear the brunt of misery caused by the epidemic. Nevertheless, new analyses of information collected at an earlier stage of the epidemic in the United Republic of Tanzania suggest that households and communities may be more resilient than once thought. A large study of rural households surveyed over a period of several years, at a time when HIV prevalence among young adults in the Kagera region was in the range of 10-25% and when AIDS had increased young adult mortality by two-thirds, casts doubt on some earlier assumptions about the consequences of a recent premature death. Very few households experiencing such a death were composed entirely of old and young people. Fewer than one household in 10 had no surviving member aged between 15 and 50. Old people were no more likely to suffer ill-health than those living in households unaffected by AIDS or other mortality, nor were they any more likely to be driven to do farming or take other jobs. Similarly, orphans were not significantly more likely to show signs of malnutrition than non-orphans, regardless of who was caring for them after their parents' death.
Another analysis in the same Tanzanian population looked in greater detail at what households do to cope financially with the loss of a young adult. The study found that there was a dramatic difference in coping ability depending on the wealth of the household. In poor households, spending on food fell by nearly a third and food consumption by about 15% in the 6 months following the death of a young adult, while in non-poor households both food spending and food consumption rose, possibly because of funeral feasting. The difference may be explained by wealthier households' better access to financial help. In the six months following a young adult death, non-poor households received an average of around 20,000 shillings per household member (around US$ 25 at current exchange rates) from family, friends, or other private sources. Poor families, on the other hand, tend to receive virtually no help from friends and family, and are forced to borrow money or to rely on public assistance, which often does not arrive until several months after the death. This reinforces the importance of targeting AIDS alleviation measures at the households in greatest need.
A study of AIDS-affected households in Zambia drew similar conclusions about the need to target resources, arguing that different impact mitigation strategies would be needed for different segments of the population. This study found that children in AIDS-affected households in urban areas were likely to drop out of school because their carers did not have the cash to pay school fees -- a problem that might be alleviated by subsidies for the education of orphans. In rural areas, on the other hand, where children were taken out of school to work the fields in the place of a sick or dying adult, one solution might be a pool of communal labour made available to AIDS-affected households.
Another challenge in rural areas is passing on knowledge to the younger generation. Studies have found that orphaned children are rarely able to cope with the agricultural tasks left to them. In Namibia, children left with small livestock -- chicken and goats -- saw many of their animals die, simply because they did not have the experience to care for them properly. In a Kenyan study, four out of five orphans who were farming in one rural area said they did not know where to go for information about food production.
Unfortunately, the resources that might help these children get back on their feet are themselves being eroded by HIV. The Namibian study estimated that agricultural extension staff, whose job is to support farmers with information and skills training, spent at least a tenth of their time attending funerals. Similarly, in Gweru district, Zimbabwe, attendance at funerals brought about a 10% loss in salary for agricultural extension workers. In Malawi, employee deaths at the Ministry of Agriculture and Irrigation doubled from 5 per 1,000 in 1996 to 10 per 1,000 in 1998, an increase largely attributable to AIDS.
AIDS and Education: Complex Links
Just as the better-educated segments of the population in the industrialized countries were the first to adopt health-conscious lifestyles featuring exercise, non-smoking and a healthy diet, a similar pattern seems to be emerging in sub-Saharan Africa with respect to HIV. An analysis of studies focusing on 15-19-year-olds found that teenagers with more education are now far more likely to use condoms than their peers with lower education, as well as less likely, particularly in countries with severe epidemics, to engage in casual sex. This was not the case early in the African epidemic. At that stage, education tended to go hand in hand with more disposable income and higher mobility, both of which increased casual sex and the risk of contracting HIV. But as information about HIV has become more widely available, education has switched from being a liability to being a shield. Because more-educated people are better equipped to act on prevention information, and because they have more options in life in general, they are now exposing themselves less to the risk of HIV.
The figure below shows the results of surveys in western Uganda of childbearing women aged 15-24. In the period 1991-94, young women with secondary education were more likely to be infected than their illiterate counterparts. By 1995-97, however, the infection rate of educated women had dropped by almost half, whereas it had fallen much less for women without formal schooling.
If this is the good news, the bad news is that AIDS now threatens the coverage and quality of education. The epidemic has not spared this sector any more than it has spared, health, agriculture or mining.
On the demand side, HIV is reducing the numbers of children in school. HIV-positive women have fewer babies, in part because they may die before the end of their childbearing years, and up to a third of their children are themselves infected and may not survive to school age. Many children who have lost their parents to AIDS, or are living in households which have taken in AIDS orphans, may be forced to drop out of school to start earning money, or simply because school fees have become unaffordable.
On the supply side, teacher shortages are looming in many African countries. In Zambia, teachers are increasingly dying of AIDS and many more show up to teach class only sporadically because they are sick. Swaziland estimates that it will have to train more than twice as many teachers as usual over the next 17 years just to keep services at their 1997 levels. Without this extra teacher training, class sizes would balloon to over 50 pupils for every teacher. Together with sickness and death benefits for teachers, Swaziland's extra hiring and training costs are expected to drain the treasury of some US$ 233 million by 2016 -- more than the 1998-1999 total government budget for all goods and services.
The High Cost of HIV to Business
HIV deals its most direct impact to companies by attacking their workforce. As far back as 1993, when HIV was just beginning to cause illness and death in the Côte d'Ivoire work-force, AIDS-related medical costs borne by four businesses in Abidjan ranged from US$ 1.8 to $3.7 million. In 1997, AIDS costs in Abidjan represented between 0.8% and 3.2% of the wage bill. A survey of five firms in Ethiopia conducted in the mid-1990s found AIDS responsible for more than half the burden of sickness over a five-year period, leading to increased absenteeism and medical costs. In the United Republic of Tanzania, in a survey of six firms, annual average medical costs per employee increased more than three-fold between 1993 and 1997 because of AIDS, while the companies' burial costs showed a five-fold increase.
After consulting with unions and workers, more and more companies are undertaking voluntary and anonymous surveys of HIV among their employees. These surveys do not reveal which individuals are living with HIV but they do give an idea of the rates of infection among workers at different skills levels. They help companies to target workplace prevention efforts more effectively, as well as to plan for future health care, pension, recruitment and training needs.
Some recent survey results show just how great the future impact of HIV is likely to be. A 1999 study among miners in southern Africa found that over a third of employees in their late 20s and 30s were infected with HIV, along with a quarter of young and older employees. Rates among workers in other sectors are similarly high, at least in South Africa. In a sugar mill, for example, 26% of all workers were living with HIV. There, as in the mining industry, HIV rates were higher among unskilled workers than among managerial-level workers. Nine-tenths of those found to be HIV-positive were married, and they had an average of 6-7 dependants. An examination of the health records of HIV-positive workers retiring for reasons of ill-health in the 1990s suggested that these employees visit the clinic over 20 times and take an average of 17 days off work in the last two years before retiring. The lost productivity associated with this level of absenteeism, the clinic and hospital costs, and the training and pay for new workers to replace those who were sick cost the sugar mill an average of around 8,465 Rand (over US $1,000) per sick worker. Because the number of workers currently infected with HIV far exceeds the number who have already left the workforce, it is expected that in just six years' time the company will find itself paying out 10 times as much for sick workers as it does now. These costs do not even take into account the likelihood that premiums on health insurance and life insurance for employees will rise dramatically in the near future.
Faced with lower productivity and higher costs, some companies are choosing to expand their dealings in countries less affected by the epidemic. Others are reported to be cutting unskilled labourers out of their workforce and contracting these services out to other companies, in part to avoid having to pay benefits to workers. This tactic obviously undermines the economic security of workers while shifting the costs of dealing with HIV on to households and governments. But it may well actually damage the interests of employers themselves. Investing in care to ensure longer, healthier lives for employees helps keep knowledgeable, experienced and loyal individuals contributing fully to the workforce for as long as possible.
The high costs of AIDS in the workforce -- lost productivity, hiring and retraining, higher payments for insurance and medical care -- strengthen the argument for investing in HIV prevention programmes for men and women at their place of work. However, private and government agencies that have had the foresight to confront HIV in their workforce remain few and far between. While business leaders may recognize the long-term threat of AIDS to their eventual profitability, their sights are often fixed on short-term survival in a climate of inflation, falling exchange rates, labour action, political turmoil, and electricity rationing.
Managers may be reluctant to embark on HIV prevention programmes in the workplace because they think they are expensive. In fact, they need not be. In one study, at a cost of just US$ 6 per worker, factory workers were trained to provide AIDS information and services in support of safer behaviour for their colleagues, cutting the number of new HIV infections by a third as compared with factories that did not make this prevention investment. For US $170 per company per year, these and other employers have now banded together to create an investment fund to pay for worker education and free counselling and HIV testing for workers who want it. Even better results may be achieved with a more comprehensive approach. A good example comes from a group of mines in South Africa, which expanded their HIV prevention activities beyond their own workforce. Using mobile clinics to reach the community of women likely to be selling sex to the miners, the project offered free screening and treatment for sexually transmitted infections, and promotion of condoms and other safe behaviour measures. Researchers estimate that this averted 235 HIV infections for the year, 195 of them among miners. The project cost some 268,000 Rand (around US $38,000 at current exchange rates), but saved the company 25 times that amount in health care, lost productivity and other costs. The programme is now being expanded in collaboration with the government's Department of Health.