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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”



By Sheila Smith and Desmond Cohen

October 2000


1. Introduction

In this paper we will discuss some broad issues concerning the relationship between the HIV epidemic and development in general, and the effects which the epidemic will have (or is already having) in undermining decades of development achievement. Secondly, we will examine the necessity for a view of development processes based on a gender analysis, and why it is not possible to understand development by means of a gender-blind approach. Thirdly we will try to provide some insights into the differential impact of the HIV epidemic on men and women, and the consequences of this for society and the economy. This will include a discussion of gender, poverty and the HIV epidemic, and the ways in which the epidemic is intensifying poverty in general and poverty among women in particular. Fourthly we review population issues in order to identify what are the critical lessons for policy that are relevant to the global and national response to HIV and AIDS. Finally we will ask some questions concerning how as development practitioners these issues can be addressed and incorporated into ongoing work; what do we mean by good development practice in the context of the epidemic?


2. Development and the HIV Epidemic

It may seem a paradox but one of the unexpected outcomes of the HIV epidemic is a deeper understanding of development. For although the global epidemic of HIV was seen initially as a crisis in public health and was defined as a health issue that required a health response, this is now generally seen as too simplistic. In part this redefining of the problem has its origins in the perceived ineffectiveness of the global response to HIV and AIDS, given that it is unfortunately the case that in almost all developing countries, that HIV has spread in spite of policies and programmes designed to reduce transmission. In part it reflects a much more complex understanding of the social, cultural and economic determinants and consequences of the epidemic so that it is now commonplace to argue that the epidemic is not simply about public health but is concerned with development in all of its dimensions.

How did the issues of HIV and AIDS come to be redefined as developmental and what is implied for effective and relevant global and national responses to the epidemic? Perhaps just as important a question is how does one get from where one is to where one needs to be if the world is to be able to respond to what is an immense challenge facing everyone – in both developed and developing countries. For while there is increasing evidence that the problem of the epidemic is increasingly perceived as developmental in its origins, in that the determinants are fundamentally structural, there remains an enormous gap between a deepened perception of the problem and a commitment to effective action. This is indeed puzzling, and is an issue that is discussed in what follows. For it is increasingly clear that the issues that prevent a more effective and multisectoral response to HIV and AIDS are bound up inextricably with the failures of development in the last 50 years.

Hence the paradox noted above: the failure of the global and national response to the HIV epidemic has its basis in a category error – the problem was misdefined as one solely of public health and not of development – but an effective response to the epidemic entails more than redefining it as a developmental problem, in that what is needed are policies for development that are themselves relevant and effective. Thus it has been precisely the failures of development that have generated the conditions in which the HIV epidemic has thrived, and which also constrain effective responses to its deepening socio-economic impact. What the epidemic has done, for good rather than ill, is to identify the depth of the social and economic divisions within countries, of poverty, inequality of wealth, social, political and economic exclusion and differential access to basic services such as health, education and housing.

Underlying these conditions and often central to the weakness of the policy and programme response to development, and to the epidemic, are the issues of gender. So not only is development at the core of the problem of the HIV epidemic, but at the centre of both are issues of gender. It is unsurprising, therefore, that the failures of development which have largely left untouched issues of gender have also contributed directly to those social, cultural and economic processes that have created the conditions in which the HIV epidemic has thrived. Worse still is the fact that unwillingness to deal with gender issues in any fundamental sense has bedevilled the national response to HIV and AIDS in many countries. Little progress is possible unless the core role of gender is understood in relation to the epidemic, and unless and until gender issues are addressed through general development policies and programmes.

So issues of gender are central to epidemic processes and are also critical for sustained human development. Addressing gender through effective policies and programmes is the way forward if development objectives are to be realised. But doing so is also necessary if HIV transmission is to be reduced and if societies are to be able to respond effectively to the widening range of social, political, cultural and economic effects of the epidemic. Redefining what is understood by development, including improvements in development praxis, and relating development activities directly to objectives that include poverty reduction, more equal distributions of wealth and income, better access to improved public services, and greater gender equality, are what are needed.

None of this is new – what is new is to move beyond the rhetoric of development to performance. What the HIV epidemic does is to illustrate only too well the costs of previous failure, and the fact that if we are to prevent an expanding epidemic which has enormous potential to disrupt not only development but also social, economic and political structures, then we have to ensure better overall development performance.


3. Gender and Development

The discourse of development has been fundamentally transformed by the introduction of gender analysis, and it is now no longer possible to construct an analysis of an economy or a society, at micro or macro levels, which is gender-blind. This is because men and women have sharply different social and economic roles, differential access to income and resources, different economic behaviours, including different patterns of consumption and expenditure, and are subject to different legal arrangements. Even in societies where there is de jure equality, for example, of pay or employment or property rights, these differences nevertheless remain as significant features of economic and social life. To attempt to understand economic and social change without incorporating an explicit gender analysis is therefore an exercise in futility.

Just as gender analysis must pervade the development discourse in order to arrive at an understanding of social change, so it might have been anticipated that the advent of the HIV epidemic would similarly transform development thinking. The epidemic is pervasive, in some societies it directly affects most households, its implications are far-reaching for every aspect of people’s lives now and in the future, and its effects are felt in every sector at every level. It is negatively affecting life expectancy, it is dramatically reducing the national capacity in every sphere, it is reducing national output, exports, savings and investment, and it is crippling the capacity of the educational system, the agricultural extension system and the health system. Rarely has there emerged a single phenomenon with such powerful consequences to undermine decades of development achievement. Yet the necessary effect on the development debate and development thinking has not taken place. Development analysts, researchers and practitioners, in general continue their work as if the HIV/AIDS epidemic were not happening, as if it could be confined to a marginal role, for example a few paragraphs at the end of a report, and the core of development work could remain unaffected.

What is most extraordinary is that gender analysis has failed to grasp the significance of the HIV/AIDS epidemic: not only is the epidemic intensifying the socio-economic inequality of men and women, it actually involves a death sentence for women as a result of following the rules of ‘normal’ monogamy. Since the vast majority of HIV infections occur as a result of heterosexual intercourse, the implications for women of sexual relations with men can be lethal.

In attempting to understand how the HIV epidemic is affecting social and economic life, it is vital to have a way of analysing systematically the contributions and demands made by men and women to the society and to the economy. Orthodox economics devotes much energy to the measurement of economic activity, and it is well known that the measurements in common use (eg. gross domestic product, income per capita, labour force etc.) are very inadequate and inaccurate as reflections of reality. A great deal has been written about the omission from standard economic measures of the vast amount of unpaid labour contributed by women in all economies, and much research undertaken to illuminate this with time-budget studies.

In rural Africa, for example, the unpaid work of women in gathering fuel wood, collecting water and processing food contributes immensely to the survival of households and to the well being of present and future workers, yet rarely are such activities accurately measured in the context of collecting standard national income data. Furthermore, the caring work that women undertake, the need for which has risen dramatically in the context of the HIV epidemic, is also generally omitted from economic data.

However, there is another dimension to the inaccuracy and inadequacy of orthodox economic measures, which relates to the failure to take full account of paid work, often but not exclusively undertaken by women. In all developing countries there is a vast array of paid domestic service, sometimes paid in kind (food, shelter) and sometimes in cash, and very young women from poor households are frequently sent to work for small but vital sums of money in more affluent households. In addition sex work is often much more widespread than data suggests, both casual and fulltime, as a means by which many poor women attempt to survive. However, there is also a vast, uncounted casual agricultural labour force involving men and women, boys and girls, in all areas of rural production, including ploughing, sowing, weeding, harvesting, pruning and processing.

This might be illustrated best in diagrammatic form as in Figure 1. Several things stand out from this classification which are important in understanding the interaction of gender, development and the HIV epidemic. These are as follows:

  • That it is not possible to make any coherent analysis and assessment of the factors driving the HIV epidemic unless it is founded on gender analysis of socially, culturally and economically determined roles.
  • That any estimates of the quantitative and qualitative impact of the epidemic on households, communities, productive sectors and nationally have to fully identify and measure the different roles that men and women play in the society and the economy.
  • That the HIV epidemic has the potential for much greater social and economic disruption than traditionally assumed once account is taken of the unmeasured contributions to social and economic activity particularly of women and young girls (although not confined to them).
  • That the effects of the epidemic will be distributed much more widely throughout society and the economy through the erosion of social capital that is caused by morbidity and mortality, such that the scale of the losses is compounded because of the losses of human resources and the disruption of social and economic systems.
  • That given the critical social and economic roles that women play it is essential that they are empowered, since only through a restructuring of social and economic relationships will it be possible to address the multiple challenges of the HIV epidemic

Figure 1





Formal wage and salary employment

Public and private sector

Commercial services (professional, technical, trade, agricultural, banking finance and other services)

Informal economic activity estimated for national accounts, eg. rural housing construction, subsistence agriculture, own consumption





Domestic service (incl. cleaning, cooking, laundry, child care)

Rural wage labour on small scale


Sex work

Domestic labour, incl. cleaning food preparation, water and wood collection, childcare, care of sick and elderly, child socialisation



4. Poverty, Gender and HIV

Amartya Sen the Nobel prizewinner in economics once said that if poverty was contagious the rich would do something about it, as they did about cholera. typhoid etc. For example the major municipal investments in the Victorian era in Britain in sewage, clean water, drainage etc. were not motivated by altruism but by the sense of collective self-interest on the part of those with capacity to mobilise political support for and finance these major investments.

By analogy HIV is highly contagious for those engaging in risky sexual and other behaviours, affecting rich and poor alike, and is threatening to undermine economic, social and political structures, and reverse social and economic development in many parts of the world – not just in sub-Saharan Africa where the epidemic is presently most severe. Just as contaminated water threatened the lives of the rich and poor alike in Victorian Britain, so also does the complex web of sexual relationships threaten the lives of the rich and poor in developing countries in the context of the HIV epidemic.

Many changes are taking place at the level of communities, to support prevention programmes and to care for those affected, including support for children. However, in order to be effective in society as a whole these micro changes need to be complemented by changes at the macro level. Macro level changes must include shifts in the structure of public expenditure, probably involving significantly increased levels of both expenditure and of taxation. In order for these to occur, support is needed among the politically and economically powerful. They need to recognise that HIV and AIDS threatens to undermine their own future and that of their children just as much as it will undermine the future of the poor and the powerless.

What are the politically and economically powerful doing about HIV and AIDS at present? In developed countries huge amounts of resources are being devoted to the development of drugs, but relatively little to the development of effective vaccines. But the drugs while they are available in rich countries to those with access to health systems under private or public insurance are still not available to all – in the US for example it is still the case that more than 40 million Americans have no health insurance at all, including many of the poorest and those who are among the working poor.

It is not surprising therefore that HIV in the USA is growing most rapidly amongst the socially and economically excluded urban populations with large numbers of badly educated poor young men and women from minority populations. This neglect of those who are economically and politically powerless in the allocation of resources to research (neglect of vaccine development) and to health care provision (including ARV drugs) is reflective of market failure. Since the poorest populations cannot display their needs through market demand so the market ignores their needs. Not least is the absolute neglect of those of the poorest living in the developing world who cannot under even the most advantageous pricing regimes for ARV drugs afford to purchase them, and for whom there is effectively no functioning health care system in operation.

The US is simply an example of a general case where drug companies, policy makers and those who have access to health care can ignore the deeply rooted social and economic bases of poverty and the relationship between HIV and poverty, which might involve them in having to do something about underlying causes (lack of employment, appalling housing conditions, poor education and few training opportunities, vastly under-resourced health services, environmental decay and a social and economic environment which destroys community social capital). They have already isolated themselves quite effectively from other aspects of poverty by ghettoising the poor and then blaming them for their poverty. Their preference for treatment (drugs) as an approach to HIV permits them to avoid addressing the fundamental conditions which give rise to those behaviours which lead to the transmission of HIV in economically and politically excluded populations.

But this way lies disaster, for unless the structural determinants of poverty, exclusion and hopelesslness are addressed then HIV will continue to spread and the socio-economic consequences intensify, with all of the implications that this implies for escalating dissension and conflict. In the end the rich and powerful cannot both ethically and practically avoid having to deal with the problems of HIV and AIDS. It is a well known policy rule that it is better to deal with a problem earlier rather than later, since delay leads to cumulatively greater problems that could have been avoided, with much higher costs.

It is a fallacy to believe that ARV drugs represent a solution to the HIV epidemic even in the rich countries, and this is self evidently also the case in the developing world where budgets constrain what underfunded health systems can provide and where the poorest who account absolutely for the largest numbers living with HIV and AIDS are excluded from access to even the barest forms of care as a result of their poverty. In so far as anyone has access to ARV therapy and other quality medical care in developing countries then it is those who are the wealthy and their family plus those who manage to gain access legally or otherwise to public budgets for their own personal use. This being so it is still a matter which is deeply puzzling that the rich and powerful in developing countries are not doing more to prevent the further spread of HIV which is killing their peers, their wives, their children and their close relatives just as it is killing the poor. The epidemic is also undermining economic development so that even the children of the rich will be facing at best an uncertain future and at worst a set of social and economic conditions that represent a reversal of development.

Furthermore, there is plenty of evidence that HIV infection rises with social and economic status in many developing countries suggesting that information on the risks of HIV have not been internalised in modification of sexual behaviour, even amongst those with secondary and higher levels of education. Not only does HIV and AIDS threaten the human capital stock of the country, and thus the capacity to maintain and advance development, but it also has direct costs for those infected with HIV. Thus the rich and those who are among the better-off in developing countries, and especially men, are not only exposing themselves to a deadly virus but also their partners and their children (through mother to child transmission of HIV).

Hence the importance of gender and its inter-relationship with poverty and wealth in the processes which are internal to the HIV epidemic. The most important form of HIV transmission is sexual in all countries, and men seem everywhere to have a dominant role in what is taking place. As noted above this is not confined to only poor men and indeed there is enough evidence now to believe that infection rates as noted above are in many countries positively correlated with socio-economic class. Since the virus is primarily spread through sexual activity the question arises as to what would be needed by way of investment in sexual and personal/social relationships so as to change these in ways favourable to reducing HIV transmission and dealing with the consequences of HIV and AIDS?

What would seem to be involved at the very least is a dramatic transformation in the economic relationships between men and women, in order that women would have sufficient economic independence to choose the terms on which they engage in sexual relationships – whether within or outside marriage. This is not to suggest that such a transformation will occur by economic change alone, economic change must be seen as necessary but not sufficient. There is now enough evidence to suggest that women’s subordination and HIV transmission are indissolubly linked so that what is required, apart from changes in the economic position of women, are improvements in access to education and training and adjustment of labour markets so as to enhance both employment and pay/other contract conditions. For women who engage in sex work this would involve investment in new skills through training etc. to improve their capacities, and corresponding changes would be needed in the labour market to open up economic opportunities from which they are presently excluded. Such exclusions are not always simply a result of differential access to skills but often because jobs have been set aside as male preserves in many industries and countries. For example in the tourist industry in Nepal where many jobs as waiters, chefs, receptionists, shop assistants, hotel managers, cashiers, etc. are done by men. It is unsurprising, therefore, that large numbers of young women excluded from many jobs have little or no option but to migrate to India where they engage in sex work with all of the risks that this entails of HIV infection.

For most women, given the effective access which they have to education and training, choices are extremely limited, large numbers work as domestic workers at home or abroad – with the worst and most exploitative working conditions, totally unregulated, with no rights as employees, frequently exposed to abuse, rape etc. With few marketable skills, many women (eg. household heads, schoolgirls, sex workers) have come to rely on ‘sexual networking’ (patterns of multi-partnered sexual relationships) as an economic strategy to sustain their families in the face of growing economic uncertainty. Migration of abandoned or rejected women to urban prostitution is only too frequent in many societies (such as India, Niger, Uganda and Central African Republic). Underlying this high risk sexual behaviour on the part of many women and young girls are intolerable economic and social conditions that offer few if any viable alternatives. It follows that changing the conditions of women's’ lives through gender sensitive and focused policies and programmes is at the core of effective and relevant responses to the HIV epidemic in all developing countries.

But the mass of women in need of protection and requiring purposive gendered policies and programmes to transform their lives are not sex workers. They are women with one partner. It is monogamous women who are increasingly at risk of HIV infection because of the sexual behaviour of their steady male partner. Many societies positively condone men in having multiple sexual relationships in spite of the clear risks that these pose to their spouse and to their children – and of course to themselves. Again it is remarkable that conventions that encourage risky sexual behaviour on the part of men are so entrenched and inflexible despite information about the consequences of continuing unsafe sexual practices, and in the face of mounting evidence of sickness and death amongst male peers.

There is now mounting evidence that women’s risk of contracting HIV goes up sharply as the age of her own first sexual intercourse goes down and/or the age of her first partner goes up. This in part explains the data on age and gender distributions of HIV where HIV infection rates in young women in many countries in sub Saharan-Africa are 4-6 times higher than they are amongst the same age cohort of young men. In part this reflects physiological factors that enhance the probability of HIV infection on exposure to the virus amongst young women and in part it reflects the fact that they often choose older partners for reasons that are partly economic and partly social. To protect young women from HIV infection would thus require changing the reality of their lives through educational opportunity and employment. Information about the risk of HIV infection unless other conditions change simultaneously will largely fall on deaf ears – hence the need for a comprehensive set of programmes if young women are to be protected from the virus.

For women who are married, there are usually important economic relationships vested in the marriage, involving the families of husband and wife. In part at least the function of such arrangements is to ensure the passing on of male wealth to male heirs and there is a large literature on this aspect of contract relations within marriage. But one consequence of this implicit contract is that it seems to require women's’ economic subordination so as to ensure that the man’s children are really his children. None of this seems to act as a constraint on the number of sexual partners a man may have in many societies although the economic (and social) subservience of women has the desired effect of limiting the freedoms and rights of women. As we shall see below this is exactly the state of affairs that is undesirable in general and specifically so in a world of HIV and AIDS. What is needed if married women are to be able to protect themselves and their children in such circumstances are precisely the same things as women need in general – access to education and training, removal of restrictions on employment, access to banking services and credit on their own surety, and so on. In addition what they require are drastic shifts in laws on property rights, rights of divorced and widowed women, child custody rights and protection against physical and other abuse.

Concurrently there would need to be investment in the education of men and boys, so that they would understand fully why equitable social arrangements are in their interests also, to lift the death sentence resulting from non-transformed modes of sexual behaviour. Overcoming men’s resistance to such investments is vital, for without such investments large numbers of men will die in their formative years when they have important social and economic reproductive functions. They will also suffer the grief of children, spouses and siblings who will also die from HIV-related illnesses. None of this is inevitable: and it represents a situation where everyone could gain from social and economic transformation. It is not a zero sum game where one only gains if someone else loses but one where there could be no losers. That is, if the opportunity is grasped to make those changes to the organisation of social and economic activity that are worth having anyway - to bring about those transformations that are in fact the whole point and purpose of human development.


5. Voice and Agency: Learning the Lessons of Population Policy

Much of the analysis and description of HIV and women is couched in the language of "vulnerability" which is not an operationally useful concept if what is needed is to change the reality of women’s lives. By its focus on those things that disempower women its shifts the focus away from those areas of women’s lives where they have the agency to order the world differently. Not always unaided to be sure, but with appropriate policies and programmes there is a great deal that can be changed so as to achieve outcomes that improve everyone’s welfare – a good example of Pareto Optimality, i.e. a policy outcome where everyone gains and no one loses.

Learning the lessons of policy areas where outcomes are clearly beneficial and applying these to the global response to HIV is clearly desirable. No better and more relevant area is the record of population policy in parts of South Asia where outcomes reflect much of what is needed if we are to structurally change the conditions of women’s lives in ways that will make a fundamental difference to the global experience of HIV and AIDS. It needs to be recalled that learning the lessons is not the same as assuming that these are directly transferable from one area of human experience to another. But at least they point the way forward and are evidence of what is achievable through policies and programmes that are relevant and effective.

There is general agreement that high fertility imposes unreasonable burdens on women and that there are benefits to be derived from reductions in family size – for all members of the family in the form of improved standards of living. Plus, of course, gains for society in general through reductions in the level of poverty, better educated and more healthy succeeding generations of children who grow into more productive adults, and gains to the state in the form of faster economic growth and lower rates of public expenditure (in areas such as education and primary health care). So it has long been argued by demographers that there are bigger social returns from investment in population control than from other competing uses of savings and that a smaller population was both feasible and desirable.

The problem was in part, as with policies for HIV and AIDS, to put in place those policies that would be effective in supporting women, and to some extent men, in limiting family size. To do so meant changing a world in which women have traditionally had little or no voice over matters relating to fertility for whatever reasons. The argument quite simply is that if women were given more voice and more power they would choose lower rates of fertility, as a result of which there would be profound outcomes for women and children and substantial social benefits. What stood in the way of these beneficial outcomes were the following basic structural conditions: -

  • Social and economic constraints that reduced the voice and power of women within the family and within society -–such as high levels of female illiteracy and little or no economic independence including weak attachment to labour markets.
  • The lack of access to knowledge about contraception and its benefits, together with more or less no provision for its supply under conditions that were unthreatening to women.
  • The existence of cultural and social pressures that reinforced other factors so as to leave women with the belief that continuous child bearing was required as part of their social and familial duties.

While each of the above enumerated elements are present in many developing countries they are not immutable and can be changed. It is now evident that appropriate policies relating to female literacy, to female employment and access to credit, and changes in property rights and so on can make a huge difference to the lives of women. With demonstrated effects that are sustained in female fertility such that women, children and their communities are better off than they would otherwise have been in the absence of the changes which brought about the fertility decline.

Also, and very important, what the data on fertility decline in South Asia demonstrates is the fact that the increases in real income are not a necessary prior condition for changes in family size to be attainable. Provided supportive policies and programmes are put in place and made available to women then they are perfectly capable of controlling family size and thus bringing about an enormous shift in the burdens that they and their families have faced for generations. If these changes are feasible in relation to population which depend intimately on changes in core values and behaviours within a family, then why are the same lessons not also relevant to the global and national response to HIV and AIDS? The argument of this paper is, of course, that they are very relevant and point the way forward in developing more effective policies and programmes for dealing with the HIV epidemic.

The key example that supports the above propositions is India. While it is the case that fertility rates vary a good deal from district to district in India it is still the case that these have fallen substantially – from 6 children per couple a few decades ago to three today. In some districts in India fertility ratios are even lower than they are in USA or UK or China although in the aggregate replacement ratios are still above 2 for India as a whole. In the States where the fertility declines have been fastest, Kerala, Tamil Nadu and Himachal Pradesh, the key factors in producing these declines seem to have been female literacy and female employment. Rapid improvements in these 2 areas seem to have catalysing impacts on women’s lives through improving their standard of living and in enhancing their voice within families and communities. Contrariwise those states in India with the highest levels of fertility are precisely those with the worst records on female literacy and female employment.

Also there is evidence that cultural and religious variables are not immune to change. A good example can again be drawn from Kerala which has one of the largest Muslim populations in India (the second largest after Kashmir) but in spite of such a high percentage of Muslims amongst its total population Kerala has seen the largest fertility decline of any state. It seems from the data as if Indian Muslims have fertility levels not dissimilar from other communities in their region – in fact much lower than in Pakistan. Similarly in Bangladesh which has a very large Muslim population but where there have also been significant reductions in fertility associated with widespread public discussion of the need to reduce gender inequity, enhanced access to family planning facilities and advice and improvements in women’s economic position through such programmes as micro-credit. Today Bangladesh’s fertility rate is much closer to that of India than it is to Pakistan’s in spite of the fact that they are both have predominantly Muslim populations.

What follows from the foregoing ? It is clear that many factors operate to change fertility and no one is suggesting that bringing about the kind of changes seen in some parts of South Asia are easy to bring about. Nevertheless there are elements in the process of fertility decline which seem to be common to all the examples given here. What seems to be needed is a coherent and general understanding of fertility decision making within families and the development and delivery of policies and programmes that change the conditions relating to fertility. These include greater access by girls to education; better employment opportunities for girls and women and enhanced access to labour markets through changes in the conditions that restrict and constrain women’s participation; addressing the social concerns of women (matters relating to exclusion in family, community and national decision making); and access to better health care and to enhanced family planning facilities. Each of the above are self-reinforcing and all are necessary for a sustained decline in fertility which has at its core the aim to in general to enhance gender equity.

The sine qua non of effective policies for population has been an improvement in the position and power of women, pursued through policies and programmes that are seen as mutually self-supporting. It is evident that much has been achieved already through recognising that policies and programmes need to address all of the structural factors that contribute to decision making within families and communities. This has entailed changing the conditions and attitudes of both men and women through activities that are social, economic and cultural in their content and by doing so to bring about sustained changes in fertility. What is now clear is that similar changes can also contribute to the kinds of changes in sexual behaviour that are so desperately needed if the transmission of HIV is to be contained and reversed. What the recent population history of India shows is that fertility can be brought down even in communities which are amongst the poorest in the world.



6. Conclusions: Applying good development practice to the HIV epidemic

Very few of the lessons of good development practice have been applied so far in the design and implementation of national policies and programmes for HIV and AIDS. This is in some ways unsurprising in that until relatively recently most of those involved in the response to the HIV epidemic have not been development practitioners and the problems were seen largely as being about public health. Given the way that the issues were identified and given the dominance of public health experts in the response, both globally and nationally, it was only natural that they would use an approach to problem solving that they were familiar with should have been used. There were advantages and disadvantages of this approach. Whatever the short term benefits to be derived from setting up in many countries a plan and structure to respond to the epidemic there have also been long term costs. Not the least problematic has been a continuing dominance of Health ministries in the national response to HIV and AIDS in many countries, and an ongoing belief that the epidemic is indeed about public health despite the evidence that this is not the case.

The dominance of public health in the response has been accompanied by a preference for expert solutions to problems which are believed to be applicable everywhere. Such an approach to problem-solving means assuming that the set of problems to be addressed are easily identified and are found in all places, and that there exist interventions that work and that can be applied in more or less all situations. Experience of the HIV epidemic tells us that nothing could be further from the truth, and that what is required are approaches to problem-solving that reflect the reality of local conditions. What we need is a determination to seek out solutions that are the outcome of local discussion and analysis, that reflect local needs and capacity, and are not simply the "turn-key" responses of experts that can be applied everywhere whatever their situational relevance.

The preceding comments contain the elements of an approach to the epidemic that is indeed based on good development practice. It is worth recalling the statement made by Robert Chambers to the effect that " We need to start from where they are at, not where we are at". Indeed this is good advice since one of the reasons for the poor performance of most national AIDS programmes is that they did not reflect Chambers’ advice but rather the views of external consultants.

So what follows from this in terms of development practice that has general relevance?

  • The HIV epidemic is not simply about public health – it is much more than health and is more generally about development. Hence the need to ensure that the development community is actively involved in national responses to the epidemic in terms of the integration of HIV and AIDS in core areas of development, such as poverty reduction, gender and social sector development. But integration does not mean treating HIV and AIDS as yet another "add-on" but ensuring that it is seen as integral to projects and programmes.
  • The development community needs to understand that if HIV and AIDS are not integrated in development activities then it is increasingly unlikely that in many countries such programmes will succeed. It is inconceivable that targets of primary education for all in Africa could possibly be achieved given the erosion of human resources (teachers and other staff) due to HIV and AIDS in many countries, and given the intensification of poverty due to AIDS being experienced by many families. Under these circumstances sectoral programmes, such as health and education, need to be revisited by all concerned with development so as to realign policies and programmes with the new conditions due to the impact of HIV and AIDS on the economic and social systems.
  • HIV-specific and HIV-related projects and programmes need to reflect the reality of local conditions. There is little point in designing and implementing activities that are unrelated to local needs and yield few if any benefits. To avoid this outcome what is needed are processes that ensure that the design of projects is undertaken with local inputs and actively involves beneficiaries. Fundamental to improvements in programme relevance and programme performance is a capacity to undertake and utilise applied research. Where this research capacity is weak then it will need to be strengthened through sustained programme support.
  • All projects and programmes should undertake a capacity assessment to identify what capacity is available for effective implementation of programme activities both within core and complementary institutions. Such a capacity assessment would include an evaluation of factors reducing capacity (such as the HIV epidemic) and would lead to a programme of activities to ensure that capacity was in fact strengthened.
  • As far as possible local institutions should be involved in the design and implementation of projects and programmes and they should be assisted in strengthening both their own capacity and in undertaking activities to strengthen the capacities of other collaborating organisations. It should be recalled that the HIV epidemic systematically destroys human capital and undermines organisational structures so that there is a need not merely for a strengthening of capacity but also for its maintenance.
  • Gender equality has to be seen as central to the development effort and as with HIV should be integrated in all development programmes. This follows from the proposition that the empowerment of women is fundamental for all development. Women and female-headed households are over represented amongst the poorest in all societies. Effective policies for reducing poverty amongst women are not only worthwhile in themselves but also because there is clear evidence that poverty is a major determinant of HIV transmission. Poverty also constrains the capacity of families to cope with HIV-related illness. Women also play a critical role in all social and economic life although their contribution is systematically underestimated by standard economic and social analysis. It is now clear that achieving development entails empowering women as is evident from research on population. Putting in place programmes for HIV that are effective in addressing issues of prevention, care, social support and mitigation of the socio-economic impact of the epidemic will depend crucially on the mobilisation of women.
  • Policies and programmes need to geared towards women’s empowerment. These would include improved access to education and training, adult literacy, access to credit, improvements in health and reproductive services, legal changes to property rights and enforcement of women’s civil and political rights. Not only is the empowerment of women central to issues such as fertility decline and the consequential benefits of this but also in ensuring that the next generation are better educated and healthier. As we have seen these are precisely the conditions that need to be created if societies are to cope with the multiple challenges of the HIV epidemic.




There is an enormous literature on gender and also on HIV/AIDS. There is also an increasing literature on Development and HIV although very little of it attempts to bring together the various components of the problem (development, gender and HIV). The following recommendations for follow-up are simply intended to provide a useful starting point and are in no sense comprehensive. In making the selections the aim has in part been to address issues of relevance but also of accessibility. We have included items which are as far as possible available electronically.

Aids in the Context of Development by Joseph Collins and Bill Rau (UNRISD, June 2000):

The Economic Impact of the HIV Epidemic by Desmond Cohen ( UNDP Issues Paper No. 2, 1992):

The HIV Epidemic and Sustainable Human Development by Desmond Cohen (UNDP Issues Paper No. 29, 1998):

Poverty and HIV/AIDS in sub-Saharan Africa by Desmond Cohen (UNDP Issues Paper No. 27, 1998):

Responding to the Socio-Economic Impact of the HIV Epidemic by Desmond Cohen (UNDP Working Paper, 1999):

Dying of Sadness: Gender, Sexual Violence and the HIV Epidemic (UNDP Issues Paper, 1999):

Adolescent Sexuality, Gender and the HIV Epidemic (UNDP Issues Paper, 1999):

Men and the HIV Epidemic (UNDP Issues Paper, 1999):

The Vulnerability of Women: Is This a Useful Construct for Policy and Planning by Desmond Cohen and Elisabeth Reid (UNDP Issues Paper No. 28, 1996):

Transforming AIDS Prevention to Meet Women’s Needs: A Focus on Developing Countries by Heise L.L. and Elias C. (Soc. Sci. Med, Vol 40 No 7, 1995)

Recognising and Countering the Psychosocial and Economic Impact of HIV on Women in Developing Countries by Catharine Hankins in Catalan, Scherr and Hedge (eds) The Impact of AIDS: Psychological and Social Aspects of HIV Infection (Amsterdam, 1997).

Development as Freedom by Amartya Sen , ch.8 and 9 ( Knopf, NY 1999)