The need to act now: HIV/AIDS and development /22.11.02
A Christian Aid position paper
'We don't have the dollars
what is literally killing the women and men and children of Africa is the lack of resources.'
Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa, October 2002
Over 8,000 people die from HIV-related illness every day worldwide, most of them in developing countries.0
The UN is calling for annual global spending of at least US$10 billion on HIV/AIDS in developing countries. This is less than one eightieth of global military spending.1
If the UK contributed £750 million a year to this, it would be less than the amount we currently spend on breakfast cereals.2
HIV/AIDS and poverty - a vicious circle
How widespread is HIV/AIDS?
In 2001 over 8,000 people worldwide died of HIV-related illness every day 3
Worldwide, 40 million people are HIV positive. Around 29 million of them live in Africa, six million in Asia and two million in Latin America and the Caribbean4
In nine African countries, 15 per cent or more of the adult population is HIV positive5
In India, the number of people living with HIV is projected to rise at least fivefold to 20 million by 2010. Projections show that Nigeria, Ethiopia, Russia and China are expected to experience similar magnitudes of increase. However in India, Russia and China less than one per cent of the adult population is currently HIV positive.6
With around 95 per cent of the people affected by HIV living in developing countries, poverty and HIV/AIDS are inextricably linked. Poverty makes people more vulnerable to HIV infection, and HIV/AIDS makes poor people poorer.
How does poverty makes people more vulnerable to HIV? Infection is more likely, for example, if you can't attend school and learn about HIV, if you cannot afford condoms, if you are forced by economic necessity to do sex work, or if you cannot gain access to testing facilities.
How does HIV/AIDS make poor people poorer? Young adults - the parents or money-earners of the family - are most likely to be affected. Becoming ill means the most basic of tasks, such as putting food on the table, become almost impossible. Lack of food reduces your ability to fight HIV-related disease. You may take your children (probably your daughters) out of school to care for you. You won't be able to afford the medicines, or the healthcare, you need. And you will be worried about your children's futures. A total of 14 million children have already lost one or both parents to AIDS.
More and more, people are learning how to live with HIV. The vast majority of HIV/AIDS prevention and care is being done by poor people in their own communities. Their efforts, however, are being hampered by poverty and by lack of access to the nutrition, services and medicines that we take for granted.
HIV/AIDS and development
The same vicious cycle operates on a social and economic level as well. Some countries, or groups within countries, are impoverished by global or national economic forces - such as unpayable debt or unfair trade rules - over which they have no control. The resulting poverty inevitably increases the spread of HIV.
The impact of HIV/AIDS on societies with advanced epidemics, most of which are in Africa, is enormous. Health and education systems - often already weak - are losing skilled teachers and health workers faster than they can be replaced. In southern African capitals there is a massive rise in the number of children living on the streets. And economic growth is being reduced by the epidemic, jeopardising long-term poverty reduction.
Impacts of HIV/AIDS
Average life expectancy in sub-Saharan Africa is now 47 years. Without HIV/AIDS it would be 62 years
Even as HIV/AIDS increases the demand on health services, Malawi and Zambia are experiencing five-fold increases in health-worker sickness and death rates
In the Central African Republic and Swaziland, school enrolment has fallen by between a fifth and a third due to HIV/AIDS, with girls most affected
By 2010 South Africa will have an economic output 17 per cent lower than it would have been without HIV/AIDS
'The HIV/AIDS epidemic poses a major threat to food security in sub-Saharan Africa, and has served to contribute to and greatly exacerbate southern Africa's growing famine', Clare Short, Parliamentary Answer, 22 October 2002.
Sources: UNAIDS Report 2002; Hansard
In countries where the epidemic is less advanced, it is equally urgent and important to pay attention to HIV/AIDS, to prevent the impacts being seen in parts of Africa. The US National Intelligence Council recently identified Russia, India and China, as well as Ethiopia and Nigeria, as the countries poised for the 'next wave' of HIV/AIDS, and said 'It will be difficult for any of the five countries to check their epidemics by 2010 without a dramatic shift in priorities.'7
HIV/AIDS is urgent and needs special attention
While there are many areas in which poverty needs to be tackled, HIV/AIDS is particularly urgent and important. The HIV/AIDS epidemic is unique, for several reasons:
HIV/AIDS is a condition that affects young adults, who are key to society's economic, social and family structures. Thus HIV/AIDS has extremely far-reaching social and economic impacts. These impacts are different from those of other diseases such as malaria, which have their greatest impact on the physically vulnerable - children and the elderly
Unlike many diseases of poverty such as malaria and TB, HIV/AIDS is incurable, and treatment is expensive
It is a relatively new, rapidly-spreading and unpredicted phenomenon
There is a period of several years, and sometimes over a decade, between HIV infection and the appearance of sickness. This means that avoiding HIV can be a low priority for people, especially when poverty means they have to deal with more immediate threats to their survival. Also, it means there is a long period when people are unaware that they are infected and that they could infect others
HIV-positive people are often stigmatised and discriminated against due to HIV's sexually-transmitted nature. This is compounded by the fact that early epidemics within countries are often among groups of people who are already stigmatised, such as sex workers, drug users or men who have sex with men.
These characteristics produce some unique dynamics:
HIV/AIDS is actually reversing improvements in development indicators, such as life expectancy, in high-prevalence countries. The extent to which HIV could reverse development gains made over the past two decades is almost unprecedented, especially in southern Africa
The time lag between infection and sickness, and the stigmatisation involved, mean that dealing with the epidemic is often not a priority until its impact becomes impossible to ignore. This applies both to populations and to politicians*
Once the impact becomes so great that it is impossible to ignore, it is overwhelming, governments may not have the means to respond, and may therefore deny the magnitude of the problem.
* [There are, of course, exceptions to this where there has been early political leadership and large expenditure, for example in Uganda and Thailand.]
Christian Aid believes that the unique nature of the HIV/AIDS epidemic means that it merits particular priority in development policy-making.
What should be done about the HIV/AIDS epidemic?
HIV/AIDS needs to be tackled in two ways: through increased and sustained actions aimed directly at the epidemic, and by addressing the underlying causes of vulnerability that are holding back these efforts. Both need to be stepped up dramatically and immediately, and both need funding. The following recommendations do not comprise a comprehensive 'solution', but a list of areas that Christian Aid believes require priority attention.
Tackling the epidemic directly - more aid
'At present the global resources committed to tackling HIV/AIDS are woefully inadequate.'
DFID HIV/AIDS Strategy, May 2001
In many of the worst-affected countries, funding is simply not adequate to tackle the epidemic. For example, in Tanzania, India and Haiti, where HIV/AIDS is a major problem, gross national income is around US$500 per person per year or less. The UK's national income is nearly 50 times that amount.8 The governments of such countries clearly cannot pay for HIV prevention and care themselves, and are forced to make impossible choices in their spending. Some other governments, with more money available, find it politically impossible to prioritise HIV, because of the very high levels of stigma attached to it in their countries. And civil society organisations tackling HIV/AIDS in these countries also need external funding.
How much is needed?
The UN has estimated that a minimum of just over US$10 billion a year (from all sources) is needed for HIV/AIDS prevention, care and orphan care in developing countries by 2005.9 This is less than one eightieth of global military spending. After 2005, the required amount will increase steadily.10 The funding target of US$7-10 billion a year was agreed at the UN General Assembly Special Session on HIV/AIDS in 2001; this estimate has already been revised upwards.
Christian Aid estimates that the UK should contribute a minimum of £750 million a year towards this target. This follows calls in 2001 by the UN Secretary General, Kofi Annan, for a five-fold HIV/AIDS spending increase. A fivefold increase on the UK 2000/01 spending level (which was £150 million) would mean an annual expenditure of £750 million. The Stop AIDS Campaign, a coalition of 22 leading UK-based HIV/AIDS and development groups is calling commensurately for the UK to contribute US$1 billion a year.
Current global spending on HIV/AIDS from all sources is around US$3 billion a year in total.11 UK spending levels are increasing. In 2001/02 the UK spent £200 million12 on HIV/AIDS in developing countries.* But this does not begin to address the enormity of the task at hand - more is needed, faster. It is also vital that future increased spending on HIV/AIDS is additional to the current aid budget, and does not divert money from other international development areas.
* [More was also spent on international work and research. This is very difficult to disaggregate to arrive at an annual figure.]
How would the money be spent?
Priorities for tackling the epidemic directly include the following. In all cases, money can sometimes be invested directly, but often a proportion needs to be invested to increase the capacity of the recipients to carry out the work. The money should be spent on:
work to prevent the spread of HIV/AIDS, for example through discussions and other HIV prevention work in schools and villages; through making condoms widely available, through the treatment of other sexually transmitted diseases, and through drugs to prevent babies getting HIV from their mothers during birth
care and treatment of people who are HIV positive, for example by expanding the availability of voluntary HIV testing and counselling through schemes, often run by churches, using home-care volunteers. More medicines should also be made available
care of orphans, for example by looking after street children, and by supporting families who have taken in orphaned children, to ensure they have access to education, food, health care and emotional support
tackling stigma, by supporting groups set up by and for people living with HIV/AIDS, and by supporting civil society groups, working to make HIV/AIDS a political priority in their countries.
Developing countries are best placed to determine their own priorities, which differ dramatically from country to country. For example, countries with lots of people already infected will need to put a higher proportion of their resources into care; countries at an early stage in the epidemic will probably focus on prevention, for example, from sex workers to the wider population, through promoting condom use.
Key to success is the people most affected identifying their own needs. Developing country governments need to develop their own national plans and priorities according to how HIV is affecting their people. All sectors of society, especially people living with HIV/AIDS, should be involved in planning, implementing and evaluating national strategies with governments, including through Poverty Reduction Strategy Processes.
How would the money be channelled?
Governments usually have the greatest capacity to respond to HIV/AIDS, and are in a position to integrate HIV/AIDS responses with other services and processes in their countries. Thus they should and will continue to receive the majority of aid. However, in many countries aid also needs to be available to civil society organisations. This is because:
One of the most effective ways of tacking the sensitive, stigmatising aspects of HIV/AIDS is by working at a personal level, through enabling discussions between people who already know and trust each other (as compared, for example, with mass billboard campaigns - although these also have their place). Often community organisations, especially those which involve people living with HIV, are best placed to do this kind of work.
In many of the poorest countries the current reality is that HIV/AIDS-related work is often run by non-government and faith-based organisations. Faith-based organisations have extensive grassroots networks making them ideally placed to carry out such work.
Civil society organisations may be the sole prevention and care providers in countries in conflict, in post-conflict situations,* and without a functioning government.
Civil society organisations may be able to lobby their governments to give HIV/AIDS a higher political priority.
* [Where responding to HIV is often particularly urgent.]
While the majority of aid needs to be targeted on the poorest countries facing the epidemic, the civil society organisations of some middle-income countries, which are unable to prioritise HIV/AIDS for political reasons, should also receive aid. Due to the urgency of the situation immediate investment is needed, alongside work to build political will on the issue.
The Global Fund to Fight AIDS, TB and Malaria should receive a proportion of the funds available, but the majority should continue to be channelled through existing bilateral mechanisms. Christian Aid's 2002 briefing Fighting HIV/AIDS with Peanuts - A Year in the Life of the Global Fund outlines Christian Aid's position on the Fund.13
Tackling vulnerability to HIV/AIDS in the longer-term
Building social systems
The estimated required annual funding for HIV/AIDS-specific interventions of US$10 billion assumes current infrastructure. It does not include funding to strengthen and expand the social systems crucial for the delivery of many of the interventions. Many countries' health and education systems are extremely weak, sometimes following cuts in social spending due to conditions attached to loans from international donors.14 A particular priority in many countries is the need to invest in human resources - in staff salaries and training.
Strengthening health and education systems is not simply a matter of increased finance - capacity building and reform are often important too. But capacity building and reform also require significant resources, as the failure of some under-resourced health-sector reforms during the 1990s demonstrated.15 Finance for system building is thus needed in addition to the minimum of £750 million required for HIV/AIDS interventions.
Many other aspects of development are also key to tackling the underlying causes of HIV vulnerability - such as programmes to empower women so that they are more able to negotiate safer sex - and to tackle the impact of HIV/AIDS - such as programmes which increase the opportunities for livelihoods. HIV/AIDS should be an integral part of national poverty-reduction and development programmes.
As with HIV/AIDS-specific programmes, developing countries, in consultation with civil society groups and those most affected, should determine their own poverty-reduction priorities and formulate national poverty-reduction processes.
Thus, increased funding for HIV/AIDS must be seen in the context of increased aid for all developing countries' needs, and as part of meeting the 30-year-old UN target that developed countries set aside 0.7 per cent of their national wealth for aid to developing countries. Currently the UK gives a total of 0.32 per cent of GNP in aid; by 2006 this will increase to 0.4 per cent. Christian Aid is calling on the UK to continue increasing aid year-on-year, and commit to a timetable for achieving the 0.7 per cent target. Other countries have done this, for example Ireland is committed to achieving 0.7% by 2007.
In addition, Christian Aid is calling for a new deal on debt cancellation, in which debt relief would be calculated in terms of the money poor countries need to reach poverty-reduction targets. Currently, 13 out of the 26 countries receiving debt relief are still spending more on debt than on public health.16
The Church and HIV/AIDS
'As the pandemic has unfolded, it has exposed fault lines that reach to the heart of our theology, our ethics, our liturgy and our practice of ministry.'
World Council of Churches, 2001
The Christian Church is in a pivotal position to have a massive positive impact on the HIV/AIDS epidemic. In Africa, where the epidemic is most advanced, the Church forms probably the most extensive grassroots civil society network, with great potential for prevention and care. The Church is already doing a lot of HIV/AIDS work, particularly home-based care and orphan support. Indeed in some countries the Church runs as much as half of available health care. In Asia and Latin America the Churches are also developing HIV/AIDS responses. Moreover, there is also now a global Ecumenical Advocacy Alliance doing HIV/AIDS advocacy work.
However, the Church response has been patchy, particularly in the areas of HIV prevention, tackling stigma and denial, and accepting people living with HIV/AIDS, because HIV/AIDS raises challenging issues for Churches. For example, the preamble to the 2001 document Plan of Action: Ecumenical Response to HIV/AIDS in Africa states that: 'Today, Churches are being obliged to acknowledge that we have - however unwittingly - contributed both actively and passively to the spread of the virus. Our difficulty in addressing issues of sex and sexuality has often made it painful for us to engage, in any honest and realistic way, with issues of sex education and HIV prevention. Our tendency to exclude others, our interpretation of the scriptures and theology of sin have all combined to promote the stigmatisation, exclusion and suffering of people with HIV or AIDS.'17 And a Christian Aid report states that: 'For almost all African churches "condomisation" has become a burning political and moral issue.'18
However, the Ecumenical Plan of Action document continues by saying that: 'The Churches have strengths, they have credibility and they are grounded in communities. This offers them the opportunity to make a real difference in combating HIV/AIDS. To respond to this challenge the Churches must be transformed in the face of the HIV/AIDS crisis, in order that they may become a force for transformation.' It continues to outline a tangible, wide-ranging action plan. As well as offering practical action, the Plan includes the commitment that: 'We will condemn discrimination and stigmatisation of people living with HIV/AIDS as a sin and contrary to the will of God.' This positive process needs to continue and accelerate, in all regions, to ensure that the actions outlined in the document are implemented.
Much of the global discussion on HIV/AIDS focuses on what individuals can do to reduce their own risk of becoming HIV positive, and on the medical interventions that can mitigate the impact of being HIV positive. While a necessary part of the response, this approach is far from sufficient. Vulnerability to HIV is also increased by poverty, and poverty is caused and maintained by global social and economic processes. These links need far more attention. More research into their exact nature is needed, to enable countries and international institutions to take the HIV/AIDS situation into account when formulating economic policy.
While HIV/AIDS should be recognised as affecting all aspects of national life in epidemic-hit countries, rather than boxed solely into the health sector, the impact of global economic policy-making on the epidemic also needs consideration. And HIV/AIDS policy-makers also need to broaden their thinking beyond the medical and beyond individual behaviour change.
Ultimately, to tackle HIV/AIDS we need to tackle poverty. This is both the most important aspect of HIV/AIDS responses, and the most far sighted. All Christian Aid's poverty-eradication programmes and recommendations - for example the current Trade for Life campaign to change unfair trade rules - are also relevant to tackling HIV/AIDS.
Christian Aid's recommendations
To tackle HIV/AIDS directly:
The UK government should contribute at least £750 million a year to the annual US$10 billion needed globally for HIV/AIDS prevention, care, orphan care and advocacy in developing countries. This money should be used to help build the capacity of the affected communities and governments to cope with the epidemic, as well as for programmes and commodities. The UK's current contribution is around £200 million a year.
The majority of this money should be channelled through existing bilateral programmes. Some should also be channelled through the Global Fund to Fight AIDS, TB and Malaria, and through civil society channels. Civil society channels are particularly important in countries in conflict or post-conflict.
Because of the unique nature of HIV/AIDS, and the urgency of the situation, donors need to think innovatively about how and where they use their money. For example, while the poorest countries should be given priority, it may be necessary to fund civil society work in some middle-income countries that may not normally receive this aid. This applies particularly where HIV/AIDS primarily affects marginalised groups and is not currently a political priority.
To tackle the underlying causes of vulnerability to HIV/AIDS
The UK government should urgently, on a sustainable basis, increase support and funding to strengthen health and education systems (including capacity building), and other poverty-reduction programmes. Thus, the government should:
- continue to increase aid year-on-year, and commit to a timetable for achieving 0.7 per cent of GNP as aid.
- champion a new deal on debt cancellation, in which debt relief would be calculated in terms of the money needed for countries to reach poverty reduction targets.
All actors - including the HIV/AIDS, academic and NGO communities - should place greater emphasis on the links between poverty and the spread of the HIV/AIDS epidemic. They should highlight the role of international economic policy, rather than focussing solely on changing the behaviour of individuals.
The church should continue and accelerate the process of expanding its role in HIV/AIDS prevention and care, and in challenging stigma and discrimination.
0 UNAIDS Report 2002
1 Schwartlander, B etc al (2002), Resource Needs for HIV/AIDS, Science Vol 292, Issue 5526, 2,434-2,436, 29 June 2001; SIPRI Yearbook 2002
2 www.euromonitor.com - Breakfast Cereals in the UK, July 2002
3 UNAIDS Report 2002
4 UNAIDS Report 2002
5 UNAIDS Report 2002
6 The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China, US National Intelligence Council ICA 2002-04D, September 2002; UNAIDS Report 2002
7 The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China, US National Intelligence Council ICA 2002-04D, September 2002
8 World Development Indicators, World Bank 2002
9 Schwartlander, B etc al (2002), Resource Needs for HIV/AIDS, Science Vol 292, Issue 5,526, 2,434-2,436, 29 June 2001
10 UNAIDS press release, New Figures Show AIDS Fight Underresourced, 10 October 2002
11 UNAIDS press release, New Figures Show AIDS Fight Underresourced, 10 October 2002
12 Parliamentary statement by Sally Keeble, Under-Secretary of State for International Development, 28 October 2002
14 Christian Aid (2000), Millennium Lottery - Who Lives, Who Dies in an Age of Third World Debt?; Save the Children/Medact (2001), The Bitterest Pill of All - The Collapse of Africa's Health Systems
15 Save the Children/Medact (2001), The Bitterest Pill of All - The Collapse of Africa's Health Systems
16 CAFOD, Oxfam, EURODAD, Christian Aid (2002) - A Joint Submission to the World Bank and IMF Review of HIPC and Debt Sustainability, August 2002
17 Plan of Action: The Ecumenical Response to HIV/AIDS in Africa - Global Consultation on the Ecumenical Response to 17 HIV/AIDS in Africa, Kenya 2001
18 Christian Aid (2001), AIDS and the African Churches: Exploring the challenges