The Macroeconomic Impact

The economic impact of AIDS in South Africa: a critique of the demographic methods used in the ING-Barings report of April 2000, and their implications

Mimeo

The AIDS epidemic has already affected many sub-Saharan African countries, and is expected to have profound effects in South Africa over the next 20 years. By striking sexually active individuals, AIDS kills individuals during their most productive years. This impact feeds into the economy in numerous ways, including: A smaller labour force; A less productive labour force; Lower savings rates; Lower aggregate demand; Shifting expenditure towards health care. ING Barings uses the ASSA600 model with a national calibration to generate demographic forecasts for the total population, as well as for four race groups. This information is merged with data from the 1996 South African census to obtain forecasts of AIDS in 16 sectors and 3 skill levels. Little information is available on these forecasts. However, a simple weighted average closely approximates these rates. When this weighted average is used with data accurately calibrated to individual race groups, two changes become apparent: The long-term rate of HIV+ infection in all sectors is 3 to 5 percent of the population higher than projected by ING Barings. The distribution of HIV+ infection across skill levels shifts towards highly skilled workers. ING use current HIV+ infection and wage distribution over skill levels to determine an index of sectors to HIV/AIDS. This is discredited because it takes no account of the future rates, is based on rankings not actual values, assumes a uniform distribution of HIV+ infection across skills levels, and ignores input supply and output demand changes. The author believes that INGs projections are too optimistic. They will, however, become more pessimistic when including increased AIDS levels in the correctly calibrated model.

AIDSCAP (1996)

AIDS in Kenya: Socioeconomic Impact and Policy implications

Family Health International (FHI) and AIDSCAP, Washington

Ainsworth, M. and Over, M. (1994)

The economic impact of AIDS in Africa

In: AIDS in Africa, Essex, M., et al, New York, Raven Press

Ainsworth, M. and Over, M. (1994)

AIDS and African development

World Bank Research Observer, 9 (2)

Alaban, A. and Guinness, L. (2000)

Socio-economic impacts of HIV/AIDS in Africa

UNAIDS, ADF 2000 (Powerpoint presentation)

Armstrong, J.

Socioeconomic implications of AIDS in developing countries

Finance and development, Dec:14-7

Arndt, C. and Lewis, J.D. (2000)

The macro implications of HIV/AIDS in South Africa: A preliminary assessment

The World Bank, presented to IAEN Conference, July 2000

In this paper, we report on the preliminary results from an analysis of the macro impact of HIV/AIDS in South Africa. We have constructed an economy-wide simulation model that embodies the important structural features of the South African economy, into which we have added major impact channels of the HIV/AIDS epidemic. Using available demographic estimates for the impact of the epidemic (on labour supply, death rates, and HIV prevalence) along with assumptions about behavioural and policy responses (household and government spending on health, slower productivity growth), we use the model to generate and compare two scenarios: a hypothetical ëno-AIDSí scenario in which the economy continues to perform as it has over the last several years, and an ëAIDSí scenario in which the key AIDS-related factors affect economic performance. Focusing on the differential between the "no-AIDS" and "AIDS" scenarios, we find that the impact of the epidemic could be substantial. Over the 1997-2010 simulation period, GDP growth rates in the two scenarios diverge steadily, reaching a maximum differential of 2.6% points. The result is a GDP level in 2010 that is 17% lower in the ëAIDSí scenario; an alternative measure of ënon-health, non-food absorptioní is 21% lower by 2010. While some of this decline is due to the lower population associated with the ëAIDSí scenario, per capita GDP does drop by around 7%. In fact, our simulations suggest that, despite the fact that AIDS impacts the high-unemployment unskilled labour category more than others, the net effect of higher AIDS-related mortality and slower growth is to leave the unemployment rate largely unchanged. We also use the model to ëdecomposeí the overall decline in growth performance into the contribution of the various channels. Given our current assumptions, the largest share (nearly half) of the deterioration in growth is attributable to the shift in government current spending towards health expenses (which increases the budget deficit and reduces total investment), while an additional third stems from slower growth in total factor productivity (TFP). The decomposition illustrates the importance of considering the slow moving nature and hence long duration of the epidemic. If the epidemic imposes a drag on the rate of accumulation of knowledge (reduced TFP growth) or the rate of accumulation of capital (through a switch from savings to current expenditure), these effects become amplified over time. Over the course of a decade, the implications for macroeconomic performance are substantial. Looking forward, our analysis suggests several avenues for further investigation. First, the parameters used in specifying the various AIDS effects are based on fairly limited empirical evidence, and it will be important where feasible to supplement these with additional data. For example, we have limited the impact of AIDS on household expenditure patterns to an assumed increase in health service spending, but there may well be other shifts that will occur and that could be incorporated, based on survey results. Second, there are important dynamic effects that are not yet included in the model: for example, lower private and government spending on education (because of higher AIDS spending) will slow down skills accumulation and change labor force growth rates. Finally, consideration must be given to how to capture the impact of alternative ëinterventioní strategies ñ for example, at present there is no feedback between possible government policies to slow the spread of AIDS, and the demographic (and subsequent economic) trajectory of the epidemic.

Asia-Pacific HIV Impact Research Team

HIV impact assessment tool: The concept and its application

UNDP, Geneva

Balyamujura, H., Jooste, A., van Schalkwyk, H., and Carstens, J. (2000)

Impact of the HIV/AIDS pandemic on the demand for food in South Africa

The demographic impact of HIV/AIDS in South Africa and its provinces conference, Port Elizabeth

The macro economic impact of HIV/AIDS has two dimensions, namely direct and indirect costs. The latter is much more difficult to estimate, whilst its effect is also much more profound. This situation is aggravated by the fact that the portion of the population most affected by HIV/AIDS is the most economically active. The result of this is reduced economic growth and hence pressures on income. This could translate into changes in expenditure patterns that would definitely have an impact on the demand for food. Although the per capita income is expected to increase, it is projected that total expenditure on food will decrease in 2004 and 2009 in the "With HIV/AIDS" scenario. In constant 1995 terms, AIDS will cause a reduction in food expenditure in 2004 from 265,6 million to 258,8 million, while in 2009 the pandemic will result in a 6,52 per cent reduction from 294,5 million to 275,3 million.

Barnett , T. (2000)

Guidelines for preparation and execution of studies of the social and economic impact of HIV/AIDS

13th International AIDS Conference, Durban

Issues: There is often pressure and need to produce socio-economic impact studies when countries reach the stage where the epidemic is visible. Impact studies have a dual purpose. They provide the rationale for both prevention and mitigation The arguments for the studies are: (a) If there is a measurable or predictable impact then people can be convinced of the problem. Showing impact becomes an important tool for advocacy. (b) If the epidemic will have an impact, we need to know its location, scale and form, to begin planning for it. Description: This project developed guidelines on how to carry out impact assessments. The method used was to review all available impact studies including many done by the authors, to establish what they did and did not show in terms of the expectations and how the methodology worked and the level of analysis was decided. Two concepts are put forward for identifying the determinants of the scale and location of the epidemic and its impact. These are susceptibility - which determines where the epidemic will be located in a society and how far and fast it will spread; and vulnerability, which determines the likelihood that AIDS will have adverse consequences. Conclusion: Impact will be (a) detectable but only if the correct instruments are developed and used; (b) located in certain social, economic and spatial groups and areas and some of these may have little political influence or importance and therefore may not attract attention; and (c) felt slowly over a long period. Impact studies have an important role but both those commissioning and those carrying them out must be clear as to what can be done and what is expected.

Barnett, T. and Blaikie, P. (1993)

Simple methods for monitoring the socio-economic impact of AIDS: Lessons from sub-Saharan Africa

In: Cross, S. and Whiteside, A. (eds), Facing up to AIDS: The socio-economic impact in Southern Africa, McMillan, London

Barnett, T. and Whiteside, A. (1996)

HIV/AIDS and Development: Case studies and a conceptual framework

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

Barnett, T. and Whiteside, A. (2000)

Guidelines for studies of the social and economic impact of HIV/AIDS

UNAIDS, Geneva, Switzerland

Many countries, particularly those with serious HIV/AIDS epidemics, are increasingly adopting strategic approaches to planning and implementation. Specifically, in planning for HIV/AIDS, they are relying on an anlysis of their particular HIV/AIDS situation and response in order to define future priorities and to set relevant objectives and strategies. Socioeconomic impact studies can be a key element in informing the analysis and in the overall planning process. However, many impact studies have not been aimed at planning, but have merely been an academic exercise of have provided less than solid data for advocacy purposes. The present guidelines are intended to place socioeconomic impact studies in the planning prcess in a systematic way. One of UNAIDís major motivations for publishing this manual is to encourage cuontries to include impact information in their strategic planning process. However, UNAIDS would also encourage specific impact studies in sectors such as education and agriculture, where a strong basis for the development of sector-specific alleviation strategies can be formed.

Barnett, T. and Whiteside, A. (1999)

Guidelines for preparation and execution of studies of the social and economic impact of HIV/AIDS

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

Barnett, T., Whiteside, A. and Desmond, C. (2000)

The social and economic impacts of HIV/AIDS in poor countries: A review of studies and lessons

UNAIDS, Geneva

Bechara, M. and Weeks, O. (2000)

AIDS ñ An economic catastrophe?

Morgan Stanley Dean Witter, London

The epidemic in South Africa is among fastest growing in the world. By 2007, 23% of the adult population may be infected, with annual AIDS deaths forecast to reach 800,000 by 2011. Infection seems to be skewed towards the unskilled. This is unlike in other parts of Africa, and may make the overall economic impact considerably less than feared. Government spending on AIDS remains strikingly low. We do not expect rising healthcare costs to reduce investment and growth significantly.

Botswana Institute for Development Policy Analysis (BIDPA) (2000)

The macroeconomic impacts of HIV/AIDS in Botswana

BIDPA, Botswana

Background: HIV/AIDS is expected to increase poverty and destitution in Botswana. The objective was to quantify the impact of HIV/AIDS on indicators of poverty and income inequality, and to explore the policy implications. Methods: Current HIV prevalence rates by age, sex and location were randomly imposed upon household and individual level data taken from a household income and expenditure survey (HIES) in Botswana. The household income position was then considered after a 10-year period, when those infected with HIV were assumed to have died. Comparative indicators were then calculated. Results: About 50% of households in Botswana have an infected household member. Half of these will lose an income earner within 10 years. In addition, 2% of all households will lose all of their income earners, and become effectively destitute. The analysis predicted an 8% fall in national household level income, and an increase of 5% in the poverty head count. Per-capita income of the poorest 25% of households is projected to fall by 13%, with an increase of 25% in the number of dependents per income earner. The widespread nature of HIV/AIDS in Botswana does however imply that income inequality will not worsen significantly. A comprehensive sensitivity analysis suggested that the results of the analysis are robust to changes in the key assumptions. Conclusions: The results imply that HIV/AIDS will have a significant impact on poverty levels in Botswana, and will cause a large increase in extreme poverty and destitution. The major implication is that the enactment and implementation of poverty alleviation policies will take on a much greater urgency. Particular emphasis will need to be given to employment creation for unskilled workers, orphan care and destitute relief, and to counselling and support services for young people.

Bloom David E. and Mahal Ajay S. D. (1997)

Does the AIDS epidemic threaten economic growth?

Journal of Econometrics (77)1 pp. 105-124

Bloom David E. and Mahal Ajay S. D. (1995)

Does the AIDS epidemic threaten economic growth?

National Bureau of Economic Research (NBER), Cambridge, Massacheussets

Bloom, D. and Lyons, J. (eds) (1992)

The economic impact of AIDS in Asia

United Nations Development Programme (UNDP), Dehli

Bloom, D.E. and Godwin, P. (eds) (1997)

The economics of HIV and AIDS: The case of south and south east Asia

Oxford University Press

Bollinger, L. and Stover, J. (1999)

The economic impact of AIDS

The Futures Group International, Washington, DC

Bollinger, L. and Stover, J. (1999)

The economic impact of AIDS in South Africa

The Futures Group International, Washington, DC

Broomberg, J. (1993)

Current research on the economic impact of HIV/AIDS: A review of the international and South African literature

In: Cross, S. and Whiteside, A. (eds), Facing up to AIDS: The socio-economic impact in Southern Africa, McMillan, London

Broomberg, J., Steinberg, M., Masobe, P. and Behr, G. (1991)

The economic Impact of the AIDS epidemic in South Africa

In: Centre for Health Policy, Aids in South Africa, The Demographic and Economic Implications, University of Witwatersrand, Johannesburg

Broomberg, J., M. Steinberg, P Masobe & G Behr (1993)

The economic Impact of the AIDS epidemic in South Africa

In: Cross, S. and Whiteside, A. (eds), Facing up to AIDS: The socio-economic impact in Southern Africa, McMillan, London

Broomberg, J., Soderlund N. and Mills, A. (1996)

Economic analysis at the global level: a resource requirement model for HIV prevention in developing countries

Health Policy, Oct;38(1):45-65

Bureau for Econonomic Research (BER) (2000)

HIV/AIDS and the South African economy

Bureau for Economic Research (BER), Stellenbosch

Butler, M., Gomez, E., Perez, Bollinger, E. and Colvin, C. (2000)

The socioeconomic impact of HIV/AIDS in the Dominican Republic, 1991-2005

13th International AIDS Conference, Durban

The purpose of this report is to summarise the process undergone to estimate both the past and future trends of HIV/AIDS in the Dominican Republic, and to evaluate the socioeconomic impact of these trends. The size of the epidemic is described by the number of people infected with HIV and the number of AIDS cases. The socioeconomic impact is measured by the impact on various demographic measures, such as total fertility rate, infant mortality rate, and life expectancy, and some economic variables, including the impact on the health sector and the Ministry of Health budget. There is a significant difference between an initial set of projections of the HIV/AIDS epidemic, estimated in 1996, and the projections presented here. The initial projections indicated that HIV prevalence in the adult population would reach 4.6% by the year 2000. The projections here estimate that, instead, overall HIV prevalence in the adult population will be 2.34 percent by the year 2000, and will reach 2.44% by 2005. The difference between these two sets of projections may be due to a number of different factors. First, there are now more and better data from surveillance sites. Three of the sites have seven or more years of data, and a fourth site now has five years of data. Increases in the amount of data available for analysis allow for more accurate predictions. Second, our understanding of the current level of the maturity of the epidemic may have changed because of these new data. The projections presented here indicate that the epidemic is at a more mature stage than the earlier projections had indicated, implying that the maximum infection rate will be lower than anticipated before. Third, the spread of the epidemic may have slowed down due to prevention efforts. Although it is difficult to assign causality to the prevention efforts directly, there are a number of examples of successful efforts.

Chevallier, E. and Floury, D. (1996)

The socioeconomic impact of AIDS in sub-Saharan Africa

AIDS 1996;10, Suppl A:S205-11

Cohen, D. (1999)

The economic impact of the HIV Epidemic

United Nations Development Programme (UNDP), Issues paper No 2

Cross, S. (1993)

A socio-economic analysis of the long-run effects of AIDS in South Africa

In: Cross, S. and Whiteside, A. (eds) Facing up to AIDS: The socio-economic impact in Southern Africa, Macmillan, South Africa

Cross, S. and Whiteside, A. (eds) (1993)

Facing up to AIDS: The socio-economic impact in Southern Africa

Macmillan, South Africa

Cross, S. and Whiteside, A. (eds) (1996)

Facing up to AIDS: The socio-economic impact in Southern Africa

Palgrave, England

Cuddington, J.T. and Hancock, J.D. (1994)

Assessing the impact of AIDS on the growth path of the Malawian economy

Journal of Development Economics, 43 (2):363-368

Cuddington, J.T. (1993)

Further results on the macroeconomic effects of AIDS: The dualistic labour-surplus economy

World Bank Economic Review 7 (3)

Cuddington, J.T. (1993)

Modelling the macroeconomic effects of AIDS with an application to Tanzania

World Bank Economic Review 7 (2):173-89

Denolf, D. (2000)

Structural obstacles for economic development in developing countries

13th International AIDS Conference, Durban

Economies of developing countries are often characterised with major macroeconomic problems limiting sustainable development. In periods of economic crisis national resources allocated for health are substantially reduced with dramatic consequences for the population. The AIDS crisis thrives on poverty, together with poor education and health. Direct obstacles which impede economic growth include national monetary policy inducing hyperinflation; excessive price regulation through state intervention; preponderance of informal sector; lack of foreign investments; poorly implemented trade legislation. Underlying obstacles which are more difficult to access: level of technical competence; conflict between personal benefits and benefits for the society; poor administrative capacities; inadequate accountability; unequal distribution of administrative and economical power; weak civil society. Internal and external obstacles in Democratic Republic of Congo are leading to a weak economy which prejudices budget allocation for health expenditures. To achieve a sustainable economic growth, the structural and political obstacles impeding development should be addressed . Introduction of progressive and feasible structural adjustment programs emphasising on social improvements are urgently needed. Economic growth with equitable redistribution of the wealth is of utmost importance to reverse the course of dramatic AIDS epidemic in the developing countries.

Department of Finance, South Africa (2000)

Budget Review 2000

Department of Finance, Pretoria, South Africa

Department of Finance, South Africa (2000)

National Expenditure Survey

Department of Finance, Pretoria, South Africa

Doehring, R.O. (1991)

The socio-economic impact of the AIDS epidemic

Degree: Graduate School of Business Administration, University of the Witwatersrand

Doyle, P.R. (1991)

AIDS in South Africa: The demographic and economic implications

The Centre for Health Policy, University of Witwatersrand

Du Plessis, P.G. (1991)

The potential influence of AIDS on the South African investment milieu

Degree: Department of Business Management, University of Stellenbosch

Godwin, P. (1998)

The looming epidemic: The impact of HIV and AIDS in India

Mosaic Press, New Dehli

Hamoudi, A. (2000)

AIDS and the economists in Durban: Laying a foundation

AIDS Analysis Africa, 11(2)

ING Barings (2000)

Economic impacts of AIDS in South Africa: A dark cloud on the horizon

ING Barings, Johannesburg

This report uses the WEFA time-series based macroeconomic model, which is a widely-used commercial forecasting model. Demographic input data is based on the ASSA600 model9 , which in turn originated from the ëDoyle modelí used by Broomberg et al. The key results are that the growth rate of GDP declines by 0.2ñ0.3% up to 2005, and thereafter by 0.3-0.4% (Figure 1). Since population growth declines by more than this ñ 1.33% - up to 2005, per capita income will actually be higher until 2005, as compared with a ëno AIDSí situation, if the modelís projections are accurate. After 2005, the decline in population growth averages 0.12% p.a., which is less than the decline in the growth rate of GDP, so per capita income will be lower than without the epidemic. Notwithstanding the ëdark cloudí image in the title, the ING Barings study gives some support to the ëcautiously optimisticí view discussed above; indeed, the study makes explicit that it is presenting a ënon-alarmistí scenario.

Jones, C. (1996)

Does structural adjustment cause AIDS: One more look at the link between adjustment, growth and poverty

In: Ainsworth, M., Fransen, L. and Over, M., Confronting AIDS: Public Priorities in a Global Epidemic, European Commission, 1998

Kambou, G., Devarajan, S. and Over, M. (1992)

The economic impact of AIDS in an African country: Simulations with a computable general equilibirum model of Cameroon

Journal of African Economies, 1 (1)

Kinghorn, A. and Steinberg, M. (1998)

HIV/AIDS in South Africa: The impacts and Priorities

Department of Health, South Africa

Kongsin, S., Lerttchayantee, S., Jiamton, S. and Watts, C. (2000)

Socio-economic determinants of HIV/AIDS in Thailand

13th International AIDS Conference, Durban

Since AIDS infects mainly adults at their prime working age, which can have a profound social and economic impact on the welfare of surviving members in low socio-economic households. Empirical information on the socio-economic impact of HIV/AIDS on households and communities in Thailand is scarce of variable quality, where the majority of cases under the re-emerging worldwide epidemic occur. Knowledge about these factors is required to assess the economic impact of the disease at the societal level. The high level of poverty among young age group of PLWHA was similar to that observed in the general population. The distribution of socio-economic variables in the study group did not differ significantly from that found in the general population. HIV/AIDS equally affects members of all socio-economic groups in Thailand. While the prevalence of poverty is higher in the study group, poverty is not a risk factor for the occurrence of the disease. Also, the higher disease risk among the young age group of PLWHA is not determined by poverty.

Loewenson, R. and Kerkoven, R. (1996)

The socio-economic impact of AIDS: Issues and options in Zimbabwe

SafAIDS and TARSC, Harare

Loewenson, R. and Whiteside, A. (1997)

Social and economic issues of HIV/AIDS in southern Africa: A review of current research

SafAIDS, Harare

Mills, A. et al (1993)

The costs of HIV/AIDS prevention strategies in developing countries

World Health Organisation, Global Programme on AIDS, Geneva

National Treasury, South Africa (2000)

Intergovernmental fiscal review

National Treasury, Pretoria, South Africa

National Treasury, South Africa (2000)

Medium term budget policy statement

National Treasury, Pretoria, South Africa

Nicholls, S. et al (2000)

Modelling the macroeconomic impact of HIV/AIDS in the English-speaking Carribean: The case of Trinidad, Tobago and Jamaica

IAEN Conference, July 2000

Over, M. (1992)

The Macroeconomic Impact of AIDS in Sub-Saharan Africa

World Bank, New York

The earliest conjectures regarding the impact of the AIDS epidemic in severely affected countries presumed that the disease would cause substantial declines in such conventional measures of macroeconomic performance as the growth of GNP per capita. This paper written in 1992, together with other papers that are cited in Chapter 1 of ëConfronting AIDS,í were the first to provide detailed calculations of the probable magnitude of these impacts. Now that some countries have in fact attained the 21% adult prevalence rate that was hypothesised in this paper, its projections are particularly relevant. Whether they are accurate is more difficult to determine. However, the continued macroeconomic growth of such severely affected countries as Uganda and Botswana, despite serious AIDS epidemics, seems to support the predictions of this paper that the impact of the epidemic on per capita GNP growth will be small. The possibility remains that profound, cumulative "disruption effects" of the epidemic not modeled in these papers will manifest themselves in the coming years.

Raditapole, D.K. (1995)

The economics of HIV transmission

In: HIV and AIDS: the global inter-connection, edited by Elizabeth Reid. West Hartford, Connecticut, Kumarian Press, 55-62

Squire, L (1998)

Confronting AIDS

Finance and Development, March

Taylor, V. (1998)

HIV/AIDS and human development, South Africa.

In: United Nations Development Report, Human development report, United Nations Development Programme (UNDP), Geneva

Trotter, G. (1993)

Some reflections on a human capital approach to the analysis of the impact of AIDS on the South African economy

In: Cross, S. and Whiteside, A. (eds), Facing up to AIDS: The socio-economic impact in Southern Africa, McMillan, London

Wehrwein, P. (2000)

The economic impact of AIDS in Africa

Harvard AIDS Review, Fall 1999/Winter 2000

Whiteford, A. (1999)

Implications of the AIDS epidemic for the South African labour market

WEFA Monthly Outlook, March

Whiteside, A. (1996)

Economic impact in selected countries and the sectoral impact

In: Mann, J. and Tarantola, D.J.M. (eds), AIDS in the world II: global dimensions, social roots, and responses, Oxford University Press, New York

Whiteside, A.

Economic effects of AIDS: Socio-economic causes and consequences

University of Natal (ERU), Durban

Whiteside, A. and Sunter, C. (2000)

AIDS: The challenge for South Africa

Human and Rousseau, Tafelberg, South Africa

This book acruges that there are many interventions that can be carried out in response to HIV/AIDS. It covers the origin of HIV/AIDS, the current situation in the world and in Africa, the South African impact, and demographic and social consequences in South Africa. The authors recommend a grassroots approach on a wide front.

World Bank (1997)

Confronting AIDS: Public priorities in a global epidemic

Oxford University Press, New York

Zungu, N.G. (2000)

Economics and globalisation: developing countries slow economic take-off and the uneven process of globalisation and HIV/AIDS epidemic

13th International AIDS Conference, Durban

The failure of the economies in Less Developed Countries (LCDs) to take off and the uneven process of globalisation contribute to the alarming spread of HIV/AIDS epidemic. It also trivialises the research projects that have been undertaken to teach poverty-stricken communities about the epidemic. It is the same situation that, in the long run, is staggering the economies of the less developed countries (LDCs). When the LDCs economies take off due to the extractive process of globalisation, it means there is little to spare for HIV/AIDS programmes. Lack of funding for HIV/AIDS programmes necessarily means higher infection rates and death instances that translate to further deterioration of the already limping economies of the LCDs.

The Demographic Impact

Boerma, J.T. et al (1998)

Mortality impact of the AIDS epidemic: evidence from community studies in less developed countries

AIDS, 12

This review focuses on the evidence of mortality impact among adults and children in community studies. The majority of these studies are located in Africa, particularly eastern Africa, where the AIDS epidemic is conjectured to be older than in other less developed countries. Community studies show a two- to threefold increase in total adult mortality with an even larger increase in mortality among young adults in communities with adult HIV prevalence levels below 10%. Mortality amongst HIV-infected adults ranges from 5 to 11% per year, and more than half of all adult deaths can be attributed to HIV. HIV-infected women die at an earlier age than men and thereby lose significantly more productive years of life. Follow-up studies of incident cases are few, but population-based data indicate that the median survival time is substantially longer than originally thought on the basis of mortality amongst HIV-infected commercial sex workers. Tuberculosis incidence is on the increase, but evidence of additional impact on mortality is hitherto limited. Infant and early child mortality among children of HIV-infected mothers is two to five times higher than among children of HIV-negative mothers in follow-up studies of maternity-based and community samples. The large increase in adult mortality and moderate increase in child mortality lead to dramatic falls in life expectancy. For instance, in a rural area of Uganda, which has an HIV prevalence of 8%, life expectancy has dropped from just under 60 years to 42.5 years.

Bos, E. and Bulatao, R.A. (1992)

The demographic impact of AIDS in sub-Saharan Africa

International Journal of Forecasting (8) 3:367-384

Bourne, D. (2000)

Demographic implications for development in Southern Africa as a result of the AIDS epidemic ñ a graphical review

Urban Health and Development Bulletin, 3 (2)

Bourne, D., Dorrington, R., and Loubser, R. (2000)

Rapid AIDS mortality surveillance in South Africa

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

Mortality patterns in South Africa are changing rapidly, with an increase in the overall number of deaths and a shift in the age structure with increased mortality among younger adults. Part of the increase can be ascribed to better reporting of deaths but the shift in age structure can be explained in terms of additional deaths due to AIDS. Official mortality statistics for South Africa currently appear four to five years after the event. By using anonymous data from the Population Register of the Department of Home Affairs it is possible to monitor mortality three to six months after the registration of death. A rapid surveillance system was piloted by comparing mortality data from the Population Register for a 12-month period in 1997/98 with the projected number of deaths from the ASSA600 model. The ASSA600 model currently reproduces the general trend of the observed mortality and the level of mortality in total, although it currently appears to overestimate female mortality and underestimates male mortality. Improvements to the model and potential sources of bias in the mortality data set are being investigated.

Bourne, D., Dorrington, R., Laubscher, R. and Bradshaw, D. (2000)

Rapid AIDS mortality surveillance in South Africa

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

This paper presents the results of the ASSA600 demographic model developed by the AIDS Committee of the Actuarial Society of South Africa. The model assumes that there are four populations at risk with respect to AIDS and further assumes an average of ten years between infection and death for adults and two years for infants. The model has been calibrated to meet the population estimate of 42.2 million in 1996 and the results of the national antenatal survey. No behavioural changes are accounted for. The model displays the increasing numbers of deaths attributable to AIDS and to the changing age profile of the population.

Brophy, G. (1993)

Modelling the demographic impact of AIDS: Potential effects on the black population in South Africa

In: Cross, S. and Whiteside, A. (eds) Facing up to AIDS: The socioeconomic impact in Southern Africa, Macmillan, London

Cameron, W., Garnett, G., Bartley, L.M., and Anderson, R.M. (2000)

Shared community benefits of good medical health care for HIV: Mathematical modelling of the potential impact of treatment on the spread of HIV infection

13th International AIDS Conference, Durban

This paper sets out to model mathematically the epidemiological and economic impact of health care including anti-HIV treatment on the public health of HIV, in comparison and in combination with accepted public health interventions. A deterministic, compartmental model of HIV transmission in a sexual activity-stratified heterosexual population was developed. This included HIV disease progression and transmissibility, related to allocation patterns of medical treatment and acquired drug resistance. The modelled population incidence of HIV and AIDS could be reduced through the use of anti-HIV treatment. A net public health benefit is possible when treatment is appropriately targeted early in an HIV epidemic in a context of a highly focused initial source of infection. Conservative assumptions about the potential alterations in parameter values suggest that HIV treatment could be more effective than other interventions. There are many barriers to the effective treatment of HIV infection in resource poor settings. This is particularly true in populations for which targeted therapy would have the most beneficial impact on HIV epidemiology. Our model results indicate that resources allocated to targeted health care as a means of preventing the spread of HIV may confer both net public health and economic benefits.

Cohen, D. (1999)

Socioeconomic causes and consequences of the HIV epidemic in southern Africa: A case study of Namibia

United Nations Development Programme (UNDP), Geneva

Colvin, M. (1998)

Draft protocol: 1998 annual antenatal HIV and syphilis seroprevalence survey

MRC, Durban

Colvin, M., Gouws, E., Kleinschmidt, I., and Dlamini, M. (2000)

The prevalence of HIV in a South African working population

13th International Conference on AIDS, Durban

Estimates of the prevalence of HIV in South Africa are almost exclusively based on data from the annual survey of public-sector antenatal clinics. There is very little HIV prevalence data on men and non-black women. This study aimed to determine the prevalence of HIV and associated risk factors among a nationally based working population comprising all race groups and both sexes.

Colvin, M. and Mullick, S,

Draft outline of a national STD/HIV/AIDS survellance strategy

MRC, Durban

Department of Health, South Africa (1999)

National HIV sero-prevalence survey of women attending public antenatal clinics in South Africa

Department of Health, South Africa

This report explains, broadly, the method used by the Department of Health, in collating the national ANC prevalence rate data. It also summarises the results for the year 1999 by age and province. The report indicates some of the limitations of the data by presenting the design adjusted confidence intervals and expressly states that the results do not adequately represent the non-African population.

Department of Health, South Africa (1998)

South Africa demographic and health survey: 1998. A preliminary report

Department of Health South Africa, with Medical Research Council and Macro International

This report presents preliminary findings from the 1998 survey. It provides the results for key maternal and child health indicators including medical care for mothers during pregnancy and at the time of delivery, infant feeding practices, child immunisation coverage and the prevalence and treatment of diarrhoeal disease among children. It also provides information on womenís status, fertility levels, contraceptive knowledge and use and adult health conditions.

Department of Health, South Africa (1998)

Report on confidential enquiries into maternal deaths in South Africa

Department of Health, Pretoria, South Africa

Dorrington, R. (2000)

HIV/AIDS in the Western Cape: Is there still time to do something?

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

The Western Cape has the lowest prevalence of all the provinces with a prevalence of pregnant women attending antenatal clinics of only 7.1% compared to an national average of 21.4% and is roughly five years behind KwaZulu-Natal. Therefore the province has the best opportunity of early intervention to slow down the spread of the infection. However, within the province there is wide variation with zero prevalence in some areas rising to highs of 18 to 19% prevalence in Guguletu and Khayelitsha. The Department of Health has set up a Provincial AIDS Management Team to implement a number of programmes designed to curb the spreading of the epidemic and to provide care and support. Although it would have been much more cost effective to have started earlier, there is still time to do something about the course of the epidemic in the province, and the Provincial AIDS Management team have, on paper, made an excellent start.

Dorrington, R. (2000)

What the ASSA2000 model tells us about the epidemic in the provinces and what it tells us about the national epidemic

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

This model is distinguished by applying a four race model to each province from which national estimates are derived. It represents work-in-progress as the model has not been fully calibrated. It improves on ASSA600 by incorporation of ë98 and ë99 ANC summary statistics, í98 DHS results, improved population estimates, mortality data. Despite little data being available to correctly calibrate the model it provides estimates for the four main race groups. The results incorporate risk group percentages and condom use profiles. It assumes migration will fall from a net in-migration of 190 000 in 1996 to a nil gain over a 30 year period. The model assumes an infant mortality rate of 30% per annum for those born infected and a median term to death of five years for those contracting disease via their mothersí milk. A contagion matrix incorporates a number of additional influences including: transmission probabilities by risk group sex and number of new partners the probability of the partner belonging to a risk group, number of contacts per new partners, condom usage by year and, condom effectiveness measures. The author indicates the resultant projections ëflatten out too sooní but concludes that the aggregated data (ie. for all nine provinces) produces a ëremarkably good fit to all data except 1998 ANCí. The ultimate plateaus of prevalence rates range from 17% for Western Cape to 43% for KwaZulu-Natal ñ assuming no changes in behaviour. A national prevalence rate of about 30% is observed.

Dorrington, R. (2000)

The demographic impact of HIV/AIDS in South Africa

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

In this paper Dorrington compares the ASSA600 model to observed HIV rates and the projections made by the US Bureau of the Census, the United Nations and the Metropolitan Doyle models. He finds that international models are more pessimistic than local models regarding mortality etc. Nevertheless even the local models confirm that the epidemic is deeply entrenched and will have a significant impact with around six to ten million (additional) deaths over the next ten years. He also finds that the epidemic has, to date, not been affected by interventions, yet the modification of risky sexual behaviour and treatment of STDs could significantly alter the progression of the disease.

Dorrington, R. (1998)

ASSA600: An AIDS model of the third kind?

Mimeo

This paper provides a brief overview of the method and output of the ASSA600 model. The first appendix summarises the findings of the Nedlac census results task team on the validity of the 1996 census population count. That team concluded that the preliminary estimates provided by Statistics SA significantly underestimated the population count ñ but was unable to measure that underestimate. The second appendix contains a similar overview of the ASSA500 model. Appendix three explains how the ASSA starting population for 1985 was derived. The fourth, fifth and sixth appendices explain the assumptions used in the model for fertility, mortality and immigration respectively. Appendix seven explains the calibration process used in the model.

Doyle, P. (1993)

The dmographic impact of AIDS on the South African population

In: Cross, S. and Whiteside, A. (eds) Facing up to AIDS: The socioeconomic impact in Southern Africa, Macmillan, London

Groenewald, C (2000)

Northern Cape: The demographic impact of HIV/AIDS

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

Groenewald compares the differences between the low and high impact scenarios for the Northern Cape. These scenarios were developed by Calitz of the Development Bank of South Africa. The author notes that, of the nine provinces, the Northern Cape has the second lowest prevalence of HIV. Nevertheless, despite the increased mortality rate and lower life expectancy (a drop of over ten years to 50.8 years in 2011) the population will still tend to age slightly. The median age in 2011 will rise from 25.9 (low impact scenario) to 26.58 years (high impact scenario).

Health Economics and HIV/AIDS Research Division (HEARD)

The impact of HIV/AIDS in KwaZulu-Natal: lessons for equitable and efficient health reform policy

Unpublished report

Herdt, G. (1997)

Sexual cultures and population movement: implications for AIDS/STDs

In: Gilbert Herdt (ed) Sexual cultures and migration in the era of AIDS: Anthropological and demographic perspectives, Oxford University Press, Oxford, England,pp3-22

ING Barings (1999)

The demographic impact of AIDS on the South African economy

ING Barings, South Africa

This study sets out to determine the demographic changes to the South African population by age, skills level and economic sector brought about by the AIDS epidemic. For the total population, HIV infections are forecast to peak at 16% in 2006. Among the economically active, HIV infections will peak at a higher 22%. It is suggested that mining, government, transport, construction and consumer manufacturing will be the highest impacted. Cost impacts include higher benefit payments, costs of rehiring and retraining, and indirect costs of productivity. A key factor likely to lower potential GDP growth after 2005 is the diversion of funds away from savings to pay for the costs of the illness.

Kalipeni, E. (2000)

Africa: a comparative and vulnerability perspective

Social Science and Medicine, 50 (7-8):965-83

Using a vulnerability and comparative perspective, this paper examines the status of health in southern Africa highlighting the disease complex and some of the factors for the deteriorating health conditions. It is argued that aggregate social and health care indicators for the region such as life expectancy and infant mortality rates often mask regional variations and intra-country inequalities. Furthermore, the optimistic projections of a decade ago about dramatic increases in life expectancy and declines in infant mortality rates seem to have been completely out of line given the current and anticipated devastating effects of the HIV/AIDS pandemic in southern Africa. The central argument is that countries experiencing political and/or economic instability have been more vulnerable to the spread of diseases such as HIV/AIDS and the collapse of their health care systems. Similarly, vulnerable social groups such as commercial sex workers and women have been hit hardest by the deteriorating health care conditions and the spread of HIV/AIDS. The paper offers a detailed discussion of several interrelated themes which, through the lens of vulnerability theory, examine the deteriorating health care conditions, disease and mortality, the HIV/AIDS situation and the role of structural adjustment in the provision of health care. The paper concludes by noting that the key to a more equitable and healthy future seems to lie squarely with increased levels of gender empowerment.

Kamuzora, C.L. (2000)

The demographic impact of HIV/AIDS in Africa

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

Contrary to most of the recent works this article is typified by an ëoptimismí regarding the demographic impact of AIDS. The author concludes an examination of UN projections and its impact of age profiles is a ëbitter sweet scenarioí. The author finds that populations of Africa will continue to grow and remain young due to the momentum in the young age structures, from past and current high fertility, offering relief to fears of being wiped out. This is justified by the disease being epidemical (only) on ësmaller locationsí. The conclusions are probably due to the authors reliance on curiously dated UN projections from the late í80s and early í90s. This allows the author to accept, as a working hypothesis, that fertility rates would not be affected if ëHIV prevalence is small, eg. maximum of 15% so far observedí. By relying on this information neither South Africa nor Botswana is identified as being part of the epidemic. Similarly, the epidemic is typified by the author as a largely urban phenomenon.

Kelly, K. (2000)

Communicating for Action: A contextual evaluation of youth response to HIV/AIDS

Beyond Awareness Campaign, Department of Health, South Africa

This paper presents the findings of a study of youth attitudes, perceptions and knowledge at six sentinel sites in South Africa. The sites are diverse and range from rural sites in the Eastern Cape to a tertiary institution in the Northern Province. The study concludes that among the youth there is both regular exposure to HIV/AIDS information and a generally high perception of vulnerability. It also points to the accessibility of condoms and their fairly widespread (albeit inconsistent) use. It however points to an underplaying by the media of other preventative measures including ëbeing faithfulí and abstinence. The report suggests that discontinuation of sexual activity is an option that is least strongly supported by the media but may be an attractive option for a ësurprisingly high proportion of youthí.

Kongsin, S. and Watts, C. (2000)

Conducting a household survey on economic impact of chronic HIV/AIDS morbidity in rural Thailand: Methodological issues

International AIDS Economics Network (IAEN) Conference, Durban

This paper concentrates entirely on the practical issues in conducting a household survey in a rural village type setting. The study seeks to identify the impact of communal coping mechanisms on how households deal with AIDS. The paper describes how the study was structured without presenting any findings. The study is in effect one on the impact on households of prolonged morbidity (probably attributable to AIDS). This impact is to be compared to a control group of similar size. The issues raised are with respect to eliciting participation, involving community leaders etc. It will probably be of use in any similar South African study.

Kremer, M. (1996)

Integrating behavioral choice into epidemiological models of AIDS

National Bureau of Economic Research, Working Paper 5428, Cambridge, MA, USA

Increased HIV risk creates incentives for people with low sexual activity to reduce their activity, but may make high-activity people fatalistic, leading them to reduce their activity only slightly, or actually increase it. If high-activity people reduce their activity by a smaller proportion than low-activity people, the composition of the pool of available partners will worsen, creating positive feedbacks, and possibly multiple steady state levels of prevalence. The timing of public health efforts may affect long-run HIV prevalence.

Kustner, H.G., Swanevelder, J.P. and van Middelkoop, A. (1998)

National HIV surveillance in South Africa: 1993-1995

South African Medical Journal, 88 (10):1316-20

Lincoln, D.W. (1998)

Reproductive health, population growth, economic development and environmental change

MRC Reproductive Biology Unit, University of Edinburgh Centre for Reproductive Biology, United Kingdom

World population will increase by 1 000 million, or by 20%, within ten years. Ninety-five per cent of this increase will occur in the south, in areas that are already economically, environmentally and politically fragile. Morbidity and mortality associated with reproduction will be greater in the current decade than in any period in human history. Annually, 40-60 million pregnancies will be terminated and 5-10 million children will die within one year of birth. AIDS-related infections, e.g. tuberculosis, will undermine health care in Africa (and elsewhere) and in some places AIDS-related deaths will decimate the work-force. The growth in population and associated morbidity will inhibit global economic development and spawn new problems. The key issues are migration, the spread of disease, the supply of water and the degradation of land, and fiscal policies with respect to family planning, pharmaceuticals and Third-World debt. Full education, particularly of women, and more effective family planning in the south have the power to unlock the problem. Failure will see the developed countries, with their 800 million population, swamped by the health, economic and environmental problems of the south, with its projected population of 5 400 million people for the year 2000.

Lurie, M. (1999)

Seeing the whole picture

AIDS Action, 6 (44)

The Hlabisa project based in northern KwaZulu-Natal, South Africa, studied the prevalence of HIV and sexually transmitted diseases (STDs) in migrant and non-migrant couples. The study participants were screened for HIV and STDs, counselled, and given health education. The findings show that migrant couples have a much higher HIV discordance and prevalence than non-migrant couples. However, according to the findings, only women were HIV positive, while their migrant partners were HIV negative. Thus, all migrants and their partners were treated for STDs and given health education. Access to health services is crucial, as is creating sustainable rural development programmes that offer local employment.

Lurie, M., Harrison, A., Wilkinson, D. and Abdool Karim, S. (1997)

Circular migration and sexual networking in rural KwaZulu-Natal: implications for the spread of HIV and other sexually transmitted diseases.

Health Transition Review, Supplement 3:17-27

Patterns of migration do not simply arise out of chance. In South Africa, for example, migration patterns are a result of decades of legislation aimed at restricting the movements of the majority of the population and providing a steady flow of cheap black labour to the gold mines and other industries. In the new democratic South Africa, restrictive laws have been lifted, but circular migration remains a way of life for several million black South Africans. This paper examines the social and epidemiological implications of widespread circular migration from the perspective of a rural South African Health District. In particular, we report our findings on the patterns and prevalence of migration into and out of the Hlabisa Health District in rural KwaZulu-Natal, and the patterns of sexual networking of migrants and their rural partners. We conclude by examining the implications of these patterns of migration and sexual networking for the spread of HIV and other STDs.

MacPhail, C., Campbell, C., Williams, B., and van Dam, J. (2000)

Gender and the relative risk of HIV infection amongst young men and women in a South African township

13th International AIDS Conference, Durban

Data was collected as part of a study of gender and the relative risk of HIV infection in a South African township which is being used to inform an intervention to reduce transmission of HIV. If interventions such as these are to succeed in managing the spread of infection, it is important to understand the patterns of infection and the way in which social, economic and biological factors might combine to make young women particularly vulnerable to infection. By examining relative infectivity amongst young men and young women, and examine the extent to which such differences are associated with four behavioural factors. A random community survey to measure rates of HIV and STDs was conducted in 1998 amongst Carletonville residents aged 13-59 years. Within this sample 600 young people aged between 13 and 25 years were identified. Analysis of variance was conducted on the data. It was found that young women had greater HIV rates than their male peers. At age 20, 43% of females were infected compared to 9% of men. Differences in infection cannot be attributed to age at first sex as the mean ages at first sex were not significantly different. Among young women the risk of infection was found to increase by 25% per partner while for young men this figure was 8% per partner after the third partner. The number of partners reported by men and women differed slightly but were statistically significant. Women were found to have partners older than themselves, and thus have higher HIV rates than their partners. The reverse was true for men. This explains some of the differences in infection rates but is not a full explanation. While some of this difference may be explained by women's higher biological vulnerability to infection, the influence of sexual networks and violence require further exploration.

Makinen, M., Waters, H., and Rauch, M. (1999)

Conventional wisdom and empirical data on inequalities in morbidity, use of services and health expenditures

Partnerships for Health Reform, Abt and Associates, Maryland

The paper summarizes conclusions from eight country-specific studies of inequalities in the allocation of resources in the health sector. The case studies include South Africa and Zambia. The study concludes that conventional wisdom regarding resource allocation and health status may be misleading. For example, ëthere is no consistent pattern that richer households are more likely to use private providersí. They conclude that using conventional wisdom concerning inequalities in the health sector could result in misguided policy decisions.

Martins, J.H. (1996)

Global population growth and structural changes in the RSA population, 1951-2011

Bureau for Market Research, South Africa

The South African population is expected to grow at a rate of 1,7% per annum from 42.1 million in 1996 to 54.1 million in the year 2011. If AIDS deaths continue at the current rate, the population may be three quarters of a million less than the projected 54.1 million. Three concerns about rapid population growth in developing countries are: that rapid population growth reduces the rate of economic growth by reducing investments in human capital; rapid population growth itself has negative externalities for the environment, leading in some scenarios to degradation of natural resources at the local and national level; and rapid population growth has negative ëpecuniaryí externalities, that is, it reduces the income of some groups (particularly the poor) in comparison with other groups, and therefore exacerbates the problems of poverty and income inequality in developing countries. The effect of the worldís population growth on poverty and the environment, as discussed in the report, should be a lesson to South Africa.

Matebeni, Z. (2000)

Has South Africa turned the corner? Reassessing the recent HIV prevalence rates

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

Matebeni shows that the unweighted ANC surveillance data presented by the Department of Health both overstates the prevalence of HIV and understates the decline in HIV rates for the period 1998 to 1999. Matebeni attributes this difference to departmental mis-weighting by race, province and age group.

Mboweni, G. S. (2000)

The demographic impact of HIV/AIDS on the Northern Province

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

Mboweni reviews the available statistics on HIV/AIDS prevalence in the province. The 1999 prevalence rate (based on ANC attendance) was 11% versus 22.8 % nationally in 1998. Mboweni attributes the ëhighí prevalence to a number of factors including sexual mores, poverty, internal migration and ignorance.

McKenzie, A. (2000)

The possible impact of HIV/AIDS on fertility decline in South Africa

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

This paper argues that fertility is far more variable than previously believed. The challenge for demographers is to recognise this historical fluctuation. Given the current fertility decline of the last 30 years and the impact of the AIDS pandemic on fertility and CBR, it is likely that the decline will speed up. To some this is the natural process as spelled out in the DTT. But, CDR has increased and part of this fertility decline is not due to factors that played themselves out in the fertility decline in developed countries. Thus, to assume that fertility will continually decline (in line with the DTT) is only one of several scenarios. More likely, with depopulation, fertility (in the medium term) will rise to compensate.

Medical Research Council (1999)

1998/9 annual report: Health impact and transformation report, South Africa

Medical Research Council, 1999

Meidany, F., Horikoshi, Y., Lewis, D., Rhode, J., Kutu, M., Mayana, V., and Ntoto, A. (2000)

Relationship between HIV prevalence and population density: The Eastern Cape experience

Poverty and inequality: The challenges for public health in South Africa Conference, Epidemiological Society of Southern Africa (ESSA), East London

Meidany et al assume that the HIV rate observed at sentinel sites in the Eastern Cape approximates the rate for the magisterial district in which the site is located. They then correlate population density and HIV prevalence. They found that there is a statistically significant correlation between the two variables ñ as population density increases so does the HIV rate (at a given point in time) HIV rate = 0.09*log (population density) +0.018. The authors reproduce results from the antenatal survey in the Eastern Cape showing the prevalence of the disease by health region, age category and area type.

Nannan, N. (2000)

Estimating childhood mortality in South Africa

Poverty and inequality: The challenges for public health in South Africa Conference, Epidemiological Society of Southern Africa (ESSA), East London

The 1996 Census and the 1998 Demographic and Health Survey are used to definitively estimate levels of childhood mortality from 1983-1996. The national pattern which emerges from both sets of data show the same trend over time. The provinces reveal huge disparities in terms of the levels of infant and under-five mortality. The findings confirm that improvements over time have been achieved, but there is a distinct reversal of this trend around 1992, when these indices begin to increase. These differences and their determinants are explored.

Nannan, N. (2000)

An overview of the demographic impact of the HIV/AIDS epidemic in the Free State

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

A series of overheads, tables and graphs detailing the prevalence and anticipated impact of HIV/AIDS in the Free State at provincial level.

Nannan, N., Timaeus, I.M., Bradshaw, D., Dorrington, R. (2000)

The impact of HIV/AIDS on infant and child mortality in South Africa

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

A generalised HIV epidemic can have a major impact on the trend in all-cause infant and child mortality. This paper investigates recent trends in infant and under-five mortality in South Africa using two new sources of data ñ the 1996 Census and the 1998 Demographic and Health Survey. The paper concludes that child mortality in South Africa are rising rapidly. The increase is about what one would expect on the basis of the prevalence of HIV infection reported in the annual antenatal surveys. This rise in mortality can be attributed to paediatric AIDS.

National Population Unit (2000)

Population, poverty and vulnerability: The state of South Africaís Population Report 2000

National Population Unit, Department of Social Development, South Africa

Nzila, N., Edidi, B., Kolo, M. and Engele, B. (2000)

Factors that may explain the differences between HIV prevalence in countries surrounding the Democratic Republic of the Congo

13th International AIDS Conference, Durban

For more than a decade, HIV prevalence has been stable around 4-8% in the general population in Kinshasa, DRC, while it has increased dramatically in the neighbouring countries. The authors examined several health, education, demographic, economic indicators published by UNICEF and correlated them to HIV prevalence. They review the literature on determinants of HIV epidemic in the DRC and in its nine surrounding countries (Angola, Burundi, Central African Republic, Congo, Rwanda, Sudan, Tanzania, Uganda, Zambia). Affluence, poverty and inequality based on gender all help in the spread of HIV (GNP per capita: US$110-670 ; male adult literacy rate: 52-87%; female adult literacy rate: 29-71%). Male circumcision (0-100%) is associated with low HIV prevalence (2.3-20.1%) in the general population. Percentage of male (15-40%) visiting a core group of female highly HIV infected sex workers (5-88%) contribute to the spread of HIV. Percentage of married women aged 15-19 years currently using oral contraception (8-26%) and cigarette smoking are simply markers of high-risk sexual behaviour. Older men are increasingly having sex with much younger girls in the hope that they are not infected. It is concluded that in Africa, cultural practices, behaviours and beliefs may explain differences between HIV prevalence rates in different countries. There is a need to look carefully at certain cultural sexual practices and behaviours such as anal intercourse, during menses, insertion of vaginal products, dry sex practice, contact with female commercial sex workers, initiation rituals and widow inheritance.

Pham-Kanter G.B., Kanter A, Spencer, D.C., and Steinberg, M.H. (1998)

Characterising an epidemic: 10 years of patient attendance at a South African HIV clinic

12th International Conference on AIDS, Geneva

South Africa has experienced a dramatic rise in the number of patients infected with HIV. Using an observational database from the Johannesburg Hospital HIV Clinic, the authors describe the changes in HIV clinic attendance over a ten year period by disease severity and patient demographics. Patient data from a retrospective, longitudinal, computerized observational database of comprehensive clinical records of > 2 100 patients, seen between 1985 and 1995, were used. Automated disease staging was performed at each visit. For the analysis, cross-tabulations were performed, and a Poisson regression was used to identify determinants of visit frequency. Initial visits by white, male, homosexual patients plateaued around 50-100/year in 1989, while visits from heterosexual black patients had risen exponentially since 1989. In 1993, the number of new women attending the clinic exceeded the number of men. The ratio of asymptomatic visits to AIDS visits had remained constant (2:1) throughout the epidemic. The predictors of visit frequency were CD4 count and the number of new opportunistic infections and secondary indicators (p < 0.01). There was a weak negative association between visit frequency and the use of personal funds for medical care (p < 0.05). Gender and race/ethnicity were not associated with the number of visits. It is concluded that women and black patients make up the largest and fastest growing patient population, and therefore, special attention should be placed on their care. Two-thirds of all patients seen in the clinic are asymptomatic and could be cared for in a less-intensive environment. Severity of illness and economic resources are important determinants of clinic visits, but demographic factors such as race and gender are not.

Pisani, E. (1997)

The socio-demographic impact of AIDS in Africa

African Journal of Reproductive Health, 1 (2):105-7

Schivte, M. (1998)

Poverty and the role of men and women in the spread of HIV and AIDS in the African subcontinent ñ situation analysis

12th International Conference on AIDS, Geneva

Poverty influences in a negative manner life expectancy at birth in developing countries around the world but more so in Africa, especially in sub-Saharan Africa where the situation of HIV and AIDS has become very critical. Morbidity and mortality among young age groups, and also among the children under the age of five, are significantly increased in poverty stricken circumstances. HIV/AIDS seems to move from older men to younger women in developing African countries, confirming the ëSugar Daddyí phenomenon. Rape, forced sex, polygamy are some of the ways in which the infection is also spread. Women on the other hand are often innocent victims. In developing situations female condoms are unavailable and where they are, it becomes impossible, economically or culturally to acquire this empowerment. Children born with HIV are on the increase as young mothers are infected. Clearly, observations in poor communities show that poverty, status of men and women in society, play a determinant and major role in the spread of HIV/AIDS. Alleviation of poverty is not only the way towards sustainable development, but can have a significantly positive impact on the spread of HIV/AIDS. Change of attitudes, improvement in socioeconomic and legal situation of women and population in general, has a positive impact on HIV/AIDS.

Schlemmer, L. (2000)

The demographic, social and economic geography of South Africa over the next quarter century, under the impact of HIV/AIDS

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

The paper first established a framework of Cohort-Component Forecasts of the future population of SA incorporating the ASSA600 HIV/AIDS model, in two ëscenariosí up to the year 2025, as well as broad future economic scenarios over the same period. Thereafter, the detailed future distribution of the population and itís broad socioeconomic circumstances as well as patterns of GGP growth are estimated and interrelated to provide pictures of the socioeconomic geography of the country in the longer-run future. The implications of the results will be explored in terms of broad social needs as well as needs for services, with due consideration of the uncertainties that attend all longer-range forecasting.

Shao, P. (2000)

The impact of HIV/AIDS on the low cost housing in Gauteng Province

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

After undertaking a study in KwaZulu-Natal to learn how its sister department is coping with the epidemic, the Gauteng Department of Housing commissioned research that would later translate into policy on approaches to be used by the department in catering for people infected and directly affected by the epidemic. The object of the research was to focus on geographic spread of the epidemic, that is ascertaining local authorities with high prevalence, settlement forms which are highly affected, eg. formal settlement, informal settlement, inner city, rural and urban settlements. Efforts to identify the migration patterns of the PWAs and their income levels were made.

Shell, R. (2000)

Yangeníinkomo endlwini. The cow enters the hut: AIDS in the poorest province of South Africa, 1976 to 2001

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

In this paper Shell presents an overview of the past and anticipated effect of AIDS in the Eastern Cape. The overview includes an examination of vectors such as migrant labour, prisons, army bases (Trojan Horses) , the transport infrastructure, STDs, Tuberculosis, etc. He points to the under-representation of the rural parts of the province in the antenatal survey. Shell speaks to cultural transmission factors in the region: nuptuality rates and traditional marriage patterns, circumcision, sex workers, myths (notably that sex with a virgin will cure AIDS) etc. He also presents a summary of patterns of transmission for region ëAí which indicates that in 43% of cases the method of transmission is not known and that five of the nine modes of transmission are almost certainly under-reported.

Shell, R. (2000)

Halfway to the holocaust: The economic, demographic and social implications of the AIDS pandemic to the year 2010 in the southern African region

In: Shell, R., Quattek, K., Schönteich, M. and Mills, G., Occasional Papers, Konrad Adenauer Stiftung, Johannesburg, South Africa

Southall, H. (1993)

South African trends and projections of HIV infection

In: Cross, S. and Whiteside, A. (eds) Facing up to AIDS: The socioeconomic impact in Southern Africa, Macmillan, London

Stillwaggon, E. (2000)

Determinants of HIV transmission in Africa and Latin America

International AIDS Economics Network (IAEN) Conference, Durban

Stillwaggon indicates that the fight against AIDS may be compromised by erroneously typifying the African situation as a special case. She indicates that the error stems from inadequately proven assumptions of African sexuality as a special case. These assumptions resulted in programmes emphasising behavioural modification rather than economic and biomedical factors. Consequently, efforts have centred on, for example, the promotion of condom use rather than the eradication of poverty and income inequality. The paper pursues the premise that ëeconomic and biomedical factors that are conventionally associated with greater susceptibility to infectious diseases in general will also be important determinants of HIV transmission in poor countriesí. She consequently outlines the impact of poverty, malnutrition, parasitosis, labour migration and the dislocation of populations, lack of access to health care and medicines, prostitution, street children and lack of awareness of prevalence. She presents a regression of AIDS rates for 20 Latin American countries on per capita GDP, urbanisation rate, nutritional status and international migration. The model is statistically significant with the regression coefficients running in the expected direction ñ except for real per capita GDP which has a positive coefficient.

Stover, J. (1996)

The future demographic impact of AIDS: What do we know?

The Futures Group International, Washington DC

Stover presents overviews of the projection models used by the United Nations the U.S. Bureau of the Census, the Population Council and the World Bank. He compares the three models and finding dramatic differences in their projections for African countries, attempts to account for the differences.

Swanevelder, J.P. (1998)

The South African HIV epidemic, reflected by nine provincial epidemics, 1990-1996

South African Medical Journal, 88 (10):1320-5

Tembo, G. (2000)

An overview of the epidemiology of HIV in Africa

In: HIV/AIDS in the commonwealth 2000/1, Commonwealth secretariat, Kensington Publications, London

Growing evidence from Senegal and Uganda shows that a strong combination of firm political support, broad institutional participation and carefully selected programme interventions can lead to a decline in the number of new HIV infections, and to improved care for those who are ill. The need to create a supportive and open environment in the community and to raise general awareness cannot be overstated. In most countries communities are responding innovatively and spontaneously, and such responses must be grasped and expanded to other communities. HIV/AIDS programmes must integrate both prevention and care aspects, and must be flexible and adapt to emerging knowledge.

Timaeus, I., Bradshaw, D., Dorrington, R., and Nannan, N. (2000)

Reversal in adult mortality trends in South Africa

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

The authors emphasise that the current projections do not indicate how many people are actually dying from AIDS. This can only be obtained by measuring mortality. The study analyses data from the vital registration statistics, household surveys and the 1996 Census to reveal indices of mortality and of the probability of dying between the ages of 15 and 60 in particular. Despite inconsistencies in the data ëthe results suggest that adult mortality declined rapidly until the mid 1970s and then more slowly until the early 1990s. Since then, adult mortality has risen at an accelerating rate.í

UNAIDS (2000)

Guidelines for second generation HIV surveillance

UNAIDS, Geneva

This report presents an overview and critique of existing methods of measuring the prevalence of HIV/AIDS. It points to the diversity of national experiences and the resultant need to have a range of tools for the effective monitoring. It emphasises that the primary roles of surveillance and measurement are to identify groups at risk (and thus optimally target interventions) and to create awareness and understanding of the epidemic The report suggests objectives for a second generation approach to surveillance. The proposed instruments build on those already established yet have additional features including: They should allow for continuing comparisons of trends; be flexible and adjust to the way the disease changes; should focus on populations and sub-populations at risk; biological and behavioural data should validate each other; information from other sources (eg. TB prevalence) should be integrated into the systems. Derived information must be used to design and promote preventative interventions and to measure change. Distinct strategies are proposed for countries with a) low level incidence b) where incidence is concentrated in sub-populations and, c) where there is a generalised epidemic. South Africa falls into the latter category. Here surveillance should track changes and indicate the effectiveness of prevention programmes. Particular attention is indicated for examining the infection rates among men, the age at infection (both sexes) and monitoring morbidity and mortality. The need to collect data coupled with population characteristics (ethical issues notwithstanding) is a defining characteristics of the new generation of surveillance as it is required, inter alia, to identify sub-populations at risk and allow for comparisons between the clinic populations with the general population.

UNAIDS (2000)

Report on the global HIV/AIDS epidemic

UNAIDS, Geneva

This report firmly locates the AIDS epidemic as a developmental problem and a security issue. It gives prominence to the situation in sub-Saharan Africa. The report points to both the magnitude of the problem in this area as well as the successes achieved in Uganda and Zambia. The latter are explicitly related to changes in sexual practices other than the wide-scale adoption of condom use. The text offers overviews of the scale and nature of the epidemic by continent. The data used is drawn from a variety of sources including the US Census Bureau, Macro Internationalís DHS surveys and UNICEF. The report also offers overviews of the climates in which the epidemic is left unhindered. The second half of the book deals with an overview of the responses to the epidemic in terms of care counselling and policies. The annexures cover the reliability of the projections and summarises (by country) prevalence rates and counts, prevention indicators and some indications of the reliability of the estimates.

UNAIDS (2000)

Surveys on sexual behaviour

UNAIDS, Geneva

An overview of types of data available from recent surveys of sexual behaviour across the world. The 25 surveys were carried out by the global programme on AIDS and were aimed at providing information on knowledge, attitudes and behaviour with regard to AIDS.

UNAIDS (1999)

The UNAIDS Report

UNAIDS, Geneva

United Nations Development Programme

Opening up the HIV/AIDS epidemic

United Nations Development Programme (UNDP), Geneva

United States Agency for International Development (USAID) (1998)

HIV/AIDS in the developing world

United States Agency for International Development (USAID), Washington

The report ranks the progressive decline in fertility rates and HIV/AIDS as the demographic events that have ësoftenedí the surge in human numbers. The report presents a range of measures (life expectancy, population growth rate, death rates etc.) for a number of developing countries including South Africa. For each rate a with-AIDS and without-AIDS rate is presented. The figures are largely based on US Census Bureau estimates ñ often using unpublished tables.

van Aardt, C. (2000)

Guestimating the number of AIDS related mortalities and AIDS medical impacts

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

There is a great deal of uncertainty regarding the number of AIDS-related mortalities in South Africa. Estimates range from 65 000 to 140 000 (1999). A method was reviewed to provide a more accurate picture. This allows for projections of hospital bed days, drug costs and other contingencies.

Weir-Smith, G (2000)

Demographic characteristics of HIV/AIDS communities

Joint Population Conference: The demographic impact of HIV/AIDS in South Africa and its provinces, Port Elizabeth

The consequence of HIV/AIDS places significant burdens on the health systems, labour forces and economies of these countries. A thorough understanding of the communities with a high incidence of HIV/AIDS is needed in terms of the following: their socioeconomic characteristics, access to services and infrastructure and the impact on the local economy. Statistics on HIV/AIDS in South Africa are scarce and incomplete in terms of geographical distribution. In order to shed some light on this issue the Human Sciences Research Council analysed data from a recent national survey. Data on HIV/AIDS prevalence was collected during this national survey. The survey data was collected at a community level and extrapolated to a police station level with the use of neural networks. The socioeconomic profiles of these communities will be explained using a combination of demographics based on the 1996 Census and data captured from the survey. Placing the HIV positive individual in a community perspective will help to understand and correctly address the problem. The identification of trends and characteristics will help to develop strategies and policies, provide the needed HIV/AIDS treatment and implement relevant campaigns.

Whiteside, A. (1999)

Projecting the epidemic: policy makers and planners needs

In: The socio-demographic impact of AIDS in Africa. Based on the conference organised by the Committee on AIDS of the International Union for the Scientific Study of Population (IUSSP) and the University of Natal, Durban, South Africa, Liege, Belgium

In general, policy-makers and planners in developing countries have not responded to the AIDS epidemic and or its consequences, partly due to denial and partly out of ignorance of the magnitude of the problem and what can be done about it. This inaction is both frustrating and inexplicable. The author considers the implications of the epidemic and how demographers should respond. The implications of the HIV/AIDS epidemic are first described, followed by what planning attempts to do, efforts to put HIV/AIDS into policy making and planning, why issues are not considered, what can be done, and how such action can be taken. The HIV/AIDS epidemic will have demographic, economic, and development effects upon the country. Experiences including AIDS in planning are described for Swaziland and KwaZulu-Natal.

Wilkinson, D. and Dore, G. (2000)

An unbridgeable gap? Comparing the HIV/AIDS epidemics in Australia and sub-Saharan Africa

Australia and New Zealand Journal of Public Health, 24 (3):276-80

Comparison of key indicators of the epidemic in Australia, and Africa are reviewed largely through the experience of the Hlabisa health district, South Africa. To the end of 1997, for all Australia, the estimated cumulative number of HIV infections was approximately 19 000, whereas in Hlabisa 31 000 infections are estimated to have occurred. Compared with the low and declining incidence of HIV in Australia (< 1%), estimated incidence in Hlabisa rose to 10% in 1997. In all, 94% of Australian infections have been amongst men; in Hlabisa equal numbers of males and females are infected. Consequently, whereas 3 000 children were perinatally exposed to HIV in Hlabisa in 1998 alone, 160 Australian children have been exposed this way. In Australia, HIV-related disease is characterised by opportunistic infection whereas in Hlabisa tuberculosis and wasting dominate. Surveys among gay men in Sydney and Melbourne indicate > 80% of HIV infected people receive antiretroviral therapy whereas in Hlabisa these drugs are not available. It seems possible that Asia and the Pacific will experience a similar HIV/AIDS epidemic to that in Africa. Levels of HIV are already high in parts of Asia, and social conditions in parts of the region might be considered ripe for the spread of HIV. As Australia strengthens economic and political ties within the region, so should more be done to help Pacific and Asian neighbours to prevent and respond to the HIV epidemic.

Williams, B. and Campbell, C. (1998)

Understanding the epidemic of HIV in South Africa. Analysis of the antenatal clinic survey data

South African Medical Journal, 88 (3):247-51

This article analyses the magnitude and the time course of the HIV epidemic in the provinces of South Africa from the antenatal clinic HIV surveys. Data on the provincial prevalences of HIV infection from 1990 to 1996 were analysed using maximum likelihood methods to determine the intrinsic growth rate and probable asymptotic prevalence of HIV among women attending antenatal clinics. The subjects were women attending antenatal clinics and included in the national HIV prevalence surveys conducted by the Department of Health. Analysis showed that in KwaZulu-Natal the epidemic is likely to peak at a prevalence of about 23% (95% confidence interval (CI) 19-36%). The intrinsic doubling time does not differ significantly among the provinces. The average length of the intrinsic doubling time is 12 months (95% CI 11.3-12.8 months). The force of infection is approximately 1/year at age 16 years and declines at a rate of about 5% per year of age above 16 years. It is concluded that South Africa is likely to experience one of the worst HIV epidemics in Africa. The lack of statistically significant differences between the growth rates of the epidemic in the various provinces constrains the possible explanations that can be advanced to explain the time course of the epidemic and may in part be a consequence of migrancy. The intrinsic growth rate is higher than previous estimates and it is possible that in those provinces where the prevalence is still low it will eventually reach the same levels as in KwaZulu-Natal.

Williams, B., Gouws, E. and Abdool Karim, S. (2000)

Where are we now? Where are we going? The demographic impact of HIV/AIDS in South Africa

Journal of South African Science, 96 (6)

Demographic forecasting models of the South African population, incorporating geographical distribution and age prevalence data on HIV infection, have been used to predict future mortality due to AIDS. In the year 2010, approximately 500 000 AIDS-related deaths are predicted, up from 100 000 this year. If anything, these models have underestimated the course of the epidemic so far. There is a need for better models to understand the dynamics of AIDS as well as to measure the effects of co-factors, in order to marshal the most effective response nationally.

The impact on sectors

Association of Commonwealth Universities and University of Natal (1999)

The social, demographic and development impact of HIV/AIDS: Commonwealth universities respond

Association of Commonwealth Universities and the University of Natal

Badcock-Walters, P. (2000)

AIDS Briefs for sectoral planners and managers: Education Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

While the potential impact of the pandemic on the education sector is profound in general terms, it is in a developing country context that the problem presently looms largest. Contextual reasons for this particular vulnerability include a higher incidence of social instability, comparatively dysfunctional education systems, higher attrition, repetition and dropout rates, and the problem of over-aged enrolment. These factors combine to create an environment in which limited numbers of system managers and under-qualified and under-resourced educators wrestle with large numbers of disparately aged learners whose home lives are all too often touched by poverty, violence and social turbulence. Exacerbating these problems, the sector is characterised by the lack of hard data on seroprevalence, an absence of policy, limited management skills and depth, and often ill-disciplined and consequently dangerously exposed educators. Add to this a disproportionately large number of overage and sexual active learners, already reflecting infection rates in the wider population of the same ages, and the system is in effect a high-risk breeding ground for infection instead of being a pre-employment area of containment. It is an opportunity presently ignored or squandered to a large extent through ignorance, wilful negligence or lack of knowledge or resources. Given the unique opportunity presented by the education system to play a central role in prevention, it is extraordinary that it has been largely ignored. To reverse this position, political and bureaucratic will is required, as is community interaction and the engagement of the private sector.

Badcock-Walters, P. and Whiteside, A. (1998)

HIV/AIDS and development in the education sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

Barnett, T. (2000)

AIDS Briefs for sectoral planners and managers: Subsistence Agriculture Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

Subsistence agriculture consists of a range of rural livelihood strategies. These strategies may increase susceptibility to HIV infection (for example through seasonal labour migration or through trading activities) and this group are particularly vulnerable to the impact of AIDS (for example through disruption of the domestic-farm labour interface). Responses must take account of general development problems and seek to enhance existing household and community coping mechanisms.

Baxter, R. (1996)

The economics of South African mines, in HIV/AIDS Management in South Africa: Priorities for the Mining Industry

In: HIV/AIDS Management in South Africa: Priorities for the Mining Industry, Williams, B.G. and Campbell, C.M. (eds). Epidemiology Research Unit, Johannesburg

Charlton, K. et al (1996)

Poverty, human rights and the health status of farmworkers in the Western Cape: Challenges for the health services

In: HIV/AIDS Management in South Africa: Priorities for the Mining Industry, Williams, B.G. and Campbell, C.M. (eds). Epidemiology Research Unit, Johannesburg

Churchyard, G. (1996)

Of soil and seed: HIV related TB on the mines¥

In: HIV/AIDS Management in South Africa: Priorities for the Mining Industry, Williams, B.G. and Campbell, C.M. (eds). Epidemiology Research Unit, Johannesburg

Cohen, D. (1999)

The HIV epidemic and the education sector in sub-Saharan Africa

Issues Paper 32, United Nations Development Programme (UNDP), Geneva

A functioning and effective educational sector is seen as central for achieving the goals of sustainable human development. An educated population which embodies the skills and capacities needed for development is essential if production levels are to be increased. One of the benefits of development is an educated society. In sub-Saharan Africa there has been extensive investment in human capital for many decades. This investment is threatened by the HIV epidemic. Previous as well as current investment in human capital is at risk. It follows that where resources (financial and human) are scarce, and where the HIV epidemic is systematically eroding the capacity for development, that urgent actions are needed to ensure that socioeconomic sectors do not collapse. The education sector is threatened where factors are operating that are systematically destroying what can be achieved. A functioning education system is both fundamental to achieving sustained development and eradicating poverty and to an effective response to the HIV epidemic.

Coombe, C. (2000)

Managing the impact of HIV/AIDS on the education sector

Commissioned by the UN Economic Commission for Africa (UNECA), Pretoria

Crisp, J. (1996)

AIDS programmes in the mining industry: an overview. In: HIV/AIDS Management in South Africa: Priorities for the Mining Industry

In: HIV/AIDS Management in South Africa: Priorities for the Mining Industry, Williams, B.G. and Campbell, C.M. (eds): 91-92. Epidemiology Research Unit, Johannesburg

Desmond, C. (2000)

AIDS Briefs for sectoral planners and managers: Financial Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

The financial sector is an integral part of the world economy. Investment, stability and economic growth in the developing world are dependent on the establishment and maintenance of a functioning set of financial institutions. The HIV/AIDS pandemic threatens to have, and in some cases has already had, a major impact on the sector. The sector depends on the skills of highly educated employees: if they become ill and die operations could be severely affected. The services offered by this sector often involve the assessment of risk. The HIV/AIDS pandemic threatens to complicate the situation and to increase the cost of offering some of these services. There are, however, a number of innovative responses that have emerged, and continue to evolve. These responses help limit impact, but more are needed.

Do Thi Nhu, T. and Kelly, F.P. (2000)

Migrants, labour, economics and HIV in Vietnam

Conference Paper: 13th International AIDS Conference, Durban

The vulnerability for HIV/AIDS infection of migrants and other mobile populations has been well documented. Both inter- and intra-country populations share common experiences, like less access to health facilities and prevention programmes. The responses, in terms of support, prevention activities and advocacy misses an economic analysis of the situation across the groups and system. Thus the commonalities, which can assist with better programming are rarely identified. CARAM Vietnam Action Research project with sex workers, domestic workers, migrant workers as well as employers and users (local tourists) worked on developing a systems approach to addressing mobile labourers vulnerability to HIV/AIDS. The economic model developed uses simple free market economy ësupply and demandí principles to identify the similarities between mobile and migrant groups within countries and across borders and to understand the chain of players within the systems. CARAM Vietnam developed a model and points of best impact to minimise vulnerability of migrant and mobile groups (supply side) and in some cases, ëdemandí side and the chain of players thus reducing HIV/AIDS cases. Amongst migrant and mobile labour groups, both ëdocumentedí and ëundocumentedí, common systems dictate their vulnerability to STD and HIV-infection. The economic framework developed by CARAM has proven an essential tool in effectively targeting these vulnerable groups in the system and addressing the conditions from demand sides.

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Drysdale, S. (2000)

AIDS Briefs for sectoral planners and managers: Health Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

Disorganisation and weakness in the health sector facilitates the spread of HIV. In spite of much effort, the seroprevalence rate is still climbing steeply. Until communities recognise and accept the solution lies with them, the health sector can only watch and record the advancing tide. Education must play a major role in the sectoral response. This must be supplemented by a determination to improve and strengthen health systems so they are able to provide treatments which are now available and that are, in most cases affordable. Continued support, with better co-ordinated research efforts is essential. Non-public providers of health care must be involved in the response. The health sector must take the lead in ensuring that all sectors are involved in planning an adequate response and that it is co-ordinated at the highest level.

du Guerny, J. (1999)

AIDS and agriculture in Africa: can agricultural policy make a difference?

Food and Agriculture Organisation (FAO), Geneva

While there are many dimensions to the AIDS pandemic, FAO has focused on the impact of the disease on agricultural production and household food security. This article presents a framework for analysing the problems and highlights key effects on farm households and larger production units. HIV/AIDS depletes both human resources and capital, leading to a reduction in land area cultivated, changes in crop patterns and declines in yields. Reduction in the formal and informal training of children and changing migration patterns can have negative consequences for development. Agricultural policies attempt to influence yields, commercial crop outputs, etc. Whether such policies can affect the spread and level of the HIV/AIDS pandemic or mitigate its impact have not been explored. The agriculture and health sectors need to become aware of the impact of the pandemic on production, food security and institutions. They also need to recognise there already exist a number of policy and programme tools that could be effective in reducing the vulnerability of rural populations to HIV/AIDS. At this stage, the most effective policy and programme instruments available need to be explored systematically. Efforts to mobilise agricultural institutions, both public and private, are worthwhile in the face of the present and potential damage of the pandemic. Reducing vulnerability influences the risks, but does not eliminate them. Policies to reduce vulnerability would not replace risk reduction ones, but should create positive synergies.

Engh, I.E. (2000)

HIV/AIDS in Namibia: The impact on the livestock sector

Food and Agriculture Organisation (FAO), Geneva

There is little information on the potential impact of HIV/AIDS on the livestock sector in Namibia. Moreover, the absence of sector-specific and agriculturally relevant interventions to counteract the potential negative impacts is an issue of concern for decision-makers. Because the AIDS pandemic is regarded as an important crosscutting developmental issue, it requires a multi-disciplinary approach to understand it and to intervene effectively. This note focuses on the specific impact on the livestock sector, and it suggests strategies for consideration by the sector stakeholders in order to minimise and/or mitigate the negative impacts of HIV/AIDS on livestock.

Floyd, K., Reid, A., Wilkinson, D. and Gilks, G. (2000)

The economic impact of the HIV/AIDS epidemic on the health sector in rural South Africa

Conference Paper: 13th International AIDS Conference, Durban

South Africa is experiencing one of the world's most severe HIV/AIDS epidemics. There is limited evidence concerning the economic consequences this will have for health services, especially in rural areas. The economic impact of HIV/AIDS on health services was studied in Hlabisa District, KwaZulu-Natal, South Africa, for the period 1991-1998. This is a rural area where HIV seroprevalence increased from approximately 2% to 29% (1991-8). Hospital admissions grew 81% (1991-8); increases for tuberculosis (TB) admissions (360%) and those for AIDS-defining conditions other than TB (43-fold increase) stood out clearly. HIV-attributable TB accounted for 1%, 1% and 10% of total hospital, adult medical ward and adult TB ward costs respectively in 1991; by 1998 the figures were 9%, 13% and 58%. AIDS-defining conditions other than TB accounted for 12% and 7% of adult female and male medical ward costs in 1998, compared to 1% in 1991. Early HIV-related morbidity (HIV-attributable but not TB or other AIDS-defining conditions) accounted for 2% and 10% of adult male and female medical ward costs respectively in 1998. Average length of hospital stay for TB patients fell from 81 to 18 days, limiting growth in the TB ward bed occupancy rate to 9%: the cost-effectiveness of care also improved. On the adult medical wards reductions in length of stay were much more limited and bed occupancy rates rose, reaching 200% on the adult female medical ward in 1998 compared to 123% in 1991. Approximately 1% of patients attending clinics met the AIDS surveillance case definition in 1998. The HIV/AIDS epidemic has thus had a major economic impact on hospital services in this district. The single largest impact has been HIV-related TB, but the importance of AIDS-related morbidity and early HIV-attributable morbidity ñ especially on the adult female medical ward ñ also needs to be recognised. Clinic services appear less seriously affected.

Forsythe, S. (2000)

AIDS Briefs for sectoral planners and managers: Tourism Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

A number of recommendations can be made based on a review of tourists, hotel employees and the tourism industry. The goals of such recommendations should be to limit the spread of HIV/AIDS, while not impeding the continued expansion of tourism. It is important to recognise that promoting a healthy tourism industry and HIV/AIDS prevention are not contradictory goals, and in many ways are likely to be complementary. By encouraging HIV/AIDS prevention among their employees, the tourism industry can contain the impact of the disease on their industry. Also, by developing non-discriminatory policies and practices that the entire industry must abide by, it is possible to develop stronger trust between employees and employers. This trust is an important tool for assuring that prevention programmes can be carried out successfully. Finally, it is to the benefit of the entire industry to develop an image of tourism that is caring, healthy and enjoyable, rather than dangerous and of low quality.

Foster, S. (1996)

The Implications of HIV/AIDS for South African Mines

AIDS Analysis Africa 7 (3)

While conceding the data is sparse and unreliable, this article attempts to assess the impact of HIV on the mining industry in South Africa. Mining constitutes about 20% of the GDP and its contribution to the annual growth of the GDP is thought to be about 3%. The industry has many forward and backward linkages in the economy. Each miner supports between seven and ten dependants, while the employment of each miner gives rise to one additional job in the South African economy. Remittances from mining is also very important to the economies of Lesotho, Mozambique, Swaziland and Botswana. The article is impact oriented and sketches the costs to the mining industry in terms of loss of skilled workers, absenteeism, medical and pension costs and a likely pattern of continuous fall in productivity. It urges the need to take urgent steps to slow the spread of HIV among mineworkers and in the communities surrounding the mines, particularly among the minersí partners, girlfriends and commercial sex workers. No specific suggestions ñ other than the need for more research ñ are put forward.

Fourie, I. (1996)

Health care in the mining industry. In HIV/AIDS Management in South Africa: Priorities for the Mining Industry

In: HIV/AIDS Management in South Africa: Priorities for the Mining Industry, Williams, B.G. and Campbell, C.M. (eds): 53-57, Epidemiology Research Unit, Johannesburg

Giraud, P. (1992)

Economic impact of HIV/AIDS on the transport sector: Development of an assessment methodology

Consultation on Economic implications of HIV/AIDS, United Nations Development Programme (UNDP), Geneva

Goyer, K.C. and Gow, J. (2000)

Contributing factors to increased levels of HIV transmission in South African prisoners

In press: Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

Goyer, K.C. and Gow, J. (2000)

Alternatives to current HIV/AIDS policies and practices in South African prisons

In press: Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

Goyer, K.C. and Gow, J. (2000)

The role of prison, prison conditions and government policies in increasing HIV/AIDS infection in South African prisoners

In press: Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

Kerkhoven, R. and Jackson, H. (2000)

AIDS Briefs for sectoral planners and managers: NGO Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

Developing, designing and delivering community focused interventions around HIV/AIDS by NGOs means engaging with the many complexities of the settings in which people live. NGOs must be aware of their chosen role as change agents and the responsibility and power this gives them. Raising the issue of HIV/AIDS means that this will have to involve a discussion around gender roles and responsibilities, sex and sexuality, culture, spirituality and basic needs. Education and development are about empowerment, self-esteem and being able to apply the knowledge gained. Too often the assumption is made that the mere provision of information and education will lead to effective behaviour change. By adopting a learning approach through which services and clients are linked in sequential loops of two-way communication and interaction, the NGOs will be able gain entry, deliver services, and build confidence for themselves and the community.

Kwaramba, P. (1998)

The socioeconomic impact of HIV/AIDS on communal agriculture systems in Zimbabwe

Working Paper 19, Economic Advisory Project, Frederich Ebert Stiftung, Harare

Meekers, D. (2000)

Going underground and going after women: trends in sexual risk behaviour among gold miners in South Africa

International Journal of STDs and AIDS, 11 (1):21-6.

This paper reports on secondary analysis of surveys conducted among the mineworkers of Welkom, South Africa, in 1995 and 1997 ñ before and after an AIDSCAP-funded programme of condom social marketing, peer education, and STD treatment. During this period, the composition of the labour force changed significantly as a result of developments in the industry: at the end of the intervention, miners were older and less educated. Adjusting for these differences, there were statistically significant increases in minersí personal risk perception, decreases in sexual relations with casual partners or sex workers, and increases in condom use during last sex. The conclusions are important: structural changes in the industry are resulting in riskier sexual behaviour at the mines; social marketing and other interventions appear to have been effective in mitigating these trends; and careful and thorough evaluative research is necessary if such effectiveness is to be observed.

Michael, K. (2000)

AIDS Briefs for sectoral planners and managers: Transport Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

More efficient and affordable transport means more mobility, which may inadvertently facilitate HIV transmission. Imaginative actions, however, can address this challenge and transport is a key role-players in any multi-sectoral response. Policy- and decision-makers need to consider the role of transport in disease prevention and mitigation. As the people in the sector form a small and easily targeted group, the problem is not insurmountable.

Michael, K. (1999)

HIV/AIDS and the retail sector

AIDS Analysis Africa, 9 (6):6-10.

Moore, D. (1999)

The AIDS threat and the private sector

Aids Analysis Africa, 9 (6)

The microeconomic impact of HIV/AIDS on the private sector is analysed from an actuarial perspective using the Metropolitan-Doyle model. Based on the most recently available statistics, the model projects that as of 1999, 11% of South Africaís workforce is HIV-positive and an estimated 0.6% are ill with AIDS. (These projections are likely a significant underestimation since many other sources point to much higher rates of infection.) The article outlines direct and indirect costs beyond the direct impact of the disease that have largely been ignored by companies. The indirect costs include: increased costs of recruiting and training staff; costs of additional sick and compassionate leave; negative impact on staff morale; costs of ensuring that occupational health and safety standards are adequate; dealing with prejudice amongst employees when some staff are HIV-positive; ensuring that HIV status of staff remains confidential; management and labour meetings to discuss the AIDS crisis as it develops; and loss of turnover and profits due to the impact of HIV/AIDS on clients.

Moorhead, K. and Trudeau, D. (2000)

AIDS Briefs for sectoral planners and managers: Social Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

The social sector is intended primarily to provide for those unable to provide for themselves. As economic inequality increases, peopleís economic opportunities decline, thereby greatly increasing the demands on the social sector. The HIV/AIDS epidemic is reducing investment and slowing economic growth, unemployment is exacerbated and there is a consequent increase in dependence on the social sector. The epidemic disproportionately affects the poor, not only forcing more people into poverty, but also making families already dependent on the social sector even poorer. Women and the elderly are especially hard hit, as they take on a disproportionate burden of care and may be subject to discrimination. The number of children affected by HIV/AIDS has reached alarming levels. Children who grow up deprived of adequate education or health care may increasingly depend on the State for support. The social sector must evaluate its capacity, define its limits and maintain and strengthen its existing programmes to ensure adequate family support mechanisms. The sector must also encourage the formation of partnerships to ensure an effective developmental social welfare response.

Parry, S. (2000)

AIDS Briefs for sectoral planners and managers: Commercial Agriculture Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

The success of any enterprise is invariably tied to the quality of its human resources. Consequently the loss of skilled and experienced personnel, for whatever reason, is of serious concern to any sector. HIV/AIDS, and the protracted morbidity and mortality associated with it, has a profound impact not only on medical but also on overall economic and social dimensions of life. Commercial agriculture has a greater capacity to cope with the impact of HIV/AIDS than subsistence agriculture and hence ensure food security for a country. It has more capacity to operate between both mechanised and labour-intensive practices than most other sectors. This advantage is dependent on the sector taking the initiative in safeguarding the welfare of its workforce, making contingency plans well in advance of serious impact, and collaborating with all key players to mitigate against the effects of HIV/AIDS. This requires a rethinking of policy, sound financial planning and a realistic look at the impact of viability and hence appropriate subsequent actions. Serious attention to these issues could ensure that further rural development takes place and commercial agriculture can continue to contribute substantially to the welfare and economy of countries and regions.

Rugalema, G.

HIV/AIDS and the commercial agricultural sector of Kenya

United Nations Development Programme (UNDP), Geneva

Findings of this study will show that the commercial agricultural sector of Kenya is facing a severe social and economic crisis due to the impact of HIV and AIDS. Protracted morbidity and mortality have profound financial, economic, and social costs for industry. The loss of skilled and experienced labour to the epidemic continues to be a serious concern. If agro-estates are to remain viable businesses, it will be necessary and urgent to approach the epidemic with the seriousness it deserves. This includes well-elaborated prevention programmes and concerted mitigation strategies at the company level, in collaboration with other sectors of the economy including the government, NGOs, and civil society.

Schwellnus, M.P. (2000)

AIDS Briefs for sectoral planners and managers: Sports Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

At the individual level, regular participation in physical activity is advocated as an important preventative health measure. However, the global pandemic of HIV infection is likely to influence physically active individuals. The association between HIV infection and physical activity therefore requires attention, namely the risk of HIV transmission during sport and physical activity, the effects of HIV infection on exercise performance, and the effects of regular physical activity on the outcome of HIV infection. At the macro-level, the potential of the sector to contribute to a multisectoral response to the epidemic lies in its ability to access and influence large sections of the population, particularly the youth.

Simon-Meyer, J. (2000)

AIDS Briefs for sectoral planners and managers: Construction Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

The construction sector has the potential to be significantly impacted upon by the epidemic, and, in turn, to significantly impact upon the manner in which any country deals with an epidemic. The sector is volatile and highly sensitive to economic conditions. Operating margins are slim and the cost of either the unmitigated impact of the epidemic, or of intervention, will take its toll. The sector is also mobile, and will seek international opportunities if necessary for survival. Any intervention must be pragmatic, given the cost and time restraints within daily operations.

Smart, R. (2000)

AIDS Briefs for sectoral planners and managers: Civil Service Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

Government has a leading role to play in defining a countryís response to HIV/AIDS. Its strategies should be developed in the context of sustainable human development and its policies and planning should, at all times, take account of HIV/AIDS. Individual departments should understand the profile of the epidemic within their specific areas of influence and utilise all opportunities to contribute to HIV/AIDS prevention and mitigation efforts ñ within the overall vision for the countryís response.

Smart, R. (2000)

AIDS Briefs for sectoral planners and managers: Manufacturing Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

The manufacturing sector is generally accepted as the most dynamic part of the industrial sector and a critical part of any countryís economy (whether developed or developing). HIV/AIDS has the potential to threaten the manufacturing sector at numerous points and in multiple ways. To minimise the effects of the epidemic requires concerted and sustained efforts in areas not traditionally addressed by organisations, ie. efforts aimed at minimising workforce susceptibility and organisational vulnerability. Success will be linked to understanding the current and future profile of the epidemic, measuring its impact within the workplace and on markets, and pooling resources and working in partnership to minimise new infections and mitigate the inevitable results of the epidemic.

Smart, R. (2000)

AIDS Briefs for sectoral planners and managers: Mining Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

The mining sector operates in a global market that is highly competitive and sensitive to fluctuating mineral prices. The sectorís unique use of labour and style of operations are both linked to an increased risk of HIV transmission. Understanding these creates multiple opportunities for action to prevent new infections and to mitigate the effects of the epidemic. This paper contains a contextual discussion of the industry, an impact checklist and a sectoral response, including management strategies.

Smith, J. and Whiteside, A. (1995)

The Socioeconomic impact of HIV/AIDS on Zambian business: Report for the BEAD and CDC

Commonwealth Development Corporation, London

Stally, A. (2000)

AIDS Briefs for sectoral planners and managers: Media Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

HIV/AIDS poses both challenges and opportunities for the media. The media should go beyond commenting on new initiatives for prevention, reporting on workshops or conferences and describing updated data. Their biggest challenge is to keep AIDS topical and newsworthy. Media coverage of HIV/AIDS must be transformed into respected and ëcutting edgeí forms of communication.

Stover, J. and Bollinger, L. (1999)

The Economic Impact of AIDS

The Futures Group International (The Policy Project), Washington DC

Agriculture: Studies done in Tanzania and other countries have shown that AIDS will have adverse effects on agriculture, including loss of labour supply and remittance income, loss of workers at planting or harvesting cycles can significantly reduce the size on harvest. In countries where for security is a continuous issue, any declines in household production can have serious consequences. Loss of agricultural labour is likely to cause farmers to switch to less-labour intensive crops. This may mean switching from export crops to food crops. Health: HIV/AIDS will affect the health sector for two reasons: 1) Increase the number of people seeking services, and 2) Health care for AIDS patients is more expensive than for most other conditions. The number of AIDS patients seeking care is already overwhelming health care systems. In many hospitals in Africa, half of hospital beds are now occupied by AIDS patients. AIDS is also an expensive disease ñ on average treating an AIDS patient for one year is about as costly as educating ten primary school pupils for one year. Transport: The transport sector is especially vulnerable to AIDS and important to AIDS prevention. Building and maintaining transport infrastructure often involves sending teams of men away from their families for extended periods of time, increasing the likelihood of multiple sexual partners. The people who operate transport services (truck drivers, train crews, sailors) spend many days and nights away from their families. Most transport managers are highly trained professionals who are hard to replace if they die. Mining: The mining sector is a key source of foreign exchange for many countries. Most mining is conducted at sites far from population centres forcing workers to live apart from their families for extended period. They often resort to commercial sex. Many become infected with HIV and spread that infection to spouses and communities when they return home. A severe AIDS epidemic can seriously threaten mine production. Education: AIDS affects the education sector in three ways. 1) the supply of experienced teachers will be reduced by AIDS-related illnesses and deaths. 2) Children may be kept out of school if they are needed at home to care for sick family members or to work in the fields. 3) Children may drop out of school if their families can not afford school fees due to reduced household income as a result of AIDS deaths. Another problem is that teenaged children are especially susceptible to HIV infection.

Tibaijuka, A. (1997)

AIDS and welfare in peasant agriculture in Tanzania

World Development, 25 (6)

Topouzis, D. and du Guerny, J. (1999)

Sustainable agricultural / rural development and vulnerability to the AIDS epidemic

FAO and UNAIDS Joint Publication, UNAIDS Best Practice Colleione, Geneva

Truyens, P. (1990)

AIDS and the South African life assurance industry

AIDS Scan, 2 (2):11-12

UNAIDS (1998)

AIDS and the military

UNAIDS, Geneva

This paper spells out risk factors including the risk-taking ethos and other attitudinal factors, such as separation from accustomed community. Identifies especially vulnerable groups within the military. Impact: Effects on military preparedness; impacts on infected individuals and families; and risk of transmission to civilian populations. Military service is seen as an opportunity for HIV prevention. Approaches addressing risk behaviour are listed including: improved or expanded prevention education; condom education and distribution; expanded STD treatment; provision of counselling and voluntary testing services. Approaches addressing the underlying vulnerability factors are listed including: changes to posting practices with the emphasis on maintaining family life; changes to military culture to allow for informed risk taking; changes to military attitudes towards civilian populations. Other sections deal with the creation of partnerships with the civilian sector in HIV/AIDS prevention and the acceptance and care of HIV-positive military staff. Concludes with a discussion of the pros and cons of mandatory versus voluntary testing. UNAIDS supports voluntary testing coupled with counselling.

UNAIDS (2000)

Programme Co-ordinating Board: HIV/AIDS and the education sector

UNAIDS, Geneva

Eight areas for priority action have been identified to mitigate the negative impact of HIV/AIDS on the education sector. These include: a) policy development and advocacy; b) AIDS curriculum reform; c) skills-based teacher training for AIDS education; d) counselling and health services; e) educational system capacity-building; f) resource mobilisation for AIDS education; g) partnerships for AIDS and education; and h) research and evaluation. In addition, three priority areas to maximize the positive impact of education on reducing HIV/AIDS transmission are recommended for the most affected countries. These are: policies to ensure comprehensive educational programmes for AIDS orphans, children who head households, and children displaced as a result of AIDS; integrating AIDS education into non-formal education programmes through community-based structures and constituencies; and developing innovative education programmes for young girls whose HIV risk and vulnerability are increasing rapidly.

Wagstaff, L.A., Chimere-Dan, O.D. and Ramontja, R.M. (1997)

A survey of health issues in a South African urban community ñ comparing findings from formal and informal dwellers

Southern African Journal Of Epidemiology And Infection, 12 (2):55-60.

Whiteside, A. (1993)

The impact of AIDS on industry in Zimbabwe

In: Cross, S. and Whiteside, A. (eds), Facing up to AIDS: The socio-economic impact in Southern Africa, McMillan, London

Wilkins, N. (2000)

AIDS Briefs for sectoral planners and managers: Informal Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

The informal sector consists of small-scale enterprises operating on the margins of the ëformalí economy. The sector encompasses very diverse and dissimilar activities, organisational forms and institutional environments and should not be treated as a homogeneous sector. HIV/AIDS is a particularly serious threat to informal enterprises because of their inherent dependence on a small labour base. Many informal enterprises consist of the operator plus one or two other workers, often paid or unpaid members of the operatorís family. Hence, when the operator (and probably one or two other family members) falls ill and dies, the enterprise may end as well. The loss of contributions to rotating savings and credit associations will reduce the funding available to finance other informal enterprises. The value of social protection schemes, which include household income maintenance in the event of illness or death of family members due to HIV/AIDS, should be recognised. Initiatives launched by the ILO and other bodies to pilot social protection schemes for the informal sector in certain countries should be adapted and replicated.

Williams, B., Gilgen, D., Campbell, C., Taljaard, D. and MacPhail, C. (2000)

The natural history of HIV/AIDS in South Africa: A biomedical and social survey

CSIR, Johannesburg

The book recounts an 'ecological study' of the Carletonville community. The rates of infection in Carletonville are extremely high, not only among commercial sex workers and mineworkers but also amongst people in the general population. Rates of STDs are also very high among all sectors of the society ñ even for easily curable diseases such as syphilis. Condom use is very low with regular and with casual partners. One of the reasons for this may be the high proportion of women using injectable contraceptives which protect them against pregnancy but not against HIV infection. Risk factors of measures of social capital are associated with an increase or a decrease in the likelihood of infection. Belonging to a church or a sports club is associated with lower rates of infection; belonging to a stokvel with higher rates of infection. Alcohol consumption is also associated with a higher risk of infection. An overview of the intervention is provided including ways in which the project is attempting to improve the management of STDs; mobilising and training community based peer educators, condom distribution, mobilisation of stakeholders from government, industry, trade unions, community organisations ad structures.

Yeager, R. (2000)

AIDS Briefs for sectoral planners and managers: Military Sector

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

Owing to their occupation and lifestyle, military personnel are among the core groups most at risk to HIV infection and transmission. Severe consequences accompany HIV/AIDS in military populations, including loss of support for dependants, depletion of force strength and command capacity, and possible socioeconomic and political destabilisation, compromised national security and generalised breakdown of public order. Measures for limiting the spread of HIV/AIDS in military and related civilian populations include: behavioural change resulting from information, education and communication programmes that encourage safe sex and consistent condom use; blood screening for HIV; effective treatment of STDs; voluntary testing for HIV and other STDs, accompanied by counselling; confidentiality of HIV test results and guarantee of job security until medical discharge becomes necessary. AIDS-related illness and death management measures include: social and psychological counselling; preservation of employment security; confidentiality in care and treatment; provision of continuing medical care of HIV-infected personnel and their dependants in military and civilian facilities; protection of legal rights of surviving dependants. Survivors can be supported by: continuation of military pensions and benefits; reintegration of military dependants within their home communities; assistance in the protection of family property rights. Immediate and long-term security impact of HIV/AIDS can be mitigated by epidemiological surveillance and monitoring together with recruitment of replacement personnel; increased inter-sectoral commitment to HIV/AIDS prevention and control moving beyond traditional distinctions among and between the public and private sectors in promoting common welfare.

The Impact on Firms and Workplaces

Baggaley, R. Godfrey-Faussett, P., Msiska, R., Chilangwa, D., Chitu, E., Porter, J. and Kelly, M. (1994)

Impact of HIV infection on Zambian businesses

British Medical Journal, 309 (6968): 1549-50

Women attending antenatal clinics in Zambia have rates of HIV infection of 11-30%. Deaths from the disease are likely to affect the economy of individual families and, if widespread, that of the country. Since December 1990 the Kara Counselling and Training Trust has offered education about HIV to local companies. We therefore studied the impact of HIV infection on businesses in Zambia as reported by senior management staff.

Crafford, G.J. (1992)

AIDS policy formulation in the workplace and the economic cost of AIDS: A Western Cape survey

M Com, University of Stellenbosch, Department of Economics

As the AIDS epidemic grows, so does the potential for the disease to disrupt the conduct of business. Each companyís survival will depend on its ability to develop a policy to manage the impact of AIDS upon its business. It is essential that there is a partnership between workers, employers and their organisations in formulating and implementing an AIDS policy. Issues to be addressed in the policy are: whether AIDS should form a separate policy or be part of a more general life-threatening disease policy; HIV testing; rights of HIV-infected and fellow employees; the confidentiality of a medical diagnosis; the prevention of discrimination; education programmes; and counselling of AIDS-infected employees. The total cost of AIDS takes the form of direct and indirect costs; direct costs consist mainly of medical care cost, while the indirect costs adopt the human capital approach. Advanced studies relating to the economic implications are inaccurate and, therefore, do not improve South Africa's position.

Crisp, J. (1999)

The likely impact of AIDS

Anglo American Corporation, Johannesburg

Department of Health

Workplace guidelines

Department of Health, Pretoria

Eskom (1999)

Managing the impact of AIDS in the workplace: Case study

Paper presented at the Council on Education in Management Conference, Johannesburg

Foster, S. (1996)

The implications of HIV/AIDS for South African mines.

AIDS Analysis Africa 1996, Oct-Nov; 7 (3):5.

Hussey, J. (1999)

The global business council on HIV/AIDS

Empower Publishing (HIV) Ltdf, London

Jochelson, K., Mothibeli, M., and Leger, J.P. (1991)

Human immunodeficiency virus and migrant labour in South Africa

International Journal of Health Services, 21(1):157-73

The authors investigate the impact of the migrant labour system on heterosexual relationships on South African mines and assess the implications for the future transmission of HIV infection. The migrant labour system has created a market for prostitution in mining towns and geographic networks of relationships within and between urban and rural communities. A section of the migrant workforce and a group of women dependent on prostitution for economic support appear especially vulnerable to contracting HIV infection since they are involved in multiple sexual encounters with different, changing partners, usually without condom protection. Furthermore, sexually transmitted disease morbidity is extensive in the general and mineworker populations. Historically, migration facilitated the transmission of sexually transmitted diseases and may act similarly for HIV. Problems of combating the HIV epidemic in South Africa are discussed.

Marcus, T. (2000)

Exposure and experience confounded by structural constraints: Assessing the impact of AIDS on long-distance truck drivers

13th International AIDS Conference, Durban

Morris, C.N., Burdge, D.R and Cheevers, E.J. (2000)

Economic Impact of HIV Infection in a Cohort of Male Sugar Mill Workers in South Africa from the Perspective of Industry

Mimeo, C.N. Morris, University of British Columbia, Vancouver, Canada,

This study demonstrates the clinical and epidemiological features of HIV infection on a male occupational cohort in rural South Africa (Sugar mill workers in KwaZulu-Natal). This population had a high prevalence of infection (26%) and this was manifested in all age groups but predominantly in those workers who were either unskilled or semiskilled. The death of 5%, and ill-health retirement of 5.7% of the workforce over the 8 years of the study period demonstrates the impact of HIV on this economically productive segment of society. Only 58% of those with identified HIV infections were still active in the workforce at the end of the study. This represents a significant cost but at least a tenfold rise in these costs can be projected over the next 6 years, as the current epidemic matures and those HIV infected develop AIDS. The development of HIV care and prevention packages for this setting may potentially have a positive economic effect given these costs.

Moore, D. (1999)

The AIDS threat and the private sector

AIDS Analysis Africa 9 (6)

Smith, A., Hoff, I. and Kruger, S. (1998)

Epidemiology of HIV prevalence in the workplace

12th International Conference on AIDS, Geneva

Issues: The education sector plays a key role in providing lifeskills training for youth. AIDS impacts both on staff and students. While full involvement of the education sector is advocated, extensive work is required to achieve this. Description: The paper describes the Gauteng Department of Educationís response to AIDS, based on a political mandate, advocacy from stakeholders and AIDS Impact Assessment. The response includes lifeskills orientation and AIDS education, which is integrated into the new curriculum. A Schools AIDS Policy and the Workplace training programme are also being implemented. The department is a key player in the inter-sectoral AIDS programme at provincial and local levels. The process involved in achieving this is described. The teacher training programme has been evaluated and will be presented. Systems are being developed to monitor and evaluate the impact on learners. Conclusion: The Department of Education has integrated AIDS into its departmental strategy and plans at a high level. Implementation of several components is well-developed. The key challenges it faces are to reduce the risk of HIV infection of youth and support the increasing number of both teachers and learners affected by AIDS.

Smith, J. and Whiteside, A. (1995)

The socioeconomic impact of HIV/AIDS on Zambian business: Report for the BEAD and CDC

Commonwealth Development Corporation, London

Stover, J. and Bollinger, L. (1999)

The economic impact of AIDS

The Futures Group International (The POLICY Project), Washington DC

HIV/AIDS may have a significant impact on some firms. AIDS-related illnesses and death to employees affect a firm by both increasing expenditures and reducing revenues. Expenditures are increased for health care costs, burial fees and training and recruitment of replacement workers. Revenues may decrease because of absenteeism due to illness or attendance at funerals and time spent on training, labour turnover can lead to a less experienced labour force that is less productive.

Totaram, K.

AIDS brief to the insurance industry

Mimeo

Thea, D., Simon, J., Rosen, S., Vincent, J. and Singh, G. (2000)

Economic impact of AIDS on developing country firms - A methodological approach

13th International AIDS Conference, Durban

The impact on companies of HIV in the workforce in developing nations is not well understood. Few attempts have been made to quantify the effects of HIV/AIDS morbidity and mortality on the profitability of private sector firms; most were done early in the epidemic and were based largely on interview data. Two models are presented that have been developed to assess the costs to companies of AIDS among employees. The first, a chronological model, is designed to demonstrate the types and sequence of workforce costs that AIDS is likely to impose on a company. The second model reconfigures the costs into discrete categories that can be readily measured using routinely-collected human resources and financial data. The models account for three kinds of costs: 1) direct or out-of-pocket costs, such as employee benefits and training; 2) indirect productivity costs, such as absenteeism and the loss of productivity experienced by sick workers; and 3) immeasurable but potentially important effects on the morale, motivation, experience, and performance of the entire workforce. To estimate the future costs of AIDS, three critical pieces of information are critical to the analysis: 1) HIV/AIDS prevalence, morbidity, and mortality; 2) a detailed demographic projection of the workforce, because HIV infection rates tend to vary with age, sex, race, location within the country, and job level; and 3) identification of critical positions or skills within the firm that are vital to a company's production process, such that production will cease or be significantly slowed if the positions are vacant or skills are not available. The analytical approach provides business managers, researchers, and policy makers with a tool that will enable them to more accurately understand the relative impact AIDS has on different production units within a company and improve both companies' and governments' strategic planning capabilities.

The Impact on Households and Communities

Aggleton, P. and Bertozzi, M. (1997)

Report from a consultation on the socioeconomic impact of HIV/AIDS on households

World Health Organisation (WHO) and UNAIDS, Geneva

Agyarko, R. and Kowal, P. (2000)

Older people, children and the HIV/AIDS nexus

13th International AIDS Conference, Durban

The increasing numbers of AIDS orphans worldwide has had far-reaching societal, economic and psychological implications. The loss of the economically active population places an enormous burden on especially older women. The World Health Organization (WHO) plans to improve the capacity of older people as assets in the provision of support to children orphaned by AIDS. WHO's interventions include: Making older people aware of the mechanisms of HIV transmission and care practices; Providing older people with the knowledge to impart HIV/AIDS education to children; Facilitating the formation of support groups of community and older people; Facilitating the identification of channels and resources to support the wellbeing of such older people. These are achieved through developing partnerships both at the community and national levels to ensure that older people's wellbeing is maintained and they remain assets in the care and support of HIV/AIDS patients and their orphans. The success of these interventions depend on older people playing a key role in the planning and implementation of community-based strategies and programmes that support their role as the surrogate parents.

Aspaas, H.R.

AIDS and orphans in Uganda: a geographical and gender interpretation of household resources

In: The socio-demographic impact of AIDS in Africa. Based on the conference organised by the Committee on AIDS of the International Union for the Scientific Study of Population (IUSSP), Liege, Belgium, and the University of Natal, Durban, South Africa

Ayieko, M.A. (1997)

From single parents to child-headed households: The case of children orphaned by AIDS in Kisumu and Siaya Districts

United Nations Development Programme (UNDP), Geneva

Baier, E.G. (1997)

The impact of HIV/AIDS on rural households and communities and the need for multisectoral prevention and mitigations strategies to combat the epidemic in rural areas

Food and Agriculture Organisation (FAO), Geneva

The FAO perceives the HIV/AIDS epidemic as a development problem of critical importance, rather than simply a health issue. It initiated a detailed sectoral analysis of the socioeconomic impact of HIV/AIDS on rural economies. There is consensus that the HIV/AIDS epidemic will not be contained as long as it is regarded as only a health sector issue and not placed within the overall context of development. In view of the rapid spread of the HIV/AIDS epidemic in rural areas, especially in sub-Saharan Africa, socioeconomic and cultural research needs to be conducted on the impact of the disease on agricultural production systems, household food security, traditional coping mechanisms, etc. to enable the development of appropriate precention and mitigation strategies. Suggestions include: research into the location-specific agricultural impact of the disease is necessary; agricultural education and training policies need to take account of the gender implications and the socioeconomic impact of the epidemic on rural households/communities; national AIDS control programmes should advocate enactment/enforcement of legal reforms to protect vulnerable groups, especially HIV/AIDS widows and orphans, focusing on land tenure, inheritance, access to assistance and inputs; specific population groups most affected by the disease must be targeted for education, training and assistance; development agencies, especially agricultural extension and relevant NGOs, need to take account of the implications of HIV/AIDS in all their outreach activities; rural households and communities develop and adapt their own coping mechanisms. Agricultural extension programmes in collaboration with other agencies and NGOs should support and assist this process. Improvement in women's social and economic status is a crucial step for increasing their ability to protect themselves and their families and children from the epidemic. Gender-sensitive agricultural extension programmes can make an important contribution in this regard.

Barrett, K (1998)

The rights of children: Raising the orphan generation

Southern African Conference on Raising the Orphan Generation, Pietermaritzburg

Chabala, S. (2000)

Social realities that hinder financial intervention in achieving poverty alleviation and sustainable development

13th International AIDS Conference, Durban

The premise that financial intervention can lead to economic empowerment and sustainable development through creation of self sustaining income generating activities among poor people is the basis of this paper. Considerable evidence is now available that there are social realities that are a hindrance in the achievement of the plight above. The findings include: inadequate resources (capital) and lack of access to credit facilities; poor people lack investment concepts resulting in short-term investment; some men with selfish motives manipulate their wives from participating in empowerment programmes or income-generating activities; selfish motives by people who have benefited from the project resulting in lack of sharing of information to other poor people; pressure of large families and dependance on income generated from small enterprise; misallocation of funds by poor people evident in using loan funds for purchasing of household assets, debt settling, weddings and alcohol; poor people lack attributes, of good entrepreneurship evident in setting of wrong priorities such as drinking during productive hours, goal setting and determinations.

Cohen, D. (1999)

Poverty and HIV/AIDS in sub-Saharan Africa

United Nations Development Programme (UNDP), Geneva

There are two bi-causal relationships which need to be understood by those involved in policy and programme development. These are: The relationship between poverty and HIV/AIDS ñ which includes the spatial and socioeconomic distribution of HIV infection in African populations, and consideration of poverty-related factors which affect household and community coping capacities; The relationship between HIV/AIDS and poverty ñ understanding the processes through which the experience of HIV/AIDS by households and communities leads to an intensification of poverty. To make sense of these relationships there has to be an understanding of the complex socioeconomic processes at work in African societies, together with a conceptualisation of poverty which is multidimensional. The HIV epidemic has its origins in African poverty and unless and until poverty is reduced there will be little progress either with reducing transmission of the virus or an enhanced capacity to cope with its socioeconomic consequences. It follows that sustained human development is essential for any effective response to the epidemic in Africa.

Cohen, D. (1997)

The HIV epidemic and sustainable human development

Issues Paper 29, United Nations Development Programme (UNDP), Geneva

Desmond, C. Michael, K. and Gow, J. (2000)

The hidden battle: HIV/AIDS in the household and community

South African Journal of International Affairs, 7(2):39-58

The AIDS epidemic will cause significant increases in illness and death in prime-age adults, which will manifest itself through negative social, economic and developmental impacts. The epidemicsís economic impacts at the household level are decereased income, increased health-care costs, decreased productive capacity and changing expenditure patterns. Three coping strategies are observed: altering household composition; withdrawing savings or selling assets; and receiving assistance from other households. Following death, the impacts break out of the family into the community, primarily through orphaning. In the near future, the sheer number of orphans may overwhelm the capacity of exisiting commntiy resources to cope. The distribution of the impacts of the AIDS epidemic falls unevenly among the genders. In Africa, women have higher infection srates and bear a disproportionate burden of the care of HIV-positive people. Orphaned girls are more vulnerable to exploitation.

Foster, G.

Children rearing children: a study of child-headed households

In: The socio-demographic impact of AIDS in Africa. Based on the conference organized by the Committee on AIDS of the International Union for the Scientific Study of Population (IUSSP), Liege, Belgium and the University of Natal, Durban, South Africa

Communities with high rates of HIV infection are experiencing a rapid increase in the number of children being orphaned. The AIDS epidemic is reducing the proportion of young adults in the population and the incomes in AIDS-affected households. Changes are therefore taking place in care-giving arrangements for affected children. An increasing proportion of orphans in several countries are now being cared for by the elderly and the very young, with some households headed by children as young as 10-12 years old. Once CHHs begin to appear in communities, their prevalence and proportion will likely increase as the AIDS epidemic generates orphans at an increasing rate. The causes of CHHs, problems associated with CHHs, coping and survival mechanisms, and the need for community-based support initiatives are discussed.

Gautier, A. and Pilon, M. (1997)

The families of the south/Families du sud

Institut Francais de Recherche Scientifique pour e Developpement en Cooperation [ORSTOM]

This issue contains a selection of papers on the changes affecting families in developing countries. These include economic and cultural changes, political changes, migration, policies of structural adjustment, and AIDS, all of which have affected the traditional family. There are papers on Mumbai, India; Hanoi, Vietnam; Samoa; Mexican families in the United States; Peru; Abidjan, Ivory Coast; Mali; and sub-Saharan Africa in general.

Gordon, P. and Crehan, K. (1999)

Dying of sadness: Gender, sexual violence and the HIV epidemic

United Nations Development Programme (UNDP), Geneva

The proportion of HIV/AIDS infections attributable to sexual violence is unknown. Existing evidence on gender and sexual inequality, together with data on the distribution of HIV among specific groups and locations, and available information on the nature and scale of sexual violence (particularly against women and girls), suggest that it is likely to be significant. In the short-term, effective responses require clearly defined strategies which are locally relevant and sensitive, which provide support services for victims, including recourse to justice and the punishment of perpetrators. Longer-term strategies need to be based upon consideration of both the specifically gendered and sexualised nature of this violence and the need to address these at the level of community and culture rather than of individual perpetrators and victims. A South African example project ëSinamandla okumvimbela. Re ya mamellaí designed to address a pervasive 'culture of sexual violence' is not only documenting the extent of sexually violent behaviour, but is contributing to its primary prevention by identifying specific ëresilienceí factors among the large number of men who are not sexually violent.

Kongsin, S., Sirinirund, P., Jiamton, S., Boonthum, A. and Watts, C. (2000)

The economic impact of HIV/AIDS on households in rural Thailand: The analysis of household coping strategies

13th International AIDS Conference, Durban

The purpose of this study was to conduct a comparative analysis of households affected and not affected by chronic HIV morbidity, and between affected households within communities with different levels of available services in order to further understand household's coping strategies in the presence of chronic HIV morbidity in their family. To cope with the situation, households used various strategies. Each strategy had an impact on welfare of the households at different degree level. These strategies include reduction of household consumption, reallocation of labour, dissaving, withdrawing children from school, depending on an extended family system and the community to support and help them cope. The income of household case descended by 70.7%. Accordingly, the total income per capita and total consumption per capita descended by 68.4% and 43.5% respectively. To ensure that households maintained consumption level, their first coping strategy was to utilise their savings. When savings have decreased, households took out loans. Households incurred a per capita loan of 28.4% and per capita debt of 118% with respect to total household income per capita. Simulation has shown the high level of dissaving and percentage of the total health care expenditure with respect to income per capita, which indicated the possibility of HIV/AIDS household entering into poverty was high and actions should be taken to avoid it. To help reduce the adverse effects of HIV/AIDS illness on the poor households, special assistance programmes were recommended which include food, clothing and cash transfer, credit fund, schooling subsidies for children, community care for sustainable activities and human rights protection for the infected.

Lyons, M. (1998)

The impact of HIV and AIDS on children, families and communities: risks and realities of childhood during the HIV epidemic

Issues Paper 30, United Nations Development Programme (UNDP), Geneva

The roles that children fill as poor, hungry, exploited and abused human beings increase their vulnerability to HIV. Poverty is a leading promotor of HIV/AIDS. Children are occupying adult roles, working to maintain home and family, failing to meet the goals of childhood. Even when adults intervene and take responsibility for children who are left without parents or guardians because of HIV/AIDS, it cannot always be assumed that children benefit. Solutions that address this include: protecting wellbeing by the elimination of conditions which nurture and strengthen the hold of HIV/AIDS on individuals and communities.

Martin, A. (1996)

The cost of HIV/AIDS care

In: AIDS in the World II, Mann, J. and Tarantola, D. (eds), Oxford University Press, New York

Nampanya-Serpell, N. (2000)

Social and economic risk factors for HIV/AIDS affected families in Zambia

International AIDS Economics Network (IAEN) Conference, Durban

Zambia is among the countries in sub-Saharan Africa most seriously affected by the HIV/AIDS pandemic. At the beginning of the epidemic in the mid-80s and early 90s, the majority of AIDS-related deaths in the adult population occurred among men in the age group 20-45 years. Loss of the breadwinners had an immense economic and financial impact on widows, their children and other dependants from the extended family. The study of the economic impact of the AIDS pandemic at household level in Zambia investigated risk and protective factors in rural and urban communities associated with the impact of premature death of the breadwinner on the livelihood of their surviving spouses, dependent children, as well as the wider circle of their extended family. Implications are discussed for the design of services to reach children and families with the greatest needs. Intervention strategies should be carefully adjusted to respond to the rural and urban differences and to the ecological, social and economic conditions of each community.

Ntozi, J.P.M. (1997)

Effect of AIDS on children: the problem of orphans in Uganda

Health Transition Review, 7:23-40

The problem of orphans is serious in sub-Saharan Africa and has been increasing with the deaths of both parents from AIDS. A study of six districts of Uganda conducted in 1992 investigated the problem. Almost all the orphans are cared for by their extended family members who made the decisions to do so. It is recommended that more assistance be given to the family to enhance its capacity to cope with increased orphans expected in the future.

Nyongesa, D.W. (2000)

The emergence of two odd generations

13th International AIDS Conference, Durban

According to the statistics given by the National AIDS and STDs Control Programme (NASCOP), a department of the Ministry of Health, between 500 and 700 people in Kenya die of AIDS everyday, 15-49 being the age bracket of the victims. These are the people in whom the government has heavily invested through education and training. Their deaths therefore impact negatively on the economic and social sectors. This study examines the socioeconomic repercussions of HIV/AIDS. It also explores how the equally widowed grandmothers (the third generation) are fostering orphans in abject poverty.

Philipson, T. and Posner, R.A. (1995)

The microeconomics of the AIDS epidemic in Africa

Population Development Review, 21 (4)

Rivers, K. and Aggleton, P. (1999)

Men and the HIV epidemic

United Nations Development Programme (UNDP), Geneva

The authors argue that the emphasis of development interventions against HIV/AIDS on outreach programmes for women may be ineffective because they fail to take into account masculine sexual and social behaviours. One of the most important ëgapsí in work for improved sexual health, is the absence of clear information about menís attitudes toward sex and sexuality. Few programmes have been designed to involve men, even fewer have attempted to systematically evaluate and report on the impact and effects of the work undertaken. The paper suggests that involving men more fully in HIV prevention work is essential if rates of HIV transmission are to be reduced. This is likely to require a considerable scaling up of existing efforts and, in the absence of new resources, some re-orientation of existing gender sensitive programmes and interventions, many of which currently work with women alone. Further research in the following areas seems most pertinent: accurate and up to date information is needed on menís beliefs and practices in relation to gender, sex, sexuality and sexual health; systematic enquiry into sex between men is important; since risk-taking appears to be an important part of dominant ideologies of masculinity in a number of societies, it is important to develop a better understanding of risk-taking behaviour among men, especially among those who work in dangerous and/or isolated environments; since condoms still provide the most useful means of preventing HIV transmission, formative research is needed to identify non-stereotypical images and messages which might appeal to men and encourage increased condom use.

Shao, P. (2000)

The impact of HIV/AIDS on the low-cost housing in Gauteng Province

The demographic impact of HIV/AIDS in South Africa and its provinces conference, Port Elizabeth

After undertaking a study in KwaZulu-Natal to learn how its sister department is coping with the epidemic, the Gauteng Department of Housing commissioned research that would later translate into policy on approaches to be used by the department in catering for people infected and directly affected by the epidemic. The object of research is to focus on geographic spread of the epidemic, that is ascertaining local authorities with high prevalence, settlement forms which are highly affected, eg. formal settlement, informal settlement, inner city, rural and urban settlements. Efforts to identify the migration patterns of the victims and their income levels will be made. Lessons from the research will help in the planning and budgeting process.

Smart, R. (1999)

Children living with HIV/AIDS in South Africa ñ A rapid appraisal

Save the Children, United Kingdom

Nearly a third of South African children live in poverty. This causes them to be highly vulnerable to HIV/AIDS. In recognition of this, Government has called for a national strategy on children and HIV/AIDS. The strategy will cover children who are infected with HIV, children who are vulnerable to becoming infected and children who are affected, with the main emphasis being on affected children, including AIDS orphans. To respond it is necessary to generate: awareness of the present situation regarding its children; an understanding of the epidemic, both currently and the future projections; an appreciation of the positions of key role-players and communities in respect of the issues of children and HIV/AIDS; an analysis of existing models of care and support for children in distress. The Rapid Appraisal reports on the following: the context of a national strategy; the needs and rights of affected children; care and support for affected children; lessons from projects; framework for a national strategy; recommendations from the rapid appraisal include, a policy framework; a database of organisations working with and for children; network and co-ordination mechanisms; poverty alleviation activities; identification of children in distress; holistic care and support within a comprehensive continuum; planning for the future of children who will be orphaned; supporting children as care givers; promoting a rights-based approach; and support for affected children, amongst other activities.

Stein, J. (1997)

The impact of HIV/AIDS on the household

AIDS Bulletin 6 (4):20-3.

Stewart, R.C. (1999)

Negative economic shocks and the changes in the composition and structure of poor, rural, African households in KwaZulu-Natal 1993-1998

M Soc Sci, University of Natal, Durban

This thesis examines the negative economic shocks and the changes in the composition and structure of poor, rural African households. The evidence from the cross-tabulations of both the poor and the non-poor groups suggests that both household groups may manipulate the size and number of generations as a coping strategy in times of economic stress. These results may be interpreted in two different ways. Firstly, that non-poor households use these methods as coping strategies and are successful in mitigating the effects on income levels to the point where they are able to remain out of poverty. A second explanation is that the relationship between the two factors may be caused by general life-cycles and not be due to an inherent relationship between the two factors in isolation. From the analysis of the data results, it becomes obvious that household boundaries are fluid and that the composition and structure of the household changes over time. Much of this change can be attributed to internal forces such as births, deaths and marriage, but it may be possible that some of the changes can be attributed to other forces. The household should not be regarded as a static and homogenous unit in social and economic planning. It appears that all households may experience sudden and negative economic shocks. However, the households that are larger are more likely than the smaller households to experience these shocks.

Stover, J. and Bollinger, L. (1999)

The Economic Impact of AIDS

The Futures Group International (The POLICY Project), Washington DC

Lists the following economic impact of HIV/AIDS on households: loss of income of the patient (frequently the main breadwinner); substantial increase in household expenditure for medical expenses; other members of the household (usually daughters or wives) may miss school or work less in order to care for the sick person; death results in a permanent loss of income. There is also less labour on farms, lower remittances, funeral and mourning costs, and removal of children from schools to save educational expenses and increase household labour.

Tallis, V. (2000)

Gender, feminism and HIV/AIDS: The global response to reduce womenís vulnerability to HIV/AIDS

13th International AIDS Conference, Durban

Womenís vulnerability to HIV has been well documented. The main reasons cited for vulnerability include biological, economic and social reasons. Women are more vulnerable due to their oppressed position in society. Vulnerability is understood on three interdependent levels: individual, societal and programmatic. In the absence of policies and programmes that work towards bridging the gender gap, many related HIV efforts will be ineffectual. Whilst individual and societal vulnerability has been well researched, little has been written on programmatic vulnerability ñ the role of HIV programmes in increasing or decreasing vulnerability. This presentation explores the extent to which the global response of National AIDS Control Programmes reduces or increases womenís vulnerability to HIV/AIDS. National AIDS programmes have a responsibility to ensure that gender is an integral part of every programme and project ñ from design to implementation and evaluation. AIDS interventions should fundamentally challenge the position of women in society.

Tallis, V. (1998)

The politics of vulnerability: women and the HIV/AIDS epidemic

Development Update 2 (2), Interfund and Sangoco, Johannesburg

Thomas, E.P., Seager, J.R., Viljoen, E., Pogieter, F., Rossouw, A., Tokota, B., McGranahan, G. and Kjellen, M. (1999)

Household environment and health in Port Elizabeth, South Africa

Stockholm Environment Institute, Sweden

This provides a focus on the environment and health problems at a household level. The study used a random sample of the whole population of the city and was thus able to examine city-wide disparities. Focusing on housing and health this study primarily examines the vulnerability of households in poverty to disease including HIV/AIDS. There are, however, no specific AIDS-related recommendations.

Topouzis, D. and Hemrich, G. (1998)

The socioeconomic impact of HIV and AIDS on rural families in Uganda: An emphasis on youth

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Study Paper 2, United Nations Development Programme (UNDP), Geneva

Data about the spread of HIV/AIDS in rural Uganda tends to be unreliable. The spread of AIDS follows a different pattern in each village and district. Geographic and ethnic factors, agri-ecological conditions, religion, gender, age and marital status all influence the pattern and impact. The critical implication for the design of HIV/AIDS interventions is that district specific approaches are essential. The burden of the socioeconomic impact of HIV/AIDS is disproportionately affecting rural women, especially AIDS widows and their dependent children who typically become entrenched in poverty as they lose access to land, labour, inputs, credit and support services. Stigmatisation compounds their situation severing assistance from extended family and the community. Women's limited economic opportunities, lack of rights to land and property need to be addressed when HIV/AIDS interventions are designed.

Wattana, J. (1996)

The economic impact of AIDS on households in Thailand

In: Confronting AIDS: Public Priorities in a Global Epidemic, Edited by Martha Ainsworth, Lieve Fransen, and Mead Over, European Commission, 1998

This article examines two questions: What is the household structure, and what are the components of the household, in households with and without an adult death?, and among households with and without an adult death, what are the factors affecting the change in household consumption? It was found that households that had experienced an adult AIDS death were not able to replace the capacity of the deceased; the composition of AIDS-death households was 15% under 14 years old, 60% in prime working age and 25% elderly; the percentage of elderly people in AIDS-death households was higher than in other types of households; education of the household head has a protective effect in case of death; deaths of adult women have a stronger negative on consumption than do deaths of adult men; deaths from AIDS are associated with a larger decrease in consumption than are deaths from other causes.

The Response of Government, Donors and Public/Private Interventions

Ainsworth, M. and Teokul, W. (2000)

Breaking the silence: setting realistic priorities for AIDS control in less developed countries

Lancet, 2000, 356:55-60

The AIDS pandemic is a human tragedy that is threatening development in the poorest countries. There is no cure or vaccine, but the tools to control the epidemic already exist. Nevertheless, there are few examples of national AIDS control programmes that have had an impact on the epidemic. This can be attributed to the reluctance of governments to confront AIDS and a failure to prioritise activities in the face of severe financial and administrative constraints. When implementation capacity is weak, expanding the number of activities may not improve programme effectiveness. Rather, by implementing a smaller, core set of the most cost-effective activities on a national scale, policy-makers could have a huge effect on the overall epidemic in a sustained way and provide a foundation for expansion.

Ainsworth, M., Fransen, L. and Over, M. (1997)

Confronting AIDS: Public priorities in a global epidemic

World Bank, Washington

This comprehensive book contains information and analysis for policy-makers, development specialists, and public health experts. It is based on the assumption that public health policy can directly influence individual high-risk behaviour. This is explored in the areas of the subsidisation of the treatment of STDs, of the subsidisation of blood safety, and of the provision of access to health care for the poorest.

Bader, J. (2000)

The use of community health workers will enhance the governmentís primary health initiative

Poverty and inequality: The challenges for public health in South Africa conference, Epidemiological Society of Southern Africa (ESSA), East London

Access to health services remains a problem for rural communities in South Africa. Very often the mobile clinic is the sole accessible form of health service for these communities, and due to the infrequent appearance of these clinics in some areas, needs are not being met. The author argues for a programme that incorporates community health workers as a fast-track intervention.

Binswanger, H.P. (2000)

Scaling up HIV/AIDS programmes to national coverage

Science, 23:288(5474):2173-6

Bossert, T., Beauvais, J. and Bowser, D. (2000)

Decentralisation of health systems: Preliminary review of four country case studies

Partnerships for Health Reform, Abt and Associates, Maryland

This paper investigates the level of health sector expenditures related to HIV/AIDS, and the division by use of funds; their relationship to overall health expenditure by use of funds; and the major determinants of the level and pattern of expenditures and financing. Case studies from five developing countries (Brazil, Cote d'Ivoire, Mexico, Tanzania, Thailand) are provided.

Cohen, D. (1999)

Mainstreaming the policy and programming response to the HIV epidemic

United Nations Development Programme (UNDP), Geneva

The HIV epidemic is a developmental issue; development is causally related to the spread of HIV infection and development affects what is feasible in terms of the response to the epidemic. What is required is the adjustment of developmental parameters through strengthening of national policy and participatory programming responses. There is a need for mainstreaming HIV as a development issue, through participatory, integrated, and co-ordinated programming responses.

Cohen, D. (1999)

Responding to the socioeconomic impact of the HIV epidemic in sub-Saharan Africa: Why a systems approach is needed

United Nations Development Programme (UNDP), Geneva

Regional and international co-operation are required to limit risks to populations through induced labour migration. There is a need for integration in planning and co-ordinating interventions in health. Problems are developmental and systemic, and require integrated and co-ordinated interventions.

Crewe, M. (2000)

South Africa: Touched by the vengeance of AIDS: Responses to the South African epidemic

In: South African Journal of International Affairs, 7 (2)

The HIV/AIDS epidemic in South Africa is at a critical phase,. Until now, the spread of HIV/AIDS has not been controlled, and the government has yet to adopt a coherent policy. The National AIDS Plan, developed in 1994, is largely unimplemented, despite having been praised as an innovative programme. Complicating the situation are the politics between government and various non-governmental organisations over the control of resources on one hand, and the control of turf on the other. Perceived incompatibilities in agendas cause in fighting between NGOs themselves and between NGOs and government. A successful HIV/AIDS policy in SOuth Africa must include the efforts of government, NGOs and communities.

Crewe, M. (1998)

HIV/AIDS: school-based policy for pupils

AIDS Bulletin, 7 (1)

Department of Welfare (1998)

Population Policy for South Africa

Department of Welfare, Pretoria

This policy document identifies some of problems related to economic and sociopolitical inequalities contributing to the rapid increase of HIV infection. It further identifies what it sees as priorities: eradication of poverty and increased access to services (primary health care, clean water, sanitation and education. The objective of the Population Policy is to resolve these concerns in a comprehensive manner within the framework of its overall development strategies as contained in the RDP and GEAR. A major strategy within the Policy are poverty reduction through meeting peopleís basic needs for social security, employment, education, training and housing, as well as the provision of infrastructure and social facilities and services. Another major strategy is the improvement of the quality, accessibility, availability, and affordability of primary health care services, including reproductive health and health promotion services, and their extension to the entire population.

Department of Welfare (Social Development) (2000)

HIV/AIDS and human development: Situation analysis

Department of Welfare, SA, June 2000

The paper lists the Social Welfare Plan on AIDS, with strategic foci on targeted preventive interventions; managing the impact of AIDS on social security; strategic alliances; and appropriate policy. The services envisaged by the department include counselling and support, income generating programmes, and foster care placements. The departments of Health and Welfare (Social Development) will co-ordinate the implementation of the co-ordinated strategy, that will involve all departments and stakeholders.

Diop, W., Trudelle, M., Champagne, P., and Beaudry, R. (2000)

The transborder initiative: a network for community partnership in STD/AIDS management

13th International AIDS Conference, Durban

The West Africa AIDS Project, Phase 2 concentrated on interventions targeting mobile groups (intra and inter country): truckers, sex workers, seasonal workers and on residents in contact with mobile groups. The transborder concept is an attempt to disregard borders and maximise the shared economic, social, cultural, and linguistic dynamics for undertaking effective intervention. The intervention seeks to: i) sustain and link local community action in various bordering countries, targeting the same mobile groups; ii) ensure continuity in services (information ñ counselling, health STD treatment and prevention) offered to individuals who travel, from the point of departure to the point of arrival and at sites in between; iii) facilitate partnership among institutions, regional projects and community organizations to encourage the most effective mobilisation of resources available. It was found that: i) a web of relationships is being woven among community organisations in various countries working toward the same goals; ii) a harmonisation of action and the availability of the same services along transborder routes ensures credibility of the messages targeting the same clienteles in different countries; iii) the use of subregional African languages in producing support and spreading messages is a pertinent strategy in educational efforts; iv) the transborder initiative is the framework for concrete field partnership among regional project workers.

Duckett, M. (2000)

Migrantsí right to health

13th International AIDS Conference, Durban

A number of studies have documented the fact that human mobility is associated with an increased risk of HIV infection. However, being a migrant, in and of itself, is not a risk factor ñ it is the activities undertaken during the migration process that are the risk factors. UNAIDS/IOM commissioned a policy discussion paper on migrants' right to health. This paper outlines key existing laws, policies and best practices in relation to the rights of migrants to health, and associated care, treatment, support and prevention, particularly in relation to HIV/AIDS/STD and reproductive health matters. The author uses this framework of existing laws and policies to address ethical and economic dimensions, and to consider the effects of globalisation and the implications of policies for migrant health. It concludes with recommendations for the future development of policies to improve the health status of migrant populations. These include acknowledgment of the right to health care access for all; attention to, and compliance by all countries with international treaties and agreements to which they are a party; health care access programmes for non-nationals that move beyond emergency care, and address physical, mental and social well being, particularly in relation to HIV/AIDS/STD and reproductive health; and attention to the gender disparities often involved in migrant worker movements, both within countries and across borders, and to gender/power relationships which frequently govern women's access to information and health care.

Gilks, C. Floyd, K., Haran, D., Kemp, J., Squire, B., Wilkinson, D. (1998)

Sexual health and health care: Care and support for people with HIV/AIDS in resour-e poor settings

Department for International Development (DFID), United Kingdom

Gillies, P. (1998)

Effectiveness of alliances and partnerships for health promotion

Health Promotion International 13, 1-21

This paper assesses the impact of alliances or partnerships for health promotion in northern and southern nations, as described in published papers and through contemporary accounts of best practice. The balance of evidence from published literature and case study accounts is clear. Alliance or partnership initiatives to promote health across sectors, across professional and lay boundaries and between public, private and non-government agencies, do work. They work in tackling the broader determinants of health and wellbeing in populations in a sustainable manner, as well as in promoting individual health-related behaviour change. The greater the level of local community involvement in setting agendas for action and in the practice of health promotion, the larger the impact. Volunteer activities, peer programmes and civic activities ensure the maximum benefit from community approaches. In addition, durable structures which facilitate planning and decision-making, such as local committees and councils, are key factors in successful alliances or partnerships for health promotion. Such mechanisms also support the sharing of power, responsibility and authority for change, the maintenance of order and of programmatic relevance, and allow local people one means of reflection and for dissent. At a national, regional, district, village and local community or neighbourhood level, this review found that the existence and implementation of policies for health promotion activities were also crucial to sustainability. The evidence from the review suggests the need for new ësocialí indicators to measure the effects of health promotion. The author suggests the notion of social capital as one important new framework for organising our thinking about the broader determinants of health and how to influence them through community-based approaches to reduce inequalities in health and wellbeing.

Gilson, L., Doherty, J., McIntyre, D., Thomas, S., Briljal, V. and Bowa, C. (1999)

The dynamics of policy change: Health care financing in South Africa, 1994-1999

Partnerships for Health Reform, Abt and Associates, Maryland

This report presents an analysis of the experience of seeking change in health care financing policy in South Africa over the period 1994-1999, the first term of the countryís first democratic government. Health financing reforms which aim to improve resource availability and use are a central component of the current wave of health sector reforms both in sub-Saharan Africa and in other parts of the world. The contribution of the study is its emphasis on the process by which policies are developed and implemented, and the factors facilitating or constraining their impact. The study also considered the linkages between different financing reforms, and between financing reforms and other health sector reforms (in particular, decentralisation), to ensure a comprehensive understanding of reforms. The study has focused on the issues of equity and health system sustainability, which have been subjected to less scrutiny internationally than, for example, efficiency. The range of reforms that have been considered are: geographic resource allocation formulae; user fees (in South Africa the removal of primary care fees); and health insurance options.

HEARD (2000)

AIDS toolkits for government ministries/departments

Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, Durban

Howse, J. (2000)

The provinces at a glance: Whoís spending what where? (Part 3)

South African Medical Journal, 90(7):678-80

Johnston, A. (2000)

Interpreting HIV trends for policy-makers: Using an intermediate variables framework as a policy advocacy tool

13th International AIDS Conference, Durban

Why is it that HIV prevalence has increased so rapidly is some countries but remained at much lower levels and increased much more slowly in other countries? Do policy-makers and programme planners fully understand the reasons for these different trends and the implications for their programme planning? When asked why HIV has increased more rapidly in some countries or parts of a country than in others, policy-makers often speculate that the differences are due to differences in poverty, urbanisation, education, social disruption, mobility, or broad social factors such as social cohesion or the status of women. But these are only indirect determinants of HIV prevalence. This paper outlines an intermediate variables framework which links the broad social, cultural and economic determinants to HIV trends through an intermediate set of biological and behavioural ëdirectí determinants, or intermediate variables, which include sexual networking patterns, prevalence and type of other STDs, condom use, specific sex practices, and prevalence of male circumcision. Using a comparison of the HIV prevalence trends in Ghana and South Africa as an example, a methodology is presented for using this framework to increase the understanding of policy-makers and other community and programme leaders about the direct determinants of HIV spread that are most amenable to programme interventions.

Kelly,M.J.J. (2000)

Adapting the education sector to the advent of HIV/AIDS

13th International AIDS Conference, Durban

Klouda, A. (1995)

Responding to AIDS: are there any appropriate development policies?

Journal of International Development, 7:467-487

Kremer, M. (1996)

AIDS: The economic rationale for public intervention

In: Confronting AIDS: Public Priorities in a Global Epidemic, Edited by Martha Ainsworth, Lieve Fransen, and Mead Over, European Commission, 1998

Even if it is assumed that the risk of contracting HIV is assumed voluntarily, there is a case for government intervention. Emphasis on social benefit of treatment as prevention. Call for subsidisation of treatment, to reflect the benefits to society of preventing infection of additional persons.

Laws, M. (1996)

International funding of global AIDS strategy: Official development assistance

In: AIDS in the World II: Global dimensions, social roots and responses, The global Policy Coalitions, New York: Oxford University Press

Universal trend of declining aid since 1990, exacerbating funding shortfalls. Donors have shifted from multilateral to bilateral and local project financing since 1990. Discrepancy in donor agenciesí reported funding, and projects reportedly received funding. Developing countries are turning to the World Bank for financing HIV prevention and care needs.

Mathews, C., Coetzee, N., van Rensburg, A., Lombard, C.J., Ballard, R.C., Schierhout, G. and Fehler, H.G. (1998)

An assessment of care provided by a public sector STD clinic in Cape Town

International Journal of STDs and AIDS, 9 (11):689-94

A study was undertaken in a Cape Town public sector STD clinic to evaluate the content and quality of care provided since it has been recognised that appropriate improvements in the management of conventional STDs, including provision of correct therapy, health education, condom promotion and partner notification, could result in a reduced incidence of HIV infection. The objectives were to assess patients' needs for health education and to assess the quality of STD management in terms of health education, condom promotion, partner notification, the validity of the clinical diagnoses and the adequacy of the treatments prescribed. The majority of patients were not receiving education for the prevention of STDs including HIV. Many were not receiving adequate treatment for their infections. The introduction of a syndromic management protocol in this setting would substantially reduce the proportion of inadequately-treated patients. However, syndromic protocols, and the means by which they are implemented, need to take into account problems with the clinical detection of genital ulcerative disease and candidiasis in women.

Mbewu, A. et al (2000)

AIDS management options for South Africa

South African Medical Journal, 90 (5)

McIntyre, D., Baba, L., and Makan, B. (1998)

Equity in public sector health care financing and expenditure in South Africa: An analysis of trends between 1995/96 to 2000/01

Health Systems Trust, Durban

McIntyre, D., Bloom,G., Doherty, J., and Brijlal, P.

Health expenditure and finance in South Africa

Health Systems Trust, Durban and the World Bank, Washington DC

This report aims to provide those involved in the restructuring of South Africaís health services with an understanding of the health sector they have inherited in order to formulate realistic strategies for change.

McIntyre, D., Gilson, L., Valentine, N., Soederlund, N. (1998)

Equity of health sector revenue generation and allocation: A South African case study

Partnerships for Health Reform, Abt and Associates, Maryland

This paper provides an overview of the South African health sector. It characterises South Africa as an upper-middle income country, with a declining economic growth rate since 1990. Yet South Africa is one of the most unequal societies. More than half of the population can be defined as poor. Similarly, the country has a complex, well-developed health sector, with relatively high levels of health care expenditure. Yet health status indicators are poor. This is partly due to the fact that a substantial portion of this spending goes to private health care that serves a minority of the population. The public/private sector mix requires serious consideration by policy-makers. Resources currently located in the private sector need to become accessible to a greater proportion of the population. The challenge for policy-makers lies in dealing with the maldistribution of resources between public and private sectors and to redistribute existing public sector health services between geographic areas and levels of care. This way, the high levels of preventable ill health and premature mortality could be reduced.

Metrikin, A.S. et al (1995)

Is HIV/AIDS a primary-care disease? Appropriate levels of outpatient care for patients with HIV/AIDS

AIDS, 9 (6):619-23

Michael, K. (2000)

Can the health sector respond?

AIDS Analysis Africa, 11 (3)

Mutzwa-Mangiza, D. (1998)

The impact of health sector reform on public sector health worker motivation in Zimbabwe

Partnerships for Health Reform, Abt and Associates, Maryland

During the past decade the economic situation in Zimbabwe has deteriorated significantly. Public sector health care workers have gone from being high status and relatively well paid members of the community to workers struggling to get a living wage from their jobs. This paper describes the specific policy measures that the Zimbabwean government has recently implemented to try to improve health sector performance, and promote higher levels of motivation amongst public sector health care workers. The overall reform package is to include financial reforms (user fees and social insurance), strengthening of health management, liberalisation and regulation of the private health sector, decentralisation, and contracting out. Unfortunately, the process of reform implementation in Zimbabwe and the governmentís poor communication with workers, combined with a conflict between local cultures and the measures being implemented, has undermined the potentially positive effect of reforms on health worker motivation. Workers perceived reforms as threatening their job security, salaries, and training/career advancement opportunities, and feared ethnic and political influence on new employment practices under a decentralised system. Worker demotivation has been expressed in terms of strikes, unethical behaviour, neglecting public sector responsibilities to work in private practice, and high turnover.

Ngwenya, C. (2000)

Alleviating poverty and securing substantive equality in health through the constitution: Tentative lessons from South Africa

Poverty and inequality: The challenges for public health in South Africa conference, Epidemiological Society of Southern Africa (ESSA), East London

The South African Constitution offers a useful model for the recognition of socioeconomic rights in Southern Africa. However, it is still premature to measure its efficacy.

OíFarrell, N. (2000)

The Commonwealth and HIV: The need for a country-specific approach

In: The Commonwealth Secretariat, HIV/AIDS in the Commonwealth 2000/01, Kensington Publications, London

Over, M. (1998)

Coping with the impact of AIDS

Finance and Development, March

Philipson, T.J. and Posner, R.A. (1993)

Private choices and public health: The AIDS epidemic in an economic perspective

Cambridge, Mass: Harvard University Press

Regensberg, L.D. (1999)

Aid for AIDS: an innovative solution?

AIDS Analysis Africa, 9 (6)

Roseberry, W. (1996)

AIDS prevention and mitigation in sub-Saharan Africa: A strategy for Africa

World Bank, Africa Region, Technical Department, Human Resources and Poverty Division, Report 15569

Schietinger, H. and Sanei, L. (2000)

Systems for delivering HIV/AIDS care and support

Discussion Paper no 8, The Synergy Project, HTS Project for USAID

Need for decentralisation of health services, while providing for integration and co-ordination, so as to avoid over-utilisation of centralised tertiary care and under-utilisation of local health services.

Shepard, D.S. et al (1996)

Expenditures on HIV/AIDS: Levels and determinants, lessons from five countries

In: Confronting AIDS: Public Priorities in a Global Epidemic, Edited by Martha Ainsworth, Lieve Fransen, and Mead Over, European Commission, 1998

Smart, R. (1999)

Local government transformation and the challenge of HIV/AIDS

AIDS Analysis Africa, 10 (1):14-5

This paper provides summaries of objectives of local government in the Constitution, and of the ëWhite Paper on Local Governmentí. The stated aims are to maximise social development and economic growth by alleviating poverty and enhancing job creation, to integrate and co-ordinate public and private sectors and development planning; to democratise development and redistribution, to work in partnerships with business, trade unions and community-based organisations, and to promote human rights and constitutional principles.

Smart, R. and Whiteside, A. (2000)

Local government responds to HIV/AIDS

13th International AIDS Conference, Durban

A global trend toward decentralisation is defining new roles for local government. In South Africa, local government has constitutional and legal obligations to promote social and economic development and provide services to communities in a democratic and accountable manner. HIV/AIDS is making this less and less achievable. However, the core functions of local government in fact offer unique opportunities for appropriate, sustainable, multisectoral, community-based responses to the HIV/AIDS epidemic. But what tools and capacity are required for this to happen? A toolkit for local government was developed and field-tested in the province of KwaZulu-Natal following a process of consultation and interviews with key stakeholders. The toolkit is a set of instruments designed for specific purposes and includes: a model HIV/AIDS strategy for a city; a model workplace HIV/AIDS policy; guidelines for networking; guidelines for multi-sectoral planning; a model advocacy presentation. The toolkit and training have been shown to be valuable resources, meeting a real need, currently within South Africa, but potentially for local government in neighbouring countries as well.

Stover, J. and Johnston, A. (1999)

The art of policy formulation: experiences from Africa in developing national HIV/AIDS policies

The Futures Group International, POLICY Project (Occasional Papers No 3), Washington, DC

AIDS has presented a major challenge to African societies during the last two decades. Governments throughout the region have struggled to develop effective policies and programmes to address the epidemic. This report presents case studies of the policy process in nine Anglophone African countries. Each country has employed a unique approach to policy development; the results are equally diverse. This report describes some of the country experiences and highlights areas of similarity and difference as well as major problems addressed by Anglophone African countries. The information has been distilled into a framework that captures key elements of the policy-making process.

Stover, J., Rehnstrom, J. and Schwartlander, B. (2000)

Measuring the level of effort in the national and international response to HIV/AIDS

13th International AIDS Conference, Durban

There are many measures of specific inputs to AIDS programmes (eg., number of condoms distributed, STD cases treated) and outcomes (eg., HIV prevalence, number of reported AIDS cases). However, there are no measures of the overall level of effort made in response to the epidemic. Such a measure would be useful for diagnosing areas where efforts are strongest and weakest, tracking changes over time and analysing the effect of programme effort in controlling HIV prevalence in regard to social, economic and cultural context. A joint activity to develop this measure has been undertaken by UNAIDS, USAID and the POLICY Project. The AIDS Programme Effort Index contributes to our understanding of the current status of programme effort and the role that programme effort plays in controlling the epidemic in various social and cultural contexts. It can be useful to build greater commitment for an effective response.

Swarts, L. (2000)

Draft NPU report on South African HIV/AIDS best practice models and strategic interventions

The demographic impact of HIV/AIDS in South Africa and its provinces conference, Port Elizabeth

The primary aim of the project was to survey NGOs and organisations active in the field of HIV/AIDS prevention and care programmes with regard to best practices. Results from the study indicated that the majority of projects focused on prevention projects as well as the HIV/AIDS infected and uninfected. Most of these projects were situated in the urban areas of Gauteng, Western Cape and KwaZulu-Natal, which illustrated that rural areas was very much discriminated against when it comes to the rendering of HIV/AIDS services. The study further indicated that government is the major funding source and recommends that local business must play a more contractive role in the funding of projects. Lastly, recommendations are suggested for the developing of programmes around the military as well as immigrants and refugees.

Task force on health research for development secretariat (1991)

A strategy for action in health and human development

United Nations Development Programme (UNDP), Geneva

This manual was commissioned by the Task Force on Health Research for Development, in order to strengthen international partnerships, increase financial support, and establish an international forum. This was done with a view to providing and updating scientific knowledge required for decisions about health actions and priorities, to ensuring best use of available resources, and to promoting research tackling unsolved problems.

Taylor, G. (1999)

Medical aid schemes respond to AIDS

AIDS Analysis Africa, 10 (1):4.

The Commonwealth Secretariat (2000)

HIV/AIDS in the Commonwealth 2000/01

13th International AIDS Conference, Durban

Topouzis, D. (1998)

The implications of HIV/AIDS for rural development policy and programming: focus on sub-Saharan Africa

United Nations Development Programme (UNDP) and Food and Agriculture Organisation (FAO)

This paper draws out the implications of the HIV epidemic for rural development policies and programmes in sub-Saharan Africa. The paper presents four case studies from Southern and Eastern Africa to help formal and informal rural institutions to generate policy and programme responses to HIV/AIDS in the areas of land tenure, agricultural research, training and extension, appropriate technology, credit, etc.

UNAIDS (2000)

HIV and health care reform in Phayao: From crisis to opportunity

UNAIDS, Geneva

This report deals with HIV/AIDS in Phayao province, Northern Thailand. HIV prevalence peaked in 1992. In the following years, several campaigns and initiatives were launched by national and provincial government, NGOs, and communities, to deal with the crisis by way of a multisectoral response and a health care reform. In 1997, a significant decrease in seroprevalence among groups studied in 1992, could be registered.

UNAIDS (1999)

Guide to the strategic planning process for a national response to HIV/AIDS

UNAIDS, Geneva

UNAIDS (2000)

National AIDS programmes: A guide to monitoring and evaluation

UNAIDS, Geneva

This guide summarises best practices in monitoring and evaluation of national HIV/AIDS programmes at the end of the 1990s, and recommends options for monitoring and evaluating systems in future. It provides a checklist of a good monitoring and evaluation system, taking into account the fact that we are dealing with second generation surveillance systems which differ substantially from the traditional ones. In second generation systems, all possible indicators are combined. The centrepiece of the guide provides an overview of indicators by programme areas, tools for management, and priority for different epidemic states. All of these programme area indicators are discussed individually according to definition, measurement tools, what they measure, how to measure, and strengths and limitations.

UNAIDS (2000)

Global HIV/AIDS strategy framework

UNAIDS, Geneva

This report formulates targeted intervention strategies focusing on particular susceptible and vulnerable groups. Starting with lessons learned, it proceeds to outline strategies with desired outcomes with respect to reducing risk of HIV infection. Vulnerability reduction strategies are integrated into policy interventions of impact mitigation at individual, household, community and national levels. The paper identifies programmes addressing individual, institutional, and community behaviours that contribute to HIV infection; social and economic factors contributing to individual and community vulnerability to infection; and capacities of individuals, families, communities and of health and social sectors to address the impact of HIV/AIDS.

UNAIDS (2000)

Governance and HIV/AIDS

UNAIDS, Geneva

Development is inversely linked to HIV prevalence. Good governance is linked to stable HIV prevalence. It is suggested that development plus good governance equals low and stable HIV prevalence.

UNDP (2000)

Governance for sustainable human development

United Nations Development Programme (UNDP), Geneva

Vos, A. (1998)

HIV/AIDS care programmes should include poverty alleviation interventions

12th International AIDS Conference, Geneva

Many breadwinners are the first to die from AIDS in rural and urban African families, leaving no support for families, creating dependency on the larger community. While one may successfully teach families to care for sick loved ones, provisions are not necessarily made for the family. The approach was taken at projects in the urban and rural areas in the Eastern Cape Province, and KwaZulu-Natal, in South Africa, where future breadwinners were identified and appropriate skills developed to enable them to provide for their families. Many of the new breadwinners were taught trench gardening methods. Some became so successful at that they were able to sell vegetables to neighbours, others were referred to technical training centres where they learned sewing, knitting, and silk screening and other skills. HIV/AIDS cannot be seen in isolation, development must be seen as an integral part of HIV/AIDS care programmes. Home carers were trained in helping families identify new breadwinners, in determining family needs, assessing breadwinner potential and interests, networking with training institutions, and referral to other support organisations. The result has been that families where this development has occurred are less dependent on social services, remain financially active in communities, and stay together as family units.

Weiner, R., Pick, W., Kgosdinsti, N., Conway, C. and Fisher, B. (2000)

The provision and distribution of HIV/AIDS related interventions in the South African public health sector

Poverty and inequality: The challenges for public health in South Africa conference, Epidemiological Society of Southern Africa (ESSA), East London

In the context of the growing AIDS epidemic, a set of indicators reflecting the provision and distribution of HIV/AIDS related interventions was measured as part of a national survey on public health facilities. Condoms were available in 79% of clinics; 53% of hospitals had post-exposure prophylaxis for needlestick injuries; TB drugs were available at 71% of hospitals and 59% of clinics, but in some provinces less than 50% of clinics had drugs in stock. The survey confirms urban, rural and provincial inequities.

West. G.P. (1996)

The integration of HIV/AIDS into national development planning

Durban, South Africa, University of Natal, Economic Research Unit, Occasional Paper No 2 of the ERU Series on HIV/AIDS

Whiteside, A. (1992)

Training for planners in AIDS afflicted developing countries: an assessment of needs and approaches

International Conference on AIDS, 1992

The ability to model the growth in numbers likely to be infected with HIV has developed rapidly over the past few years. Greater certainty as to numbers means the ability to plan for the disease is also growing. It is vital that this planning be done as the disease will affect virtually all sectors of society and the economy. This paper looks at the ways in which planners in government, the private sector and NGOs can begin to be trained to assess the likely effects of the epidemic and plan for it.

Whiteside, A. (ed) (1998)

Implications of AIDS for demography and policy in South Africa

University of Natal Press, Pietermaritzburg

This book is a collaborative effort between demographers, sociologists, and health systems analysts to relate HIV modelling and projections to policy and development planning. Projections and methodological considerations are integrated with policy and planning. A chapter on AIDS and development planning notes the failures in setting up interdepartmental structures across national and provincial levels. Revisiting lessons learnt, a path for 'the way forward' is charted.

Whiteside, A., Wilkins, N., Mason, B. and Wood, G. (1995)

The Impact of HIV/AIDS on planning issues in KwaZulu-Natal

KwaZulu-Natal, South Africa, Town and Regional Planning Commission Town and Regional Planning Supplementary Report Vol 42

An overview of the impacts of HIV/AIDS in KwaZulu-Natal and its implications for the Town and Regional Planning Commission of the province.

World Bank (1999)

Considering HIV/AIDS in development assistance: A toolkit

World Bank, Washington

This toolkit considers the implications of HIV/AIDS in the provision of development assistance. It provides a sectoral analysis, looking at HIV/AIDS in education, in rural development, and in the transport sector as specific examples. In the presentation of these examples, action-orientations are indicated. The book concludes with guidelines for including HIV/AIDS in Project Cycle Management, and for including HIV/AIDS in consultants' terms of reference.

World Bank (2000)

Intensifying action against HIV/AIDS in Africa: Responding to a development crisis

World Bank, Africa Region, Washington

Provides an overview of World Bank oriented activities that can contributed to HIV/AIDS prevention and care.

Zeitz, P. (2000)

UNAIDS activity: Debt-for-AIDS

13th International AIDS Conference, Durban

Recognising the magnitude and the reach of the HIV/AIDS crisis in sub-Saharan Africa, African leaders, the UN agencies, and many other governments are declaring HIV/AIDS as the most critical developmental and humanitarian crisis on the continent. Developing, financing, and implementing programmes to slow the spread of the epidemic and reduce its impact is now seen as an urgent priority, as HIV/AIDS is obstructing other development goals, including economic growth, political stability, and security in Africa. Simultaneously, a new era of debt relief for highly-indebted poor countries is being launched in many countries around the continent. Among the many legitimate claimants on new funds potentially freed up by debt relief, it is easy to justify placing HIV/AIDS prevention and mitigation at the front of the queue. To this end, UNAIDS is advocating and initiating a process to expand the resource envelope through debt relief in order to scale-up the implementation of a performance-based multisectoral HIV/AIDS response, as an integral part of the broader HIPC Initiative. If Debt-for-AIDS is successful in the initial pilot countries, then UNAIDS may support efforts to expand this activity to other interested countries.

Zeitz, P., Rosen, S. and Simon, J. (2000)

Implementing debt relief to accelerate the HIV/AIDS response in sub-Saharan Africa

In: HIV/AIDS in the commonwealth 2000/1, Commonwealth secretariat, Kensington Publications, London

The expansion of the delivery of HIV/AIDS interventions to produce tangible, measurable and rapid results can be accomplished if a concerted effort by African governments and civil society is forthcoming. Whilst the need for financial resources is not the only barrier, the Debt-for-AIDS approach is advocated to fast-track the response.

The Response of Firms and Workplaces

ActionAid

Work against AIDS: Workplace based AIDS initiatives in Zimbabwe

Strategies for hope, No 8. London, ActionAid in association with AMREF

Anonymous (1998)

An AIDS management service for the managements of South African companies

AIDS Analysis Africa 1998, Feb 8 (1)

Campbell, C. and Williams, B. (1999)

Beyond the biomedical and behavioural: Towards an integrated approach to HIV prevention in the southern African mining industry

Social Science and Medicine, 48 (11):1625-1639

While migrant labour is believed to play an important role in the dynamics of HIV-transmission in many of the countries of southern Africa, little has been written about the way in which HIV/AIDS has been dealt with in the industrial settings in which many migrant workers are employed. This paper takes the goldmining industry in the countries of the Southern African Development Community (SADC) as a case study. While many mines made substantial efforts to establish HIV-prevention programmes relatively early on in the epidemic, these appear to have had little impact. This paper analyses the response of key players in the mining industry, in the interests of highlighting the limitations of the way in which both managements and trade unions have responded to HIV. It will be argued that the energy that has been devoted either to biomedical or behavioural prevention programmes or to human rights issues has served to obscure the social and developmental dimensions of HIV-transmission. This argument is supported by means of a case study which seeks to highlight the complexity of the dynamics of disease transmission in this context, a complexity which is not reflected in individualistic responses. An account is given of a new intervention which seeks to develop a more integrated approach to HIV management in an industrial setting.

De Coito, A.J. (1999)

Periodic presumptive treatment of women at high-risk. In Managing HIV/AIDS in South Africa: Lessons from industrial settings

In: HIV/AIDS Management in South Africa: Priorities for the mining industry, Williams, B., Campbell, C. and MacPhail, C.: 31-33. CSIR, Johannesburg

De Coito, T. et al (2000)

Forging multi-sectoral partnerships to prevent HIV and other STIs in South Africaís mining communities

In: Impact on HIV, Family Health International, Washington

In three years of implementation, Lesediís approach to community-based STI prevention and treatment for women at high risk of infection has developed from a small pilot project to a self-sustaining intervention that is being replicated in mining communities and other areas with similar transmission dynamics. This paper provides an overview of the initiative.

De Witt, C.C. (1991)

AIDS in the workplace. A legal perspective

Degree: Postgraduate division: labour relations, Rand Afrikaans University

The aim of this study was to investigate the impact of AIDS in the workplace from a legal point of view and to isolate some of the most important areas where legal regulation could become problematic. In general it was found that the best way to deal with AIDS is to try and prevent it by eliminating ignorance as far as possible and to bring the disease into the open by means of the early distribution of facts through proper education and counselling and especially the formulation and implementation of a sympathetic aids policy. This should prevent litigation on the basis of the unfair labour practice concept in the industrial court to a large extent. The legal position regarding specific problem areas such as confidentiality, testing, the value and regulation of screening, the freedom to employ, dismissal, termination and safety was analysed both in terms of existing South African law and also by comparison with developments internationally. It was found that a high premium is placed on security of employment and that AIDS sufferers should not be discriminated against, but treated objectively like other cases of serious illness.

Department of Health (1997)

Guidelines for developing a workplace policy and programme on HIV/AIDS and STDs

Department of Health, South Africa

These guidelines offer a comprehensive blueprint for a collaborative approach to HIV/AIDS at the workplace. As such, they address concerns and responsibilities of both employers and employees, of shopstewards, trade unions, supervisors, and managers. Principles for policy and programme development are outlined, together with checklists for HIV/AIDS and STD programmes. Matters concerning human resources and personnel include the management of employees who have HIV/AIDS, HIV testing in the workplace, and employee benefits. As the workplace is an ideal setting for prevention programmes, steps are outlined for education and information on risk reduction, basic principles of infection control, for condom distribution. A section on wellness management advises on counselling and care for PWHA and on links with other programmes in the workplace and with health services outside the workplace.

Department of Health (2000)

HIV/AIDS policy guideline: Management of occupational exposure to HIV

Department of Health, South Africa

The booklet offers advice on the management of occupational exposure to blood and body fluids that may contain HIV. It includes recommendations for HIV post-exposure prophylaxis, for the assessment of risk, and information on compensation for occupationally acquired HIV infection.

FHI/AIDSCAP (1995)

Private sector AIDS policy: Business managing HIV/AIDS

Family Health International, Washington

This is a ëhow-toí manual that describes a step-by-step approach to planning and implementing HIV/AIDS prevention programmes and policies for businesses. It is designed to help managers understand the impact of HIV/AIDS on business and to give guidance on how to minimize that impact through the development and implementation of appropriate policies and ongoing employee prevention programmes.

Gahagen, P. (1996)

An integrated approach to HIV/AIDS prevention programmes: The New Vaal experience

In: HIV/AIDS management in South Africa: Priorities for the mining industry, Williams, B.G. and Campbell, C.M.: 95-100. Epidemiology Research Unit, Johannesburg

Galloway, M.R. and Stein, J. (1998)

HIV/AIDS in the workplace: What South African companies are doing

AIDS Bulletin, 7 (1)

To obtain a clearer picture of the response of South African industry to HIV/AIDS, a questionnaire was mailed to 16 selected large and small companies representing different sectors of the economy. This article presents the responses of the four companies that responded: Impala Platinum, Woolworths, Tongaat-Hulett Group, and Nasionale Pers. None of the companies requires pre-employment HIV testing and employees who become ill as a result of HIV infection are treated according to general sick policy. Three companies have a formal HIV/AIDS policy document that is available to workers. Although employees are not obligated to report their HIV status to their employer, such disclosure is recommended so the worker can access treatment or disability benefits. Three companies have extensive AIDS education and counselling programmes in place and the fourth is in the process of developing one. These programmes may include peer counselling, condom distribution, prevention of social discrimination, and syndromic treatment of sexually transmitted diseases. HIV statistics were provided by some companies.

Ganesan, M. (2000)

Government, private sector and NGOs responses to HIV/AIDS at workplaces

13th International AIDS Conference, Durban

The issue of dealing effectively with the problems of HIV/AIDS in relation to workplace is crucial, at the local, national as well as international level. At present the policies drawn by ILO/WHO are being followed as guidelines by the developed countries; in India the initiatives taken at the workplace are still at a preliminary and premature stage. This paper reviews the global scenario of HIV/AIDS and the workplace within the overall context of the pattern of HIV/AIDS in the region, related issues of labour structure and conditions, state of health care services and the workplace responses to HIV/AIDS. This paper attempts to understand the implication of HIV/AIDS for the working population both in organised and unorganised sectors, in terms of factors influencing the vulnerability to HIV/AIDS and the social context which promotes these factors. Also, it deals with the national AIDS control initiatives taken by government, private sector and NGOs at the workplace.

Gresak, G.A. (1998)

AIDS in the workplace: HIV/AIDS and the law

AIDS Bulletin, 7 (1)

South Africaís Department of Labour is currently redrafting its Labour Relations Act, Employee Equity legislation, and Wage and Basic Conditions of Employment Acts. This process represents an opportunity to guarantee greater legal protection for HIV-infected employees and to develop more comprehensive workplace-based HIV/AIDS education, prevention, and care programmes. The courts are expected to classify HIV/AIDS as a disability, in which case affected individuals would be protected from discrimination and unfair dismissal under the new Labour Relations Act and Employment Equity Bill. A Code of Good Practice on HIV/AIDS has been developed by the AIDS Law Project to set employment standards and transform notions of equity into practice. Still required are objective criteria to ensure that company policy and procedures are not based on unfair discrimination against HIV-infected employees and mechanisms for protecting HIV-positive workers from harassment. The feasibility of passage by Parliament of a bill prohibiting pre-employment or pre-benefit HIV testing under any circumstances remains under debate. For companies to prevail in unfair discrimination charges, they will now be required to prove that HIV infection was unrelated to the action taken, there was consultation with and agreement from the unions, or that there is clear evidence that alternative measures would mitigate against the majority of employees.

Heywood, M. (1996)

Mining industry enters a new era of AIDS prevention. Eye witness: South Africa.

AIDS Analysis Africa, 6 (3)

Miners in South Africa are now more at risk of contracting HIV than of being in a mining accident. Some epidemiologists predict that the mines could be experiencing 12 000-40 000 deaths related to AIDS by 2010. In 1986, HIV infection among mineworkers was 1/3 500. Gencor medical personnel now estimate that 20% of the company's employees are HIV-positive and that 30 workers are dying of AIDS each month. In August 1995, the Chamber of Mines, the World Bank, and the World Health Organization (WHO) held a seminar to discuss the potential impact of the epidemic; it was followed by a workshop, ëResearch Needs and Priorities for the Management of HIV/AIDS Transmission in the Mining Industry,í which was organised by the Epidemiology Unit in Johannesburg. The mining sector is in a unique position to fight HIV because it already has an extensive medical infrastructure with the capacity to treat STDs effectively, a unionised workforce to provide a pool of peer educators, and recruitment agencies to extend HIV-prevention into rural areas. Obstacles to effective HIV/AIDS education include discrimination (workers are tested for HIV without consent, and dismissed, if found to be positive, regardless of union agreements); a psychological factor that is related to underground work and produces recklessness; poor living conditions; and illiteracy. Many myths remain about the cost of improving social conditions and introducing HIV-prevention programmes.

Heywood, M. (1995)

The rights of people with HIV/AIDS to employment, benefits and social security.

AIDS Bulletin, 4 (2):10-1.

In South Africa, the business sector and the South African National Defence Force try to explain their discrimination against persons with HIV/AIDS in terms of their special circumstances, which require them to protect themselves from HIV/AIDS. Yet business can benefit from nondiscrimination policies. Major employers, including the Chamber of Mines, contributed to the drafting of the most comprehensive statement on the rights of people with HIV ñ the National AIDS Plan. This plan is also the policy of the government. Yet this commitment to nondiscrimination is shaky. The mining industry is considering implementing a pre-employment HIV testing programme. The policy of excluding HIV-positive persons from employment is bad for business. There are large direct and indirect costs in determining HIV seropositivity of employees. Implementation of the policy would exacerbate existing social problems, resulting in a reduction in foreign and domestic investment. The business sector challenges the notion that HIV-positive employees should have the same rights and entitlements as other employees. Businesses sometimes exclude HIV-positive employees from their employee benefits or medical plans. More and more health care professionals feel that medical aid plans should include people with HIV. The cost per person on a managed health care programme should be shared among employers, the government, and the individual employee. The cost is better than the much greater costs that will occur as a result of reduced productivity, high employee turnover, industrial relations in turmoil, and the burden to the government of tens of thousands of unemployed people with HIV who are healthy enough to still contribute. Workplace HIV/AIDS prevention programmes can prevent more than 50% of all new HIV infections, according to the World Health Organization.

Llados, J., Plumley, B., and Hussey, J. (1998)

The global business council on HIV/AIDS

12th International Conference on AIDS, Geneva

A global private sector initiative to promote public/NGO/private partnership responses to HIV/AIDS. The launch of the Global Business Council (GBC) on HIV/AIDS in Edinburgh in October 1997, offers both an opportunity and a challenge to business leaders. Companiesí interest in HIV/AIDS extends beyond their immediate experience. Thanks to the variety of existing successful business initiatives, the GBC can use leadership, networking and discussion to widen that interest, to learn from companies, and ultimately to help UNAIDS and others to maximise the benefits to the global fight against AIDS. Examples show private/public sector partnerships do work, extending the company's reach beyond the workplace and its immediate community.

London, L. (1998)

AIDS control and the workplace: The role of occupational health services in South Africa

International Journal of Health Services, 28 (3):575-91.

London, L. (1996)

AIDS programmes at the workplace: A scoresheet for assessing the quality of services

Occupational Medicine, 46 (3):216-20

Meeson, A. (2000)

Mining for solutions to HIV/AIDS

South African Labour Bulletin, 24 (1)

This article provides an overview of interventions at Harmony Goldmine in Virginia, South Africa. It includes perspectives from the National Union of Mineworkers (NUM).

Meeson, A. (2000)

Tackling HIV/AIDS: Sactwu sets the example

South African Labour Bulletin, 24 (3)

This article reviews the South African Clothing and Textile Workers Union (Sactwuís) response to HIV/AIDS. The approach includes short-term education, and the development of an industry model, including partnerships with businesses.

Meeson, A. (2000)

Not so sweet: HIV/AIDS and South Africaís canefields

South African Labour Bulletin, 24 (5)

This article provides an overview of sugar industry issues including perspectives of workers, unions and managers.

Meeson, A. and van Meelis, T. (2000)

Practising in parallel: Not the best practice

South African Labour Bulletin, 24 (2)

This article reviews the AIDS strategy of Eskomís widely acclaimed workplace intervention. There is some evidence of schisms between unions and management that undermine AIDS programming.

Michael, K. (1999)

Best practices: A review of company activity on HIV/AIDS in South Africa

AIDS Analysis Africa 1999 Oct-Nov; 10 (3):5-6

In 1998 the Health Economic and HIV/AIDS Research Division at UND surveyed a number of companies, in order to document ëbest practicesí in the management of HIV/AIDS at the workplace. The paper documents the results.

Moema, S., Mzaidume, Z., Williams, B., Campbell, C., Wilson, D. and Dube, N. (1998)

An intervention trial in South Africaís goldmining industry

12th International Conference on AIDS, Geneva

South Africa's mining industry is central to the country's economy, employing almost a million people and accounting for 60% of export earnings. Carltonville goldmines in Gauteng Province represent South Africa's largest mining area, with over 100 000 miners. The West Rand Region, in which Carltonville is situated, has Gauteng Province's highest HIV prevalence, of 22%. The social context of mining, particularly migrant labour and hazardous physical work, relieved primarily by alcohol and sex, is conducive to rapid HIV transmission. An intervention trial, involving government, corporate, union, community and research partners, to reduce STD/HIV transmission in Carltonville, was developed in 1996. The research trial compares STD and HIV incidence in among 1 000 miners in Carltonville intervention arm and 1 000 miners in the adjacent Westonaria goldmining comparison arm. The intervention has two major components: comprehensive STI care; and peer education to motivate behavioural change and promote condoms. It has sub-components: formative assessment to understand the social context of STD/HIV transmission; mapping to understand the distribution of risk and STIs; training and supervising STI care providers, to provide comprehensive, primary, STI management; recruiting and training community peer educators to promote STI symptom knowledge, recognition, suspicion and prompt, informed, care seeking, to motivate behavioural change and promote condoms; extensive condom distribution, in workplaces and the wider community; and comprehensive evaluation, using an intervention trial design and collecting detailed annual behavioural, STI prevalence and incidence and HIV incidence data. The project has secured the commitment of all key stakeholders, to support a comprehensively implemented, rigorously evaluated intervention trial, in South Africa's most strategic industry. The project's approach, building crosscutting alliances to implement well evaluated interventions, may have broader relevance, as an approach to the central problem of reducing STI/HIV transmission in situations of migrancy, whose centrality to HIV transmission throughout Africa, is increasingly recognised.

Mzaidume, Y. (1999)

Managing HIV/AIDS in South Africa: Lessons from industrial settings

In: HIV/AIDS management in South Africa: Priorities for the mining industry, Williams, B, Campbell, C. and MacPhail, C.: 103-106. CSIR, Johannesburg

NEDLAC (1995)

HIV/AIDS and the employment code of good practice

SA Labour Bulletin, 19 (5)

Pikholz, T. (1992)

An investigation into AIDS prevention in the workplace ñ guidelines to a social marketing workplace preventative AIDS strategy

Degree, Dept of business science, University of Cape Town

AIDS is not only a medical issue: it has social, political, religious, economic, financial, legal and ethical implications. AIDS in the workplace is a vital cog in the AIDS pandemic wheel and its potential impact on the workplace is immeasurable: employees fall into the reproductive age group and are therefore vulnerable to AIDS. This in turn adversely affects business in terms of loss of skilled manpower, decreased productivity, workplace disruption, higher health care and employee benefits costs . It is in the interests of employers and employees to take advantage of the organisational structure and undertake preventative AIDS efforts in the workplace. This dissertation comprises an application of social marketing principles and techniques to AIDS prevention in the workplace. This research investigates the provisions made for AIDS in companies in South Africa, and to gain an understanding of the preventative aids provisions which the respondents consider practical to implement in their workplace, in order to generate conclusions and recommendations. From the research findings and discussions arduous challenges have been identified. The solution does not lie simply in recognising these challenges. There is a need for action. Evidence from the literature suggest that social marketing principles and techniques are compatible with the task of AIDS prevention in the workplace. It is proposed that a solution to the identified challenges is a workplace social marketing preventative AIDS programme.

Regensberg, L.D. et al (1988)

Affordable management of HIV infection in the private sector

South African Medical Journal, 88 (8):945- 948

Reyna, F.J. (2000)

Mobilising the private sector to support NGOs actions

13th International AIDS Conference, Durban

Given the total lack of government funds to support NGO's initiatives in Venezuela, it is necessary to develop strategies to have access to private funds. This task has required intense awareness initiatives, given also the lack of a broad information and prevention government promoted campaign. The HIV/AIDS epidemic is still not considered one of those pressing and urgent issues that society as a whole, including the private business sector, has to deal with. Description: A series of step-by-step initiatives was developed in order to reach the private business sector and to motivate some of its leaders in supporting the HIV/AIDS cause. First, the authors started with programmes that were helpful to people living with HIV/AIDS, but easy to finance. At the same time, they also had to implement some initiatives that would have a broader scope, such as information and prevention efforts for the community. Once they had acquired in depth experience and specific data on the problems posed by the HIV/AIDS epidemic, they were ready to present those business leaders, on the one hand, with practical and measurable results of their work, and, on the other hand, with proposals that would help broaden even more the scope of such work. Conclusions: Working with the private business sector, breaking through its resistance to face up to the HIV/AIDS epidemic, requires persistent and continuous work, both in terms of information and awareness and of getting its financial backing to carry out HIV/AIDS community initiatives. Even though Venezuela has been undergoing a deep political and economic crisis, four years after the establishment of the programmes, the authors have carried out many initiatives funded exclusively by individuals and the private business sector: access to treatment, multimedia awareness campaign, national AIDS hotline and, opening in February 2000, Venezuela's first HIV/AIDS Care and Prevention Center. Lessons Learned: Committed HIV/AIDS activists must permanently find creative ways to make their work possible, and financial resources are one of the most pressing issues they have to deal with permanently. However, building on the initiatives we carry out and showing results that are truly beneficial to the community, it is possible to mobilise the private business sector to back HIV/AIDS programmes.

Rosen, S., Vincent, J.R., Simon, J.L., Singh, G. and Thea, D.M. (2000)

A model for assessing the costs of workforce HIV/AIDS

Harvard Instititute for International Development, Harvard University, MA, USA

As AIDS morbidity and mortality skyrockets in the countries of southern and eastern Africa, there is a great need for careful quantitative assessments of the workforce-related costs of HIV/AIDS to busnesses. This paper presents and approach and methodology for carrying out the assessments. Because of the time gap between infection and symptoms, the discounted present value of incident HIV infection, not the current costs of prevalent infections, should be the unit of concern to companies. The impact of HIV/AIDS on the workforce can reduce a companyís profits in two ways; increased expenditures and reduced revenues that are directly associated with an infected employee and replacent; or due to the spillover impacts of HIV/AIDS on the workforce as a whole.

Shepard, D.S.

Levels and determinants of expenditures on HIV/AIDS in five developing countries

In: Ainsworth, M., Fransen, L. and Over, M., Confronting AIDS: Public Priorities in a Global Epidemic, European Commission, 1998

Simon, J., Rosen, S., Whiteside, A., Vincent, J.R. and Thea, D.M. (2000)

The response of African businesses to HIV/AIDS

In: HIV/AIDS in the commonwealth 2000/1, Commonwealth secretariat, Kensington Publications, London

Sub-Saharan Africa faces daunting economic and social challenges. Although a few countries posted economic gains and carried out multiparty elections, the 1990s were a period of slow economic growth. This paper provides and overview of responses.

Rosen, S., Simon, J.L., Thea, D.M. AND Vincent, J.R. (2000)

Care and treatment to extend the working lives of HIV-positive employees: calculating the benefits to business

Harvard Instititute for International Development, Harvard University, MA, USA

Although HIV infection rates in South Africa have been high and rising for nearly a decade, the epidemic of HIV/AIDS-related morbidity and mortality is just beginning. As South African adults start to sicken and die, concern is mounting about the potential costs to companies of HIV/AIDS among employees. When a business recognizes the threat posed by HIV among employees, it can pursue three basic response strategies for mitigating short- and long-term financial consequences: (1) try to prevent new infections; (2) avoid or reduce the costs associated with existing and future infections; and (3) provide treatment and support for infected employees to extend their productive working lives and thus postpone the costs of infection. This paper assesses the potential benefits to South African businesses of the third strategy. We describe an approach and methodology for analyzing the benefits of interventions that extend the working life of employees and demonstrate such an analysis using published data on the costs of HIV/AIDS to companies. The analysis indicates that the benefits to companies of investments in treatment and care are likely to exceed the costs for some existing interventions. Further work is needed to identify effective and affordable interventions, assess the benefits to companies of implementing the interventions, and bring these benefits to the attention of business and government leaders.

Smart, R. (1999)

HIV/AIDS in the workplace: Principles, planning, policy, programmes and project participation

AIDS Analysis Africa 1999 June-July; 10 (1):5-6

The workplace is an appropriate and important setting for AIDS programmes because workers spend a significant amount of time at work. This article outlines the criteria for a successful HIV/AIDS/STD/TB programme for the workplace.

Smart, R. (2000)

AIDS care: Why and how should industry respond?

AIDS Analysis Africa, 10 (5):13-4

Decentralisation and integration of HIV/AIDS services offer the best chance of sustainability and cost-effectiveness. There is a need for comprehensive care through all stages of infection and across a continuum of care.

Smart, R. and Strode, A. (1999)

South African labour law and HIV/AIDS

AIDS Analysis Africa, 10 (3)

Organisations should review all workplace policies and practices and employment conditions to check for compliance with the legislation. These laws, codes, and rights pertain particularly to HIV testing, policy on occupational exposure and prophylaxis, and confidentiality of medical information. This paper provides an outline of laws and regulations impacting on the management of HIV/AIDS in the workplace, providing for the protection of the environment, employees and the public: South African labour legislation, legislation pertaining to medical insurance/benefits, international agreements and codes, and the Bill of Rights in the South African Constitution.

Strachan, K. and Clarke, E. (2000)

Everybodyís business

Metropolitan Group, South Africa

UNAIDS (1998)

HIV/AIDS and the workplace: Forging innovative business responses

UNAIDS, Geneva

UNAIDS (2000)

The business response to HIV/AIDS: Impact and lessons learned

UNAIDS, Geneva

This report provides an outline of the macroeconomic and business impact, and of the business response to HIV/AIDS. Profiles of business activities in response to HIV/AIDS are appended. Global systems of production offer opportunities for cross-sector collaboration on HIV/AIDS interventions. Apart from company-provided HIV/AIDS programmes, partnerships with governmental organisations and NGOs are of utmost importance. Programmes and statistical indicators should be monitored. Early investments, such as education and prevention campaigns and health care provision, while initially costly, have long-term cost benefits.

Williams, B., Campbell, C. and MacPhail, C. (1999)

The Carletonville pilot survey. In: Managing HIV/AIDS in South Africa: Lessons from industrial settings

In: HIV/AIDS management in South Africa: Priorities for the mining industry, Williams, B., Campbell, C. and MacPhail, C.,: 131-149. CSIR, Johannesburg

Williams, B. and Campbell, C. (1998)

HIV/AIDS: Policy and practice in the South African mining sector

AIDS Bulletin, 6 (1-2):45-6

South Africaís mining sector employs approximately 350 000 people, mainly migrant workers. While the major mining houses are committed to fighting HIV and have provided information and education on HIV, there has been little evidence of significant behavioural change. A need exists to go beyond traditional, information-based approaches and develop innovative interventions at the biomedical and social levels. More participatory programmes are needed. Mine-based programmes will succeed only if they are integrated with programmes which address the needs of the broader communities within which the mines operate. Industry, unions, state health services, research institutes, and local community organisations must therefore be actively involved in, and have co-ownership of, the programmes. The syndromic management of STDs is already being implemented in many mine and provincial health clinics, and condoms are provided free by the mines. Peer education and counselling, and evaluation are discussed.

Williams, B. and Campbell, C. (1996)

HIV/AIDS management in South Africa: Priorities for the mining industry

Epidemiology Research Unit, Johannesburg

Williams, B. and Campbell, C. (1998)

Creating alliances for disease management in industrial settings: A case study of HIV/AIDS in workers in South African gold mines

International Journal of Occupational and Environmental Health, 4 (4):257-64

UNAIDS (1998)

Corporate planning for prevention and mitigation of HIV/AIDS

UNAIDS, paper prepared for UNAIDS consultation on workplace actions for HIV/AIDS in East and Southern Africa

The Response of NGOs, CBOs and Communities

Ali, S. (1998)

Community perceptions of orphan care in Malawi

Southern African Conference on Raising the Orphan Generation, Pietermaritzburg

This paper reviews community perceptions of orphan care. The author finds that community participation is vital, and that the extended family can absorb orphans if community efforts are employed to lessen the financial strains on the family.

Caldwell, J., Caldwell, P., Ankrah, M., Anarfi, J.K., Agyeman, D.K., Awusabo-Asare, K. and Orubuloye, I.O. (1993)

African families and AIDS: Context, reactions and potential interventions

Health Transition Review, 3, Suppl:1-16

This paper reviews publications and research reports on how sub-Saharan African families have been affected by, and reacted to, the AIDS epidemic. The nature of the African family and its variation across the regions is shown to be basic to both an understanding of how the epidemic spread and of its impact. The volume of good social science research undertaken until now on the disease in Africa is shown to be extremely small relative to the need.

Chandran, J., Aylur Kailasom, S., Solomon, S., Santhanam, A., Plewman, C. and Crane, S. (2000)

Community based social marketing in India ñ a unique concept

13th International AIDS Conference, Durban

As the HIV/AIDS epidemic and sexually transmitted diseases continue to advance at a rapid pace in India, the strategies to promote condom usage and other quality reproductive health care products is imperative. Conventional product delivery mechanisms have their own advantages but lack personal interaction and end user knowledge levels remain unmeasured. An alternative to the conventional social marketing methodology was tested at Chennai, south India, between July '97 and December '99 with the following objective. ëTest if remunerating individuals for their effectiveness in selling products through word of mouth networks can significantly increase the demand for supply of the reproductive and sexual health products.í Some 8 000 people from the community registered to become active change agents and 40% were women. Seventy-five percent of all the people who attended the initial training sessions, enrolled as change agents and close to 50% of the condoms and sanitary pads sold were on repeat purchase indicating a strong demand creation. If this project is further fine-tuned to enrol change agents on a predetermined economic incentive pattern, a strong community movement is envisaged. Community outreach meetings and network creation is a positive indicator in a conservative environment such as this city in south India, with strong traditional values and beliefs.

Costigan, A., Ngugi, E., Odek, W.O., Plummer, F.A., Moses, S. and Oneko, M. (2000)

The applicability of micro-finance models in providing economic alternatives to HIV vulnerable sex workers in Nairobi, Kenya

13th International AIDS Conference, Durban

Many marginalised women in Nairobi, Kenya are 100% dependent on commercial sex. Such dependence renders them vulnerable to client refusal to use condoms and STI/HIV infection. The sex workers persistently request income-generation support to reduce/eliminate their dependence on sex work. Two hundred and nine commercial sex workers were, therefore, recruited by the University of Nairobi into an alternative economic activities study to explore the extent of their uptake of credit and small business activity through an adapted micro-finance model and the impact of this uptake on safer sexual behaviour. An initial baseline was conducted and a follow-up credit and training needs assessment carried out. Ninety out of 209 women withdrew participation prior to receiving credit funds. The women exited the study for the following reasons: a) 24.2% feared their capacity to meet the weekly repayments; b) 16.8% did not like or wish to be a co-guarantor of the loans of the other women in their small group of 5 or larger group of 25; c) 14.7% reported domestic problems; d) 11.6% did not know the women in their credit group well enough; e) 8.4% were rejected by their group members; f) 7.4% felt that the first loan of US$143 was too small to start a business. Data from the exit survey suggests that if the micro-finance model is to serve the HIV vulnerable female sex workers, it needs to be applied in a way that suits their context. Women without prior business experience should be given added training, the loan guarantee groups should be formed with women who know each other very well, and where applicable, new approaches used to complement existing models.

Cruse, D. (1997)

Community health workers in South Africa: Information for provincial policy makers

Health Systems Trust, Durban

International experience has shown that community health workers can make a valuable contribution to improving basic health status in poor communities. However, the nature of their role in South Africa's primary health care system has yet to be defined. This paper reviews the role of community health workers, and their cost effectiveness.

Department of Social Development (2000)

A draft national strategic framework for children infected and affected by HIV/AIDS

Department of Social Development, Pretoria

Dijkstra, L. (1997)

Suffer the little children: conviction or compassion? Hospice care for HIV orphans in a rural area of KwaZulu-Natal

AIDS Bulletin 6 (1-2):39-40.

Donahue, J. (2000)

Community-based economic support for households affected by HIV/AIDS

The Synergy Project, Discussion Paper No 6, HIV/AIDS Division of USAID, Washington

The burden of HIV/AIDS is felt first by the families of those stricken, and the first line of response should be to mitigate the impact on those households, in particular by improving their impact-earning capacities. It is suggested that planners should consider a two pronged approach to mitigating impacts ñ building economic resources of households, primarily through microcredit programmes, and supporting the creation of community safety nets.

Donahue, J. (2000)

Microfinance and HIV/AIDS: Itís time to talk

Displaced Childrenís and Orphans Fund, USAID, Washington

The consequences of HIV/AIDS in Africa are unprecedented and far-reaching. For many families, concerns about sliding into poverty subsume the other effects of HIV/AIDS. Income and savings become crucial weapons against the impact of HIV/AIDS as households struggle to build and protect their income resources. Microfinance services can help families increase their income and build their savings. However, from most microfinance institutions the impact of HIV/AIDS on their clients and on the institution is an emerging issue. Innovations are vital for the good of clients and institutions. Three areas should form the basis of innovation: developing new products and services; watching the bottom line; and fostering strategic alliances with HIV/AIDS organisations.

Donahue, J. and Williamson, J. (1999)

Community mobilisation to mitigate the impacts of HIV AIDS

Displaced Childrenís and Orphans Fund, USAID, Washington

Provides and overview of a range of programmes in African countries, and identifies processes contributing to effective strategies.

Goma, G.M.N., Ngoma, F.J., Kruger, C.H., Manda, C., Mwape, K., Chilangwa, M., Kampamba, C., Kasanka, E., and Kaviswile, U.K. (2000)

Strengthening community home-based care programs

13th International AIDS Conference, Durban

In Zambia, many communities are operating Community Based Home Care (CBHC) programmes to support the infected and affected. The quality of services offered is inadequate due to high levels of poverty. HELP in partnership with other NGOs is implementing this programme to achieve its intended goal of strengthening them. Through donor funding, the programme embarked on the following (a) forming partnerships with identified NGOs; (b) provision of funds, technical and training for improved management of volunteer based initiatives; (c) provision of nutritional and income supplements and food to insecure homes; (d) provision of funds, technical assistance and training for increased access to economic opportunities, surviving members and CBHC volunteers. The programme has achieved the following: (a) establishment of partnerships; (b) volunteer-based initiatives improved; (c) improved service delivery by CBHC programmes; (d) nutritional and income supplement provided; (e) increased access to economic opportunities through income-generating activities.

Goudge, J. and Govender, V. (2000)

A review of experience concerning household ability to cope with resource demands of ill health and health care utilisation

Regional Network for Equity in Health in Southern Africa (Equinet) and Training and Research Support Centre (Tarsc), Harare

Policy has generally been ineffective in reaching the poor who have substantial problems accessing health care. The links between poverty and ill health are examined. There is a need to take an holistic view of poor households and to design health provision and financing mechanisms in order to understand the responses to ill health.

Halkett, R. (1998)

Enhancing the quality of life for children without parents in the South African context

Southern African Conference on Raising the Orphan Generation, Pietermaritzburg

This paper reviews literature on orphan care and additional care options in the context of the Child Welfare Movement.

Harber, M. (1998)

Developing a community-based AIDS orphan project: A South African case study

Southern African Conference on Raising the Orphan Generation, Pietermaritzburg

This paper describes the development of an AIDS orphans project under the auspices of the Thandanani Association. The complexity of setting up a community-based project is noted to be a slow process which contrasts strongly with the rapidly developing AIDS epidemic. The importance of support to women is noted ñ particularly access to credit and reducing demands on women's labour.

Hecht, R. (2000)

Poverty, debt and AIDS ñ Mainstreaming the epidemic and mobilizing additional resources for the response

UNAIDS Inter-country team for West and Central Africa

Developing and financing programmes to slow the spread of the epidemic are amongst the highest priorities of development organisations and governments. There is a need to mobilise large-scale resources rather than adopt piecemeal approaches.

Herz, A.M., Kasiyamhuru, J., Martin-Herz, S.P., Powell, G., Herz, D.M., Kanhema, N., and Herz, H.A. (2000)

Zimbabwe AIDS orphan projects funded through privately organised shona stone sculpture ëcultural diplomacyí

13th International AIDS Conference, Durban

The AIDS crisis in Zimbabwe is creating an overwhelming orphan tragedy. New projects can be initiated with foreign financial assistance, but private individuals in countries of the developed world feel far removed from this African crisis. Donor fatigue may be widespread due to a commonly distorted image of sub-Saharan Africa as a hopeless world of war and disease solely reliant on foreign aid. In sharp contrast, however, the Western art world highly values many Zimbabwean Shona stone sculptors for their contributions to modern art. Individual, private efforts identified two grassroots programmes in Zimbabwe presently in need of outside financial assistance: Vimbainesu, a small, African model orphanage caring for orphans on rural communal land requires short-term financial assistance and the Child Protection Society which needed funds to pay annual school fees for growing numbers of children without sufficient family financial support to attend primary school. Due to the economic disparity between the Zimbabwean economy and the prices Shona stone sculptures can achieve in Western markets, a programme was developed to export sculptures for sale abroad. This resulted in multiple benefits: supporting local Zimbabwean artists, broadening appreciation of modern African culture, while exposing a new audience to the current Zimbabwean orphan tragedy. Donor response thus far has been overwhelming, creating the prospect of sustainable support for AIDS orphans in Zimbabwe. It can be concluded that using a fair-trade concept, highly valued Shona Stone sculptures produce financial resources for Zimbabwean AIDS orphan projects. More importantly, they create an environment of mutual cultural respect that provides the basis for collaboration between Zimbabwean sculptors, individual financial supporters of two fundraising foundations (in Germany and the United States), and the Child Protection Society. Together they are supporting children orphaned by AIDS in Zimbabwe.

Hughes-Gibbs, B. (2000)

The care umbrellas of Kalafong ñ a continuum of holistic care and prevention for people infected affected by AIDS

13th International AIDS Conference, Durban

The ëCare Umbrellas of Kalafongí is a unique series of linked modular care and prevention programmes in support of people infected or affected by AIDS. The programmes were designed by multi-disciplinary teams of professional and volunteer Health, Welfare, Education, Early Child Development specialists and general care givers drawn from an NGO (KERUX/MOHAU), the University of Pretoria, Kalafong Hospital and the community. The six-year-old programmes, provide holistic care and prevention which simultaneously address the physical, emotional, socio/economic, spiritual, legal/human rights and information needs of patients and their families. Care is provided for 7 500 HIV positive adults, 2 500 infected children and approximately 12 000 family members. Most of the people are from disadvantaged circumstances. The main thrust of the programme is to translate people from dependence to sustained socio/economic independence. The programmes include feeding and clothing schemes, employment of People Living With AIDS, and training in a range of income generating skills. Specialist programmes include counselling and a legal/human rights advisory service. A Transport and Social fund assists patients to obtain medical care. Dedicated children's facilities include a 30 bed hospice for respite and terminal care and a 35 bed children's home for AIDS related abandoned or orphaned children. A community Child Life Centre is about to be built to address growth and development retardation problems in HIV infected and affected children. A successful fostering and adoption programme is also in place. Clinical drug trials, for infected mother/child pairs, are conducted under university ethical guidance. A recent development is the training of 50 people, from a nearby former township, in home based holistic care. Negotiations are currently being held with the National Department of Welfare to replicate what is known as the KERUX/MOHAU Holistic Care Model in other parts of the country.

Hunter, S. and Williamson, J. (2000)

Responding to the needs of children orphaned by HIV/AIDS

The Synergy Project, Discussion Paper No 7, HIV/AIDS Division of USAID, Washington

The growing number of orphans in countries hard-hit by HIV/AIDS suffer a variety of deprivations and vulnerabilities. These include the loss of their families, depression, increased malnutrition, lack of immunisations or health care, increased demands for labour, lack of schooling, loss of inheritance, forced migration, homelessness, vagrancy, starvation, crime and increased exposure to HIV infection. Given the scale of the problems, the first line of response from the affected children, families and communities will be insufficient. Recent experience suggests that five basic intervention strategies can help maximise the impact of local, community-based responses: strengthening the capacity of families to cope with their problems; stimulating and strengthening community-based responses; ensuring that governments protect the most vulnerable children; building the capacities of children to support themselves; and creating an enabling environment for the development of appropriate responses.

Jackson, H. and Mhambi, K. (1992)

AIDS Home care: A baseline survey in Zimbabwe

Research Series No 3, Research Unit, School of Social Work, Harare

This research reviews organisational responses to AIDS home care. A common finding was that poverty is the primary concern of patient and family, and that home care must involve the provision of basic food, medication and possibly money for essentials. Funds tend to be allocated to training of health care workers, but lesser amounts are devoted to programme implementation and basic welfare needs. The most effective schemes tended to be ones in which home care providers were involved in planning and establishment of services. Care programmes incorporating existing staff in hospitals fared less well.

Kezaala, R. (1998)

The practicalities of orphan support in East and Southern Africa: Planning and implementation of multi-sectoral social services for children and child carers

Southern African Conference on Raising the Orphan Generation, Pietermaritzburg

This paper examines the practicalities of caring for orphans in east and southern Africa, highlighting the issues, ideas and experiences in responding to the challenges, particularly in Uganda, Tanzania, Zambia, Malawi and Zimbabwe, with a view to guiding policy direction. There is a need to document where the most vulnerable orphans are likely to be. There is a multiplicity of considerations for raising the available income for families taking in orphans. The role of private sector partnerships should be explored. With regard to psychological support to orphans, expert care will not be accessible, hence there is a need for training of volunteers and extension workers to fill this gap.

Khonyongwa, L. (1998)

Children and families affected by HIV/AIDS: A community-based income generation project with a focus on needy children in Malawi

Southern African Conference on Raising the Orphan Generation, Pietermaritzburg

The care of orphans and families taking care of the chronically ill calls for immediate community action. This burden compounded with high poverty levels means that coping mechanisms of families and communities are impaired. ActionAid and UNICEF undertook a pilot project to strengthen families and community coping capacities through income generating activities with a focus on vulnerable children and families. The programme demonstrated the benefits of community participation in saving schemes, and there were significant benefits in the area of food intake, purchase of clothing and support to orphans.

Kitheka, J.K. (2000)

Strategies to cope with the socioeconomic stress caused by HIV/AIDS (pilot testing phase)

13th International AIDS Conference, Durban

The aim of the programme is to test and develop a cost effective and psychosocially convenient care system for people living with AIDS (PWAs). Current hospital care systems for PWAs often results in the depletion of families resource base, eventually leaving families destitute upon the death of their ailing members. It also plucks the sick away from the loving care of the family confines, subjecting them to protracted loneliness, suffering and death. Further, AIDS sufferers alone currently occupy over two thirds of national hospital beds, often for long periods of time, thereby denying access by and attention to other health issues. This programme aims to develop a home/community care system as opposed to hospital care, for PWAs to cope both with phychosocial and the economic impacts of HIV/AIDS. Skilled functionaries and specially trained health workers are used to train carers and potential carers as well as in outreach activities which include home visits, counselling, treatment of opportunistic infections, supply of drugs/supplies and condoms as well as offering referral services. The programme extensively uses the traditional extended family and the relatively modern socioeconomic networks (eg. specific interest groups) in providing home based care and support for the affected and infected. Results: The programme has attracted local support and participation as well as increased voluntary HIV testing. However, it has been difficult to retain the trained home care givers in their role since they often go out to seek paying activities for their subsistence ñ leaving the task of care with the younger members of the family. It has therefore been widely recommended that an income-generating component be integrated into the project and to use elderly, more stable members of the family in the caring role.

Knight, S. (1996)

National review of community health worker programmes

Independent Development Trust, South Africa

Krift, T. and Phiri, S. (1998)

Developing a strategy to strengthen community capacity to assist HIV/AIDS affected children and families: The COPE programme of the Save the Children Federation in Malawi

Southern African Conference on Raising the Orphan Generation, Pietermaritzburg

This paper reviews community-based responses to orphan care. It notes the strains on community coping methods. A range of observations are made including the generalisation of community support initiatives to include both families that are not directly affected by HIV/AIDS.

Lamont, G.J. (1998)

Creating community workers for under resourced nations using income generation programmes as subsidies to increase staff team

12th International AIDS Conference, Geneva

Wola Nani a caring response to AIDS operates by providing counselling services and family and community support programmes in so called poorer areas of South Africa including ëtownshipsí. With the current rise in infections being parallelled with the reduction of available funding for programmes Wola Nani increases staff compliment by creating sustainable job creation programmes. Selected staff at each centre are offered income generation facilities in response to a contracted period of community work. For example, 15 hours work per week on income generation programme may yield US$100 per month. In response to access to income generation programme client puts back 12 hours per week to the agency for counselling programmes. These subsidised staff operate in clinics and move from clinic to community for follow up of families affected by HIV providing primary health care advice and counselling as well as support in treatment and prevention programmes. Linked to the income generation programme is a strategic marketing strategy for goods to sustain the programme. Wola Nani would like to present a workshop on strategic income generation subsidies for increasing staff compliment and present in slide and poster display the overall strategy for developing such a programme.

Loewenson, R. (2000)

Public participation in health: Making people matter

Training and Research Support Centre (TARSC), Zimbabwe, and Institute of Development Studies (IDS), UK

Participation of communities is widely argued to be an important factor in improving health outcomes and the performance of health systems. Despite this, and the common inclusion of ëparticipationí as both means or end in health policy, participation is poorly conceptualised and operationalised. This paper argues for wider inclusion of social groups from civil society, elected leadership and health systems in structures that set and audit health policies and priorities. It is argued that the social investments in building participation and public accountability are an essential area of health investment.

Lundberg, M. and Over, M. (2000)

Transfers and household welfare in Kagera

International AIDS Economic Network (IAEN) Conference, Durban

This paper explores one of the mechanisms by which households deal with a death. The evidence shows clearly that some households fare much worse than others. But that observation itself motivates the key question: why do some households manage better than others? Own wealth, and the ability to self-insure, appears to be part of the answer. Although this analysis has only made oblique reference to it, it is clear that not all households need assistance. Similarly, it appears that wealthy households are wealthy not only in physical and human assets, but also in ësocialí assets, or social capital. They have a larger, broader, and presumably wealthier network of friends and relatives on whom they can depend in times of crisis. They are more likely to receive assistance, and they receive more assistance, than poorer households. In an environment of incomplete and unenforceable contracts, a larger social network provides greater resources for common risk-pooling. Those outside the network, in this case the poor, can only have access to the risk-pooling resources through formal credit contracts. While some leakage is necessary to maintain wider political acceptance of assistance programmes, indiscriminate provision of assistance is both fiscally irresponsible and socially inefficient. It is preferable to focus attention to those who are unable to self-insure.

Luzinda, I.N., Senabulya, M. and Musiitwa, R. (2000)

The quality and continued care for the PWAs at their homes, a case study in Taso Entebbe, Uganda

13th International AIDS Conference, Durban

In Uganda, one in four people is reported to have HIV. Unfortunately, for many, hospital care is not affordable due to the economic and social impact of AIDS on families. Secondly, accessibility to treatment centres is also a problem. Therefore, the need for home- and community-based Care services was found to be a real necessity to the PWAs. In 1999, 100 clients who had AIDS manifestations were reported by care givers and caretakers. A ëhome care teamí comprised of nurses with counselling skills visited and followed them for six months offering them home counselling, medical/nursing care, personal hygiene and AIDS education. After six months 64 had improved health, 12 had died, conditions of 8 worsened and taken to their villages, while 16 had problems still persistent but had a will to live. The quality of life of PWAs is determined in large measure by their access to care at home. To bridge the gap and to improve the quality of life, home-based care is an important ingredient in this aspect.

Makan, B. and Bachmann, M. (1997)

An economic analysis of community health worker programmes in the Western Cape Province

Health Systems Trust, Durban

This study describes five community health worker (CHW) programmes and one CHW training centre operating in the Western Cape. CHWs provide essential primary health care services, particularly in marginalised communities. A key finding was that the curative and preventive roles of CHWs are integrally linked, with curative visits forming a platform for health education. There is a clear need for policy related to CHW programmes, as well as further exploration of CHW models.

Mamari, R. and Rasoamanarivo, R. (1997)

UNDP microfinance assessment report: South Africa

Prepared as a component of the Microstart Feasibility Mission, United Nations Development Programme (UNDP), Geneva

This report discusses the practical issues involved in microfinance services in South Africa. Existing programmes indicate a wide acceptance of group lending, and considerable local expertise. Reviews various microfinance programmes.

Marks, A.S. and Downes, G.M. (1991)

Informal sector shops and AIDS prevention. An exploratory social marketing investigation

South African Medical Journal, 20:79(8):496-9

Martin, A.L., van Praag, E. and Msiska, R. (1996)

An African model of home-based care: Zambia

In: AIDS in the World II: Global dimensions, social roots and responses, The global Policy Coalitions, New York: Oxford University Press

This short review details potentials for efficiency savings in the design of home-based care models, and the relative cost-benefits of home-based care models.

Matamoros, A. and Moreira-Arturo, M. (2000)

The recycling of waste products in Costa Rican hospitals by people living with HIV/AIDS

13th International AIDS Conference, Durban

Costa Rican laws call for the recycling of waste in all public institutions. Costa Rican hospitals have not implemented these laws due to a lack of know how and training. With anti-retroviral medicines people with AIDS experience favourable recovery and improved health and are able to return to work. Due to unemployment, some of these people have chosen to participate in recycling projects in Costa Rican hospitals which sort recyclable paper, cardboard and x-ray film, and other materials, as a means of employment and social support. A recently recovered AIDS patient initiated the idea of recycling material in Costa Rican hospitals. The concept of people with AIDS recycling materials in hospitals was later presented to the Calderón Guardia Hospital in San José and then the Monseñor Sanabria Hospital in Puntarenas (Pacific coast). Each hospital formed work therapy groups to exchange ideas, information and support to better manage their health. One of the work therapy groups missionís is to educate members and provide support in the taking of the medications according to their prescription. Other vital benefits of the programme include the employment received by the participants, on-the-job rehabilitation, health education and social support, and the positive contribution to the Costa Rican environment. The revenues received from the recycling projects support people living with AIDS, and other hospital patients suffering from infections, and are used for social, educational and cultural activities.

Mburu, B. (2000)

Integrating PLWA in the community through training and financial support

13th International AIDS Conference, Durban

There is growing evidence that poverty, the spread and impact of AIDS are linked. Women face particularly difficult circumstances because of widespread socioeconomic disadvantages. Measures that increase economic opportunities for women therefore serve both preventive and care functions in HIV/AIDS management.

McCormick, D., Munguti, K., Ngugi, E., Waweru, A. (2000)

Finance for health: An impact assessment of Kenya voluntary women rehabilitation centreís (KVOWRC) support programme for commercial sex workers (CSWS)

13th International AIDS Conference, Durban

Health, social and economic empowerment of commercial sex workers remains crucial for prevention and control of STD/HIV/AIDS. The Kenya VOWRC was started in 1992 and has about 600 CSWs who have received micro-credit. Loan repayments are better from CSWs who have exited sex work and are fully employed in alternative income generating activities and also those with a regular partner. In addition, there has been a marked improvement in their economic status. CSW intervention in Africa should include not only STD/HIV/AIDS education and counselling, but a micro-credit element so as to enable the women to make well-informed choices about their participation in sex work.

Murni, S., Syah, S., Aprilawati, L., and Marguari, D. (2000)

Positive fund ñ a non-government financial assistance project for people with HIV/AIDS (PWHA)

13th International AIDS Conference, Durban

Negative impacts of HIV infection on a person's life include financial problems, especially for those from poor economic backgrounds: medical treatments and hospitalisation is costly; care at home also needs money, eg. for nutritious food and maintaining hygiene; PWAs lose their livelihood because of discrimination, and this makes it difficult to maintain a healthy living. There is limited budget for care and support activities nationally. A community response is needed to assist PWHAs financially, especially in emergency cases. Spiritia (an NGO) started a trust fund from money raised from individual contributions. PWAs without other source of income can apply for this fund to pay for basic treatments and care, start a small business, or start local peer support activities. A guideline was drawn to direct fund usage, criteria of applicants, responsibility of Spiritia and applicants, monitoring and evaluation. This type of project is new and often mistaken for charity. Our partners (both hospitals and NGOs) and fund recipients are not accustomed to being accountable for fund given. Frequent contact for monitoring and assistance is necessary. In the case of starting up a small business, partnership with local NGOs is important since local NGOs also have a longer-term role in the project especially with business' sustainabililty. A method that enables both transparency of fund management and respect to confidentiality of PWAs to fit together is required.

Mutungadura, G.B. (2000)

Household welfare impacts of mortality of adult females in Zimbabwe: Implications for policy and programme development

International AIDS and Economics Network (IAEN) Conference, Durban

This study describes the major household impacts of female mortality in Zimbabwe, identifies the household coping mechanisms adopted and the current formal and informal social support mechanisms. Findings indicate that the major household welfare impacts were food insecurity, decrease in school access, increased work burden on children and loss of assets.

Ntozi, J.P.M. and Nakayiwa, S. (1999)

AIDS in Uganda: How has the household coped with the epidemic?

In: The continuing African HIV/AIDS epidemic, Caldwell, J.C., Orubuloye, I.O. and Ntozi, J.P.M., (eds) Health Transition Centre, National Centre for Epidemiology and Population Health, Australian National University, Canberra

This paper examines how households are coping with the AIDS epidemic and is based on data from four studies of six districts in Uganda between 1992 and 1995. Patient care was found to be principally given by the parents and other relatives. A considerable proportion of spouses cared for the male AIDS patients. Orphans were mainly cared for by relatives, especially grandmothers. Upon the death of one parent, the surviving parent was the principal caretaker. A number of orphans cared for themselves. People cope with widowhood by either remarrying or migrating. The effects of HIV and AIDS on traditional norms were reduction in widow inheritance, household management by the widows or relatives after the death of the household head, and resorting to shorter funeral ceremonies. In marriage, people coped by changing their behaviour to sexual abstinence, fidelity, separation or dissolution of marriages, decrease in polygamy, delayed marriage, and careful selection of potential marriage partners, including tests for HIV before marriage.

Ntozi, J.P.M. and Zirimenya, S. (1999)

Changes in household composition and family structure during the AIDS epidemic in Uganda

The paper examines aspects of changes in the family and household structure during the AIDS epidemic in Uganda using data collected from a multi-phase study in six districts. The majority of households were of an extended nature and there were high levels, though declining, of orphanhood and widowhood. There was also an increase in the dependency burden. Households headed by males and the elderly increased and a few were headed by children. Monogamous households with children were increasing.

Ntozi, J.P.M., Ahimbisibwe, F.E., Odwee, J.O., Ayiga, N. and Okurut, F.N. (1999)

Orphan care: The role of the extended family in northern Uganda

This paper examines the traditional role of the extended family in orphan care in northern Uganda. The extended family provides much support in looking after orphans, but has been overburdened by the AIDS epidemic with the result that some care is being provided by the older orphans, who are too young for the responsibility. The main problems of orphans are lack of money, inadequate parental care and some mistreatment by the care givers.

Nxumalo, S. (1997)

The Tugela AIDS Programme Trust: Aiming to reach remote communities

AIDS Bulletin. 1997 May-June; 6 (1-2):43-4.

Odek, W.O., Costigan, A., Ngugi, E., Plummer, F.A., Oneko, F. and Moses, S. (2000)

Benefits of collaboration between HIV/STI prevention projects and Micro-enterprise Development Organizations (MDOs): Experience of the strengthening STD/AIDS control in Kenya project

13th International AIDS Conference, Durban

The multifaceted nature of both risk factors and effects of HIV/AIDS call for multi-pronged prevention and mitigation measures that address, in addition to specific behaviour patterns associated with the spread of HIV such as commercial sex work, the socioeconomic contexts that shape such behaviours. Among female sex workers in the slums of Nairobi, Kenya for instance, economic deprivation is the main reason for venturing to and remaining in commercial sex work. While a micro-enterprise development approach that emphasises the provision of small loans for low-risk but quickly repaying economic activities is acknowledged as an effective measure for improving the socioeconomic livelihoods of the poor, both HIV/AIDS prevention projects and Micro-enterprise Development Organisations (MDOs) have been notably slow in considering the potential benefits of their collaboration. The Strengthening STD/AIDS Control in Kenya Project has, with financial support from the Canadian International Development Agency, established a partnership with a small enterprise development organisation called Improve Your Business ñ Kenya. The objective of this partnership was to improve understanding of the effectiveness of providing support for alternative economic activities to female sex workers as an HIV prevention strategy. This collaborative approach between an HIV/AIDS prevention project and a micro-enterprise development organisation underscored the need for a multi-sectoral complementarity of efforts in the prevention and mitigation of HIV/AIDS. For prevention projects to be effective, they should avoid the grab-bag approach of seeking to address every complex dimension of the pandemic by seeking comparative advantage partnerships.

Parker, J. (2000)

Microfinance and HIV/AIDS: Discussion paper

USAID Microenterprise Best Practices (MBP) Project, USAID, Washington

This paper is written for microfinance practitioners worldwide. Its purpose is to heighten awareness of the impact of HIV/AIDS on microfinance institutions (MFIs) and the communities they serve. The paper does not propose recommendations on how MFIs can directly fight HIV/AIDS. It does, however, point out a range of options open to MFIs that decide to play a pro-active role in HIV/AIDS-affected communities.

Parry, S. (1998)

Community care of orphans in Zimbabwe: The Farm Orphans Support Trust (FOST)

Southern African Conference on Raising the Orphan Generation, Pietermaritzburg

The overall aim of the Farm Orphans Support Trust (FOST) is to pro-actively increase the capacities of the farming communities to respond to the impending orphan crisis and ensure that systems are in place to protect and care for the most vulnerable individuals. This paper provides a descriptive overview of the programme.

Russell, M., and Schneider, H. (2000)

A rapid appraisal of community-based HIV/AIDS care and support programmes in South Africa

Centre for Health Policy, University of Witwatersrand, Johannesburg

A review of 20 community-based care and support projects was conducted. The definition of, and package of activities varied enormously. Many projects were faced with having to find solutions for orphaned children. Overall, there was a need to build capacity, to be clear about the role for government. There was also a need for general guidelines.

Sanei, L. (2000)

Palliative care for HIV/AIDS in less developed countries

The Synergy Project, Discussion Paper No 3, HIV/AIDS Division of USAID, Washington

Palliative care models emphasise patient's physical, spiritual and psychosocial comfort during the terminal stages of illness. Palliative care for HIV/AIDS extends more broadly, given the long term nature of infection. This paper suggests that palliative care is a comprehensive care which is affordable and can be delivered in the home.

Schapink, D., van Poelje, R., Reerink, I.H., Deliaon, J. and Gurung, D. (2000)

Strategy to involve rural workers in the fight against HIV/AIDS through community mobilisation programmes

Working Document, World Bank, Washington

This working paper reviews rural HIV/AIDS activities in sub-Saharan Africa to develop a framework of strategies to involve rural workers and rural communities in HIV/AIDS prevention and mitigation efforts.

Sisli, E. (2000)

Empowering the victims via microcredit

13th International AIDS Conference, Durban

AIDS is considered as a ëlong-waveí disaster, ëthat is long time in the making and in which the major effects have already begun to occur long before the magnitude of the crisis is recognised and any response is possible.í This unique characteristic of the epidemic has been treated as an adverse condition, limiting the householdsí ability and willingness to react early. However, with a properly designed policy response, the 5-7 years between the HIV-infliction and the height of AIDS can be utilised to reduce the economic vulnerability of the HIV-inflicted households. This study advocates a policy framework encompassing two steps: (i) early diagnosis of HIV/AIDS, (ii) mobilising the donor funds via microcredit to the diagnosed households for income-generating purposes. The primary aim is to limit the negative coping strategies (reduced food consumption, use of savings and sale of assets) and to reinforce the positive coping strategies (income diversification) of the households. Both steps combined would potentially avoid economic collapse of the households due to too much strain in the worst stages of the illness. Financing the HIV/AIDS inflicted clients via microcredit is the most viable option, as the informal financial sector is unsustainable and the formal sector is out-of-reach for this high-risk group. The sustainability of the microcredit programmes can be mitigated by transferring resources from the non-AIDS population in the form of savings. This policy would assist the households living with HIV/AIDS to sustain a steady flow of future income and to eliminate sharp reversals in their economic conditions. Not many HIV/AIDS programmes have taken such an approach of helping to build a productive base as an insurance mechanism for the victims. The study attempts to fill this gap.

Taylor, M., Naidoo, K., Jinabhai, C.C. and Bailey, M. (2000)

Promoting community health in a rural area of KwaZulu-Natal: Linking community health workers, NGO, Department of Health, University of Natal

Poverty and inequality: The challenges for public health in South Africa Conference, Epidemiological Society of Southern Africa (ESSA), East London

Inadequate health and social services in rural communities, coupled with high illiteracy, limited information and skills require innovative, low cost interventions. It is concluded that volunteer Community Health Workers can assist in under-resourced communities, whilst training improves their knowledge and skills, and those of other community members.

Tindi, S., Nyaundi, J.K. and Ojiambo, J.M. (2000)

UNAIDS (2000)

A review of household and community responses to the HIV/AIDS epidemic in the rural areas of sub-Saharan Africa

UNAIDS, Geneva

This document reviews literature on household and community responses to HIV/AIDS and makes policy recommendations. These include strengthening capacity of rural households, developing social assistance programmes, working through traditional community mechanisms, promoting NGOs and CBOs, developing long-term poverty alleviation strategies, and evaluating activities.

UNAIDS (2000)

The role of the social welfare sector in Africa: Strengthening the capacities of vulnerable children and families in the context of HIV/AIDS

UNAIDS Inter-country team, Southern and Eastern Africa, Pretoria, South Africa

UNICEF (1999)

Children orphaned by AIDS: Front-line responses from eastern and southern Africa

United Nations Childrenís Fund (UNICEF), New York

Young people who have lost one or both parents to HIV/AIDS are extremely vulnerable. Social support systems in sub-Saharan Africa are largely provided by extended families, with broader social services being largely inadequate. There have been a number of country level responses and those in Botswana, Malawi, Zambia and Zimbabwe are reviewed. Emphasis is largely on strengthening the capacity of communities to respond.

UNICEF (1997)

Give us credit: How access to loans and basic social services can enrich and empower people

United Nations Childrenís Fund (UNICEF), New York

This document reviews poverty reduction through microcredit programmes. Linking of microcredit programmes with basic social service provision is seen as a vital component. Microcredit successes involve a combination of credit and savings, and group lending has helped marginalised groups gain access to credit. Examples from developing countries in Asia and Africa are reviewed.

van Praag, T. (1998)

Care programmes for people living with HIV/AIDS

In: Operational approaches to the evaluation of Major Program Components, Noriega-Minichiello, World Health Organization

Care and support for people living with HIV/AIDS is an important component of a nations response to the epidemic. The increasing number of people infected by HIV have put a great burden on health care systems making it apparent that there is a need for appropriate care and support. Care and support activities can draw on a variety of resources throughout a continuum, to impact those affected and infected.

Williamson, J. (2000)

Finding a way forward: Principles and strategies to reduce the impacts of AIDS on children and families

In: The orphan generation: the global legacy of the AIDS Epidemic, Levine, C. and Foster, F. (eds) Cambridge University Press

The economics of interventions

Achmat, Z. (2000)

Legal strategies to improve access to treatment: An overview of successes and failures

13th International AIDS Conference, Durban

Access to treatment for people with HIV/AIDS in countries of Africa, Asia and Latin America remains elusive. Exclusion from public and private health care programmes is not limited to anti-retroviral access, but in many cases, includes treatment or prophylaxis for opportunistic infections. Governments and private medical agencies of poor countries identify costs as a key reason for limiting access. In their turn, drug companies rely on patent laws and other intellectual property instruments to maintain high prices. People with HIV/AIDS lack cohesion, mobilisation, material resources, and therefore, the political strength to alter the relationship of forces between drug companies, private agencies and government. Can a rights-based approach or other legal strategies assist PWAs to win treatment access? Research based on case studies in Venezuela, Costa Rica, India, South Africa, Zimbabwe and Thailand examines different legal and social approaches to mobilising PWAs to gain treatment access. These case studies include litigation proceedings, lobbying and advocacy campaigns, as well as social movements. Three areas of law will be canvassed: administrative law; constitutional or human rights law; and, intellectual property protection.

Attawell, K. and Grosskurth, H. (1999)

From knowledge to practice: STD control and HIV prevention

European Union HIV/AIDS Programme in Developing Countries, European Union, Brussels

To provide empirical evidence for policy-makers about the potential contribution of STD control to HIV infection rates and about the feasibility and affordability of this strategy in developing countries, the EC and National Institute for Health (NIH) initiated and funded two major community trials, in Tanzania and Uganda. At the same time, the EC commissioned the development of a simulation model, STDSIM, to explore STD transmission dynamics and the impact of different STD control interventions on HIV spread, in order to provide an additional tool for decision-making. STD control needs to encompass a wide range of interventions, of which syndromic management is only one. Strategies to improve symptom recognition, prompt treatment seeking and partner referral are also required. In HIV prevention programmes, STD control must be complemented by primary prevention interventions, including information, education and communication to reduce sexual risk behaviour and promote condom use.

Busulwa, W.R., Buyse, D., Mulligan, J., Walker, D., Fox-Rushby, J. (2000)

Analysing the analyses: A review of a set of economic evaluations of introduction of anti-retroviral therapy to reduce vertical HIV transmission in a hypothetical sub-Saharan African health district

IAEN Conference, July 2000

This paper documents an investigation of the influence of the health analystsí values on the design and outcome of the evaluations in resource-allocation decision-making within the health sector, especially with regard to HIV transmission interventions.

Chela, C.M. et al (1994)

Cost and impact of home-based care for people living with HIV/AIDS in Zambia

World Health Organization, Geneva

Chequer, P., Sudo, E.C., Vitfria, M.A.A., Veloso, V.G., Castilho, E. A. (2000)

The impact of anti-retroviral therapy in Brazil

13th International AIDS Conference, Durban

The Brazilian Ministry of Health has made the combined anti-retroviral therapy including PI universally available since 1997. As a result there has been a significant reduction in morbidity/mortality rates and in the costs of treating HIV/AIDS carriers. Analysis of the effects of the initiative showed similar results as those obtained in developed countries. Mortality was reduced by approximately 50% and there was a notable reduction in the number of main opportunistic infections (OIs). This was reflected in the marked reduction of the average number of hospital admissions and the length and complexity of treatment needed, suggesting a significant improvement in patient wellbeing. As regards costs, it was shown that the policy of universal access to combined anti-retroviral therapy led to savings both on medicines to treat opportunistic infections and on the direct costs of hospital admissions arising from these. It is estimated that approximately 146 000 admissions were avoided in 1997-99, representing a saving to Brazil of about $US420 million. Moreover, a change in the type of services used was noted, namely significant growth in demand for outpatient services at the same time as a decrease in that for home attendance and day-hospital services. The financial resources devoted to the initiative in effect represents an economically viable investment.

Cyrillo, D.C., Paulani, L.M., and Aguirre, B.M.P. (2000)

Direct costs of AIDS treatment in Brazil: A methodological comparison

International AIDS Economics Network (IAEN), Durban

The paper compares two alternative methodologies to calculate the direct cost of AIDS treatments ñ input utilisation on the basis of medical records of HIV patients (annual HIV treatment costs), and on the basis of input use registration (more accurate treatment costs).

Department of Health (2000)

HIV/AIDS policy guideline: Ethical considerations for HIV/AIDS clinical and epidemiological research

Department of Health, South Africa

Clinical and epidemiological research involves complex ethical challenges, such as access to clinical trials, informed consent, use of medications after the completion of drug trials, drug toxicities, long-term side effects, the appropriateness of the proposed research for South Africa, and the release and publication of research results. This booklet deals with several ethical issues relating to HIV/AIDS clinical and epidemiological research in South Africa.

Department of Health (2000)

HIV/AIDS policy guideline: Feeding of infants of HIV positive mothers

Department of Health, South Africa

The booklet presents options for infant feeding in cases of MCTC, and weighs up the options of breast and formula feeding. MTCT from breast-feeding is influenced by the stage of HIV condition in the mother, or by breast pathology. MTCT is more likely the longer the period of breast-feeding, also with new HIV infection during the breast-feeding period.

Department of Health (2000)

HIV/AIDS policy guideline: Managing HIV in children

Department of Health, South Africa

Comprehensive HIV care for children includes nutritional support, immunisation (except for TB), treatment of common clinical problems, and prophylaxis for common and severe infections.

Department of Health (2000)

HIV/AIDS policy guideline: Prevention and treatment of opportunistic and HIV related diseases in adults

Department of Health, South Africa

This booklet uses the WHO clinical staging system for HIV infection as a guideline for the management of HIV infected adults at primary health care level. It includes HIV and STD diagnosis, education, voluntary counselling, support to families, treatment of opportunistic infections, prophylactic medication, palliative care, referral, treatment for TB, and issuing of condoms.

Department of Health (2000)

HIV/AIDS policy guideline: Prevention of mother-to-child HIV transmission and management of HIV positive pregnant women

Department of Health, South Africa

The booklet lists factors of increased risk of MTCT, and some risk-reducing measures. The latter include vaginal lavage before and during delivery, avoidance of invasive measures during delivery, elective Caesareans, formula feeding (where it can be done safely), vitamin supplementation during pregnancy.

Department of Health (2000)

HIV/AIDS policy guideline: Rapid HIV testing

Department of Health, South Africa

This booklet provides recommendations on the use of rapid HIV tests. Such testing can provide a result within 10-30 minutes as compared to 1 to 2 weeks for the EIA. Rapid HIV testing must be conducted according to the same ethical standards as for any other HIV test. Most people receiving rapid HIV test results can receive counselling and learn their HIV status in a single visit, without the requirement of a formal laboratory and laboratory personnel. Therefore rapid testing can increase the number of people undergoing HIV testing who know their results.

Department of Health (2000)

HIV/AIDS policy guideline: Testing for HIV

Department of Health, South Africa

Testing for HIV infection presents serious medical, legal, ethical, economic and psychological implications in the health care setting. Policy guidelines that will guarantee freedom and security of the person, and the right to privacy and dignity have to be heeded. This brochure spells out the national policy for HIV testing.

Department of Health (2000)

HIV/AIDS policy guideline: Tuberculosis and HIV/AIDS

Department of Health, South Africa

TB is the most common disease and the leading cause of death in people living with HIV/AIDS. HIV, by attacking the immune system, makes a person who is infected with TB bacilli more likely to get sick with TB. TB can be prevented in people living with HIV/AIDS, and cured. The brochure offers practical advice on how to prevent, diagnose and treat TB and to deliver care to patients with the symptoms of TB and HIV/AIDS, and when to refer patients to more specialised care.

Floyd, K., Nganda, B., Okello, D., Moalosi, G., Maher, D., Ya Diul, M., Raviglione, M., Sinanovic, E. (2000)

Providing tuberculosis treatment in sub-Saharan Africa in the face of the HIV/AIDS epidemic: An economic evaluation of 5 pilot projects emphasising increased community and primary care facility involvement in care

13th International AIDS Conference, Durban

The HIV/AIDS epidemic in sub-Saharan Africa has caused a substantial increase in tuberculosis cases. In the context of limited budgets and hospital ward capacity, this has made it difficult to maintain traditional approaches to care. New strategies that are lower cost, less dependent on hospital admission, and more cost-effective are required. Five pilot projects emphasising community and primary care facility involvement in tuberculosis treatment were implemented in Botswana, Kenya, Malawi, South Africa and Uganda. Costs, cost-effectiveness, and average length of hospital stay were assessed for (a) the new strategy and (b) the traditional approach to care. The new strategies involving community contribution to care and/or decentralisation to primary care facilities were almost always lower cost, less hospital dependent, and more cost-effective. The reduction in the average health system cost per patient ranged from 16% to 72%. Average patient and family costs were lower by a margin of between 19% and 75%. Average length of stay in hospital fell by between 73% and 98%. The effectiveness of the new strategies was similar or higher compared to the traditional approach to care, so that cost-effectiveness usually improved, by between 17% in South Africa and 73% in Kenya. The only instance where costs increased and cost-effectiveness worsened was community-based treatment for new smear-negative pulmonary tuberculosis patients in Malawi. Wider implementation should be considered, though careful monitoring is important for confirming that pilot project results can be reproduced elsewhere.

Gertler, P. and Hammer, J. (1997)

Strategies for pricing publicly provided health care services

World Bank, Policy Research Department

Govender, V., McIntyre, D., Grimwood, A. and Maartens, G. (2000)

The costs and perceived quality of care for people living with HIV/AIDS in the Western Cape Province in South Africa

Partnerships for Health Reform, Abt and Associates, Maryland

The aim of this study is to evaluate the costs of care for people with HIV/AIDS at the different levels of care in the Western Cape metropolitan area and the patientsí perception of care. Overall, respondents were generally satisfied with the health services they received. Dissatisfaction with the health services related mainly to the provision of ëinadequate and ineffective drugsí, poor staff attitudes, and fears of discrimination and confidentiality being compromised by staff. To avoid having their HIV status discovered, patients sometimes sought care further away from home. Changing attitudes on the part of the health care providers and communities is crucial if barriers are to be overcome. A key recommendation based on study findings is to improve the management of TB at all levels, and this is necessary if expensive secondary and tertiary inpatient costs are to be reduced. In addition, the development of standard treatment guidelines for the management of those infected with HIV is essential. This will assist in ensuring that early diagnosis and appropriate treatment of patients are conducted at the appropriate levels of care. Improved knowledge and awareness of HIV/AIDS is critical if discrimination against those with HIV/AIDS is to be reduced, if not eliminated, in communities and health care facilities.

Haile, B. (2000)

Affordability of home-based care for HIV/AIDS

South African Medical Journal, 90 (7):690-1

Holtgrave, D.R, Qualls, N.L. and Graham, J.D. (1996)

Economic evaluation of HIV prevention programmes

Annual Review of Public Health, 17:467-88

Programme managers and policy-makers need to balance the costs and benefits of various interventions when planning and evaluating HIV prevention programmes. Resources to fund these programmes are limited and must be used judiciously to maximise the number of HIV infections averted. Economic evaluation studies of HIV prevention interventions, which we review and critique here, can provide some of the needed information. Special emphasis is given to studies dealing with interventions to reduce or avoid HIV-related risk behaviours. Ninety-three cost-benefit, cost-effectiveness and cost-utility analyses were identified overall. However, only 28 dealt with domestic, behaviour change interventions; the remainder focused on screening and testing without prevention counselling, and on care and treatment services. There are compelling demonstrations that behavioural interventions can be cost-effective and even cost-saving. The threshold conditions under which these programmes can be considered cost-effective or cost-saving are well defined. However, several important intervention types and multiple key populations have gone unstudied. Research in these areas is urgently needed.

Kaplan, J.E., Hu, D.J., Holmes, K., Jaffe, H.W., Masur, H., DeCock, K.M. (2000)

Preventing opportunistic infections in HIV-infected persons: Implications for the developing world

Discussion paper No 4, HTS, USAID

The spectrum of opportunistic infections (OIs) varies among regions of the world. Different OIs seem to be prevalent in different parts of the world. TB is the most common serious OI in sub-Saharan Africa, and is also common in Latin America and Asia. Bacterial and parasitic infections are prevalent in Africa. Protozoal infections are common in Latin America. Fungal infections appear to be more common in Southeast Asia. Research is needed to determine the spectrum of OIs and the efficacy of various prevention measures in resource-poor countries.

Kinghorn, A.W., Lee, T.C.M., Karstaedt, A.S., Khuonane, B. and Schneider, H. (1996)

Care of HIV-infected adults at Baragwanath Hospital, Soweto

South African Medical Journal, 86 (11):1484-1493

Kumar, M.P. (2000)

Cost effectiveness of prevention of mother-to-child HIV transmission in Karala, India

International AIDS and Economics Network (IAEN) Conference, Durban

A cost effectiveness analysis of the anticipated results of various options/strategies was done. Cost benefits from early prevention due to avoidance of secondary cases are considerable and must be considered. The cost benefits of screening mothers go far beyond averting the births of infected children. The benefits achieved will include lower long-term medical costs, reduction in pain, suffering and mortality as well as increased productivity. In communities where the HIV prevalence among antenatal women is low, screening and counselling will become viable options only if they have well developed health infrastructure and only incremental costs need be met and the cost of treatment is high.

Kumaranayake, K. and Watts, C. (2000)

The costs of scaling-up HIV prevention and care interventions in sub-Saharan Africa

13th International AIDS Conference, Durban

While there are strong HIV/AIDS interventions across Africa, few are implemented at a national scale. A key priority is the rapid expansion of activities. Despite this, resources to address HIV/AIDS have been relatively limited ñ external spending on HIV/AIDS in Africa was approximately US$165 million in 1998. A key question is how much would it cost to scale-up different HIV/AIDS prevention and care strategies to a national level. A model-based approach is used to develop a method to calculate costs, and to obtain estimates of the resource requirements of scaling-up HIV/AIDS interventions. The model combines data taken from cost-studies, with data from 34 sub-Saharan African countries on sexual behaviour, HIV prevalence and other epidemiological, demographic and health systems variables. The model estimates the size of the groups that could be potentially reached by: youth interventions, interventions focused on sex workers and their clients, condom social marketing, increased public sector condom provision, improved STD management, voluntary counselling and testing, workplace interventions, blood safety measures, prevention of mother-to-child transmission, mass media, palliative care, clinical management of opportunistic infections, home-based care, care for HIV-infected infants, support for orphans, psychosocial support and counselling. Unit costs are then used to the total annual cost of implementing the scaled-up interventions at different levels of coverage.

Ledru, E. et al (1999)

Prevention of wasting and opportunistic infections in HIV-infected patients in West Africa: A realistic and necessary strategy before anti-retoroviral treatment

Sante 1999, Sept-Oct 9 (5)

Maceira, D. (1998)

Provider payment mechanisms in health care: Incentives, outcomes and organisational impact in developing countries

Partnerships for Health Reform, Abt and Associates, Maryland

This paper assists with development of a research design for a study exploring the impact of alternative methods of provider payment mechanisms in developing countries. The paper sees provider payment as a form of contract between purchaser and provider and draws upon the economic literature on agency contracts to consider the problem of how best to develop appropriate payment mechanisms. In addition, the paper suggests the need to study the effects of payment mechanisms on the organisation of the health care system, not only in terms of market structure, but also in the way providers are organised internally. It is argued that changes in payment mechanisms provoke realignments in the mode of service delivery through risk shifting, specialisation, competition, integration, etc., which in turn affect health care outputs. At the same time, different basic conditions in the health care sector may affect the impact of new incentive mechanisms. The main payment methods and the incentives inherent in them are discussed. The paper concludes with a list of issues that should be taken into account in the research design on provider payment systems.

Makan, B. and Bachmann, M. (1998)

An economic analysis of community health worker programmes in the Western Cape Province

Health Systems Trust, Durban

This study describes five CHW programmes and one CHW training centre operating in the Western Cape province. These programmes jointly account for an estimated 49% of the total CHW programme expenditure in the province (an estimated R11,7 million for 1994/95). Research included household surveys in the areas served by programmes, which provided demographic health profiles and information on the health knowledge of communities served by CHW programmes and detailed cost analyses of each programme. It helped answer questions about what CHWs do, which communities they serve, how programmes differ and what their service costs are. The true efficiency of the programmes depends, however, on whether they are effective in preventing serious illness through health promotion, early diagnosis and treatment and, where necessary, referral. CHWs should be seen as complementary to the formal services and not as cheap substitutes. The particular strengths of CHWs (eg. accessibility, acceptability, and cultural sensitivity) as well as their limitations (eg. ability to diagnose and treat serious illnesses) should be considered.

Marseille, E., Kahn, J.G., Mmiro, F., Guay, L., Musoke, P., Fowler, M.G., Jackson, J.B. (1999)

Cost effectiveness of single-dose nevirapine regimen for mothers and babies to decrease vertical HIV-1 transmission in sub-Saharan Africa

Lancet, 354:803-809

Background identification of economical interventions to decrease HIV-1 transmission to children is an urgent public health priority in sub-Saharan Africa. The authors assessed the cost effectiveness of the HIVNET 012 nevirapine regimen. The authors assessed cost effectiveness in a hypothetical cohort of 20 000 pregnant women in sub-Saharan Africa. The main outcome measures were programme cost, paediatric HIV-1 cases averted, cost per case averted, and cost per disability-adjusted life-year (DALY). The authors compared two implementation strategies: counselling and HIV-1 testing before treatment (targeted treatment), or nevirapine for all pregnant women (universal treatment, no counselling and testing). For universal treatment with 30% HIV-1 seroprevalence, the HIVNET 012 regimen would avert 603 cases of HIV-1 in babies, cost US$83 333, and generate 15 862 DALYs. The associated cost-effectiveness ratios were $138 per case averted or $5.25 per DALY. At 15% seroprevalence, the universal treatment option would cost $83 333 and avert 302 cases at $276 per case averted or $10.51 per DALY. For targeted treatment at 30% seroprevalence, HIVNET 012 would cost $141 922 and avert 476 cases at $298 per case averted or $11.29 per DALY. With seroprevalence higher than 3% for universal and 4.5% for targeted treatment, the HIVNET 012 regimen was likely to be as cost effective as other public-health interventions. The cost effectiveness of HIVNET 012 was robust under a wide range of parameters in the sensitivity analysis. The HIVNET 012 regimen can be highly cost-effective in high seroprevalence settings. In lower seroprevalence areas, when multidose regimens are not cost effective, nevirapine therapy could have a major public-health impact at a reasonable cost.

Marseille, E. and Kahn, J.G. (1999)

Manual for use of a cost-effectiveness tool for evaluating antiretroviral drug and substitute feeding interventions to prevent mother to child transmission of HIV

Health Strategies International, California

McIntyre, J and Gray, G. (1999)

Mother-to-child transmission of HIV: where to now?

AIDS Bulletin, 8 (1):16-8.

Mckerrow, N.H. et al (1996)

AIDS, orphans and affordable care

Human Sciences Research Council, Pretoria

Mills, A. and Watts, C. (1996)

Cost-effectiveness of HIV prevention and the role of government

In: Confronting AIDS: Evidence from the Developing World, Selected background papers for the World Bank Policy Research Report, Confronting AIDS: Public Priorities in a Global Epidemic, Ainsworth, M., Fransen, L. and Over, M., Office for Official Publications.

Msobi, N. and Msumi, Z. (2000)

HIV/AIDS and other chronic conditions: Home-based care cost study, Bagamoyo District, Tanzania

International AIDS and Economics Network (IAEN) Conference, Durban

The report shows that the cost for home-based care (HBC) is comparatively lower than institutional care. It stands at US$66 per day, while the cost of hospitalisation is US$4.9. The cost of home visits is comparatively lower than the cost of female programmes in the region. This can be explained by the fact that HBC operated from first line health facilities, reduced the average travel distance to 10 kms per day. It can also be concluded that much of the cost of care has been transferred to households and that much of this was shouldered by women. The estimated house hold costs/opportunity cost stands at US $22 per month. Cost reduction can further be achieved if care providers come from stations as close to the patients as possible. This suggests that there is a need for distance optimisation .In fact, the use of volunteers from the communities, as HBC providers is the better and cheaper option.

Ngwena, C. (2000)

Access to drugs: The limitations of South Africaís section 15 of the medicines and related substances control act

13th International AIDS Conference, Durban

Section 15 of South Africa's Medicine and Related Substances Control Act of 1997 makes provision for the supply of affordable medicines. In pursuit of the protection of public health, it permits the Minister of Health to authorise the importation of medicines which are already registered in South Africa, but ostensibly in disregard of the manufacturer's patent rights. Section 15, which is about parallel importation and has the potential of rendering drugs more accessible in the wake of HIV/AIDS, has been the subject of national and international controversy, with the government very much on the defensive side. The paper appraises the case for s15 of the Act against the backdrop of an international legal order which recognises patents and other intellectual property restrictions on medicines, including those that are life-saving. Agreements reached through the Global Agreement on Tariffs and Trade and the World Trade Organisation are a formidable constraint on any attempt to circumvent strict adherence to patent restrictions through mechanisms such as parallel importation and compulsory licensing. Apart from moral arguments which cast inflexible intellectual property restrictions on drugs in the wake of HIV/AIDS as short-sighted and indifferent to human suffering, better-endowed countries share a quasi-legal or human rights obligation to assist the developing world in securing better access to drugs. International co-operation that is envisaged under instruments such as the International Covenant on Economic, Social and Cultural Rights points towards a waiver of patent rights where the developing world faces a dire human and economic calamity.

Over, M. (1999)

The public interest in a private disease: An economic perspective on the government role in STD and HIV control (Chapter 1 of ëSexually Transmitted Diseasesí),

In: Sexually Transmitted Diseases, King, K., Holmes, P., Sparling, F., Per-Anders, M., Lemon, S., Stamm, W.E., Piot, P., and Wasserheit, J. McGraw-Hill

Sexually transmitted diseases are painful and sometimes deadly. Should the prevention and control of sexually transmitted diseases be one of the short list of activities that are part of the irreducible core of government responsibility? For reasons not unlike the ëtragedy of the commonsí that exacerbates pollution problems, individually optimal decisions about risky sexual contacts lead to a higher prevalence of STDs than the individuals would choose. The implication is that some government intervention to prevent and control STDs is socially desirable.

Sacks, H., Bell, J., Rose, D.N. and Sacks, H.S. (1998)

Cost-effectiveness of isoniazid preventive therapy for HIV infected people in sub-Saharan Africa

International Conference on AIDS, 1998

To perform a cost-effectiveness analysis of isoniazid preventive therapy (IPT) for HIV-infected sub-Saharan African adults with positive tuberculin skin tests. IPT decreases the lifetime incidence of TB cases by 36%, extends life expectancy by 0.82 years, and costs US$36 per life-year saved. Under optimistic assumptions regarding effectiveness in the years following IPT and the costs of IPT and treating TB and IPT adverse effects, IPT decreases the lifetime incidence of TB cases by 63%, extends life expectancy by 4.99 years, and reduces total medical care costs. Under pessimistic assumptions, IPT decreases the lifetime incidence of TB cases by only 18%, minimally shortens life expectancy and increases medical care costs by US$31 per person. The most important variables are the costs of IPT and TB treatment and effectiveness in the years following IPT. IPT could both save lives and reduce total medical care costs if the cost of preventive therapy could be moderately reduced.

Skordis, J. (2000)

Mother to child transmission of AIDS: What is the cost of doing nothing?

Bachelor of Commerce (Hons), School of Economics, Cape Town

Soderland, N., Zwi, K., Kinghorn, A., and Gray, G. (1999)

Prevention of vertical transmission of HIV: Analysis of cost effectiveness of options available in South Africa

British Medical Association, 318:1650-6.

This paper reviews the cost effectiveness of vertical transmission prevention strategies by using a mathematical simulation model. A Markov chain model was used to simulate the cost effectiveness of four formula feeding strategies, three antiretroviral interventions, and combined formula feeding and antiretroviral interventions on a cohort of 20 000 pregnancies. All children born to HIV positive mothers were followed up until age of likely death given current life expectancy and a cost per life year gained calculated for each strategy. The chosen setting was a working class, urban South African population. Low cost antiretroviral regimens were almost as effective as high cost ones and more cost effective when formula feeding interventions were added. With or without formula feeding, low cost antiretroviral interventions were likely to save lives and money. Interventions that allowed breast feeding early on, to be replaced by formula feeding at 4 or 7 months, seemed likely to save fewer lives and offered poorer value for money. It is concluded that antiretroviral interventions are probably cost effective across a wide range of settings, with or without formula feeding interventions. The appropriateness of formula feeding was highly cost effective only in settings with high seroprevalence and reasonable levels of child survival and dangerous where infant mortality was high or the protective effect of breast feeding substantial. Pilot projects are now needed to ensure the feasibility of implementation.

Sweat, M., Gregorich, S., Sangiwa, G., Furlonge, C., Balmer, D., Kamenga, C., Grinstead, O., and Coates, T. (2000)

Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania

The Lancet, 356:113-121

Access to HIV-1 voluntary counselling and testing (VCT) is severely limited in less-developed countries. We undertook a multi-site trial of HIV-1 VCT to assess its impact, cost, and cost-effectiveness in less-developed country settings. The cost-effectiveness of HIV-1 VCT was estimated for a hypothetical cohort of 10 000 people seeking VCT in urban east Africa. VCT was estimated to avert 1 104 HIV-1 infections in Kenya and 895 in Tanzania during the subsequent year. The cost per HIV-1 infection averted was US$249 and $346, respectively, and the cost per DALY saved was $12.77 and $17.78. The intervention was most cost-effective for HIV-1-infected people and those who received VCT as a couple. The cost-effectiveness of VCT was robust, with a range for the average cost per DALY saved of $5.16-27.36 in Kenya, and $6.58-45.03 in Tanzania. Analysis of targeting showed that increasing the proportion of couples to 70% reduces the cost per DALY saved to $10.71 in Kenya and $13.39 in Tanzania, and that targeting a population with HIV-1 prevalence of 45% decreased the cost per DALY saved to $8.36 in Kenya and $11.74 in Tanzania. With the targeting of VCT to populations with high HIV-1 prevalence and couples the cost-effectiveness of VCT is improved significantly.

The Panos Institute (2000)

Beyond our means? The cost of treating HIV/AIDS in the developing world

The Panos AIDS Programme, London

UNAIDS (1998)

Cost-effectiveness analysis and HIV/AIDS

UNAIDS, Geneva

UNAIDS (2000)

Costing guidelines for AIDS prevention strategies

UNAIDS, Geneva

WHO (1999)

Feasibility assessment of using antiretroviral therapy to prevent vertical transmission of HIV from mother-to-child in Cambodia

World Health Organization (WHO), Western Pacific

This paper documents a feasibility assessment of antiretroviral therapy to prevent vertical transmission in Cambodia. A recent study shows that a short course regimen of a single 200mg oral dose given to women at onset of labour and a 2mg/kg dose given to neonates within 72 hours of birth, reduced the transmission rate by at least 47% from 28% to 13.1%. Key issues affecting costs would be the price of drugs, HIV prevalence, capacity to administer the drug, the acceptability of treatment and compliance, and the secondary effects of nevirapine, if any. The paper concludes that it is not recommended to enlarge the ARV treatment programme to areas where initial investment in training and equipment of testing for HIV has not yet taken place. Where this investment has been made, however, running pilot projects in these selected locations is feasible, contingent on donor funding.

Winsbury, R. (1999)

HIV vaccine development: Would more (public) money bring quicker results?

AIDS Analysis Africa 1999 June-July; 10 (1):11-3

Vaccine development is faced with a financial dilemma: there are no returns on investments in products to be marketed in developing countries. New approaches have been mooted by the World Bank, and by international partnerships between companies and universities in industrialised and developing countries. Examples are two new HIV vaccine development projects based on partnerships between Oxford University and Nairobi University, and between the US company ALphavax and UCT.

Wood, E., Braitstein, P., Montaner, J.S.G., Schechter, M.T., Tyndall, M.W., OíShaughnessy, M.V., and Hogg, R.S. (2000)

Extent to which low-level use of antiretroviral treatment could curb the AIDS epidemic in sub-Saharan Africa

Lancet, 355:2095-100

Despite growing international pressure to provide HIV-1 treatment to less-developed countries, potential demographic and epidemiological impacts have yet to be characterised. We modelled the future impact of antiretroviral use in South Africa from 2000 to 2005. The authors produced a population projection model that assumed zero antiretroviral use to estimate the future demographic impacts of the HIV-1 epidemic. With no antiretroviral use between 2000 and 2005, there will be about 276 000 cumulative HIV-1-positive births, 2 302 000 cumulative new AIDS cases, and the life expectancy at birth will be 46.6 years by 2005. By contrast, 110 000 HIV-1-positive births could be prevented by short-course antiretroviral prophylaxis, as well as a decline of up to 1 year of life expectancy. The direct drug costs of universal coverage for this intervention would be US$54 million ñ less than 0.001% of the per-person health-care expenditure. In comparison, triple-combination treatment for 25% of the HIV-1-positive population could prevent a 3.1-year decline in life expectancy and more than 430 000 incident AIDS cases. The drug costs of this intervention would, however, be more than $19 billion at present prices, and would require 12.5% of the country's per-person health-care expenditure. Although there are barriers to widespread HIV-1 treatment, limited use of anti-retrovirals could have an immediate and substantial impact on South Africa's AIDS epidemic.

Behavioural and social response

Attawell, K. (1998)

HIV/AIDS knowledge, attitudes, beliefs and behaviours in South Africa

Beyond Awareness Campaign, Department of Health

A fairly comprehensive although not exhaustive review of KAP studies done in South Africa up to 1998. Points to areas in particular need of attention and the need for integration of what is known in this area. Although there is much contextual data it has been difficult to put together a national profile because of the lack of standardization of methodologies and indicators used and because of lack of data in certain areas.

Campbell, C. (1999)

Moving beyond health education: The role of social capital in conceptualising ëhealth enabling communitiesí.

Unpublished paper, London School of Economics and Political Science.

This paper explores the concept of social capital and its potential value in community health development.

Department of Health (1998)

South Africa demographic and health survey

Department of Health, South Africa.

Preliminary report on the 1998 demographic and health survey. The only national population based survey which includes data on STD exposure, HIV/AIDS attitudes and risk reduction behaviours. HIV/AIDS section limited to women.

Gillies, P. (1998)

Effectiveness of alliances and partnerships for health promotion.

Health Promotion International, 13, pp 99-120

This study explores the need to understand community networks and mobilization in understanding the factors associated with community health development. The concept of social capital is explored and it is suggested that the concept is important for understanding the varying ways in which communities respond to health needs and development opportunities.

Kelly, K. (2000)

Communicating for action: A contextual evaluation of youth response to HIV/AIDS

Beyond Awareness Campaign, Department of Health, South Africa.

A study conducted in six communities across South Africa in 1999. A quantitative survey of 618 youth, the study shows that the response to HIV/AIDS in parameters of both prevention and care varies greatly across different sites. The study points to the complexity of the epidemic and the need to understand the lack of uniformity in youth response, ranging from high levels of response in particular communities, to low levels in other areas, and particularly rural areas. A number of overlooked areas of intervention and response are pointed to and the implications for programme planning are discussed.

Kelly, K. and Parker, W. (2000)

Communities of practice: Contextual mediators of youth response to HIV/AIDS

Beyond Awareness Campaign, Department of Health, South Africa

A qualitative follow-up of Kelly (2000) which explores social factors which explain the findings of the former quantitative survey. The report strongly points to the lack of effective and sustained institutional and community mobilization to support behaviour changes. The study points to the need for a social epidemiology approach and points to the limited focus of behavioural prevention programmes. The need for, and some suggestions towards an improved conceptual model for understanding behavioural change in development contexts, is described.

Richter, L.M. (1996)

A survey of reproductive health issues among urban black youth in South Africa

Society for Family Health, South Africa

This study examines a range of reproductive health issues amongst township youth in the three largest South African cities. Not specifically focussed on HIV/AIDS it provides insight into the social and psychological context of reproductive health behaviour amongst urban African youth. A useful annotated bibliography of literature on youth reproductive health is provided.

UNAIDS (2000)

National AIDS programmes: A guideline for monitoring and evaluation

UNAIDS, Geneva

A comprehensive guide to monitoring and evaluation of national aids programmes, with suggested indicators in the following areas: policy and political commitment, condom availability and quality, stigma and discrimination, knowledge about transmission of HIV, voluntary counseling and testing services, mother to child transmission, sexual negotiation and attitudes, sexual behaviour, sexual behaviour among young people, injecting drug use, blood safety, STI care and prevenion, care and support for the HIV-infected and their families, Impact: HIV, STIs, mortality and orphanhood. In each area the report describes relevant indicators, measurement tools and strengths and limitations of the indicator.

UNAIDS (1998)

Reaching regional consensus on improved behavioural and serosurveillance for HIV: Report from a regional conference.

UNAIDS, Geneva

Reports on the needs for development of behavioural and serosurveillance systems in East Africa. Limitations of current surveillance systems are spelled out and recommendations are made to improve existing systems in specific areas of monitoring and data collection. The document demonstrates the importance of collecting behavioural data to inform epidemiological understanding and discusses the major components of second-generation surveillance systems.

UNAIDS (2000)

Guidelines for second generation HIV surveillance: The next decade.

UNAIDS, Geneva

Sets out the foundational principles of an integrated, contextually sensitive approach to HIV surveillance, which includes seroprevalence, behavioural, social mobilization and other aspects.

UNAIDS, Measure, WHO (2000)

HIV/AIDS prevention indicators survey for the general population aged 15-49: Field test reports ñ Burkina Faso, Costa Rica, Nigeria, South Africa, Tanzania, Thailand, Uganda

UNAIDS, Geneva

Six reports on field tests using UNAIDS/ Measure indicators for monitoring and evaluation. Points out various problems associated with use of standard indicators in different contexts and points to need for contextual adaptations. Includes a trial in Duncan Village, Eastern Cape, conducted by X.Mahlasela.