SOCIO-ECONOMIC CAUSES AND CONSEQUENCES OF THE HIV EPIDEMIC IN

SOUTHERN AFRICA:

A CASE STUDY OF NAMIBIA part 1

Parts: 1 2 3

                                         Desmond Cohen

Issues Paper No. 31

           INTRODUCTION

           Part 1: Socio-economic Causes of the HIV Epidemic

           1. The Roles of Income, Occupational Status and Poverty

           2. Economic Organisation and Public Policy

           3. Social Organisation, Gender and Public Policy

           4. Social Learning

           Part 2: Estimating Demographic and Developmental Impacts - a Case Study of Namibia

           Epidemiological Situation in Southern Africa

           Demographic Effects of HIV and AIDS

           Estimating the Impact of HIV and AIDS on Human Development

           Results

           Comments

           Part 3 : Estimating Sectoral Impacts of the Epidemic in Namibia

           1. Households

           2. Productive Sectors

           Conclusions

           INTRODUCTION

           This paper is in three parts. Part 1 reviews in a schematic way existing knowledge of the

           socio-economic causes and consequences of the HIV epidemic in sub-Saharan Africa. Part 2 looks

           more closely at the socio-economic impact of the epidemic on Southern Africa. Analysis is focused on

           Namibia as a specific case study, within a framework which addresses both demographic and

           developmental impacts. Estimates are presented on the effects of the epidemic on human

           development, the UNDP Human Development Index, for both Southern Africa and for Namibia. Part 3 is

           a review of the impact on economic sectors in Namibia.

           It needs to be stressed at the outset that much of the applied research on socio-economic causes and

           consequences of the HIV epidemic in sub-Saharan Africa has yet to be done. This is even more true in

           Namibia where the absence of appropriate policy and programme related research imposes severe

           constraints on effective responses to the epidemic. It is thus a priority area for Namibia and for other

           countries in the region to strengthen national capacity for undertaking applied policy and programme

           relevant research on the epidemic. It has to be stressed that such research on both the causes and

           consequences of the epidemic needs to be timely -- the problems to be addressed are important -- but

           are generally everywhere under-recognised. There has been a fair amount of research undertaken in

           some countries in the region but this has often been of low value to those with policy and programme

           responsibilities. This can be avoided from the outset through appropriately designed strategies for

           undertaking socio-economic research on the epidemic.

           Part 1: SOCIO-ECONOMIC CAUSES OF THE HIV EPIDEMIC

           More than ten years into the global HIV epidemic there is still great unclarity as to the precise

           importance of different factors in explaining both the levels and the distribution of HIV infection in Africa.

           About 70% or more of total HIV infections globally are in sub-Saharan Africa, with some 90% of all

           infections concentrated in developing countries. The distribution of global infections will change in the

           next 5 to 10 years as the share of the total which is African shrinks as Asia experiences a growth in

           HIV transmission. It was already the case in 1997 that about one half of new infections worldwide were

           in Asia, a trend which is expected to deepen in the coming years. There is some very preliminary

           evidence which suggests that in a number of countries in sub-Saharan Africa the epidemic may be

           stabilising. But it is also the case that rural rates of HIV infection in many countries in sub-Saharan

           Africa are moving closer to urban rates (which have typically always been higher).

           The issue to be addressed is why HIV infection has been so concentrated in the past-decade in

           sub-Saharan Africa, more especially in Eastern, Southern and Central Africa? What have been the

           dynamics of the various sub-epidemics, and what role have social and economic factors played in the

           development of the epidemic? Socio-economic and cultural factors appear to have been significant in

           explaining HIV transmission throughout the region. The process in the following discussion is partly

           inductive and partly empirical, with the ultimate objective of identifying those factors which are

           amenable to policy and programme response. In no sense is this a fully comprehensive analysis of the

           issues. The aim is to deepen understanding of those factors which seem to be important in explaining

           what is happening to the HIV epidemic in sub-Saharan Africa and more particularly in Namibia.

           1. The Roles of Income, Occupational Status and Poverty

           The poor account absolutely for the largest numbers of those infected with HIV. But the relationship

           with poverty is by no means simple and many of the poor, even the poorest of the poor, remain

           uninfected in many countries. Furthermore, and this is very important and to some extent reasonably

           well documented, HIV infection is also high among those who are better educated and highly trained.

           The epidemic is thus bi-modal in its distribution with peaks in both the poorest segments of the

           population BUT also amongst the richest and best educated. So the relationship cannot simply run

           from poverty to behaviours which expose individuals and their families to HIV infection because there

           are the non-poor who also exhibit risk behaviours which can and do lead to HIV infection. The non-poor

           in Africa are the region's most scarce resource who are essential for the effective governance of their

           countries and who play essential economic and social roles. As will be seen in a later Section, the fact

           that HIV infection is also present amongst the most economically favoured - with high levels of HIV

           prevalence in some countries - will lead to substantial economic losses through the erosion of Africa's

           most able and most educated segment of the population.

           So quite different factors other than poverty must be operating in the cases of the skilled, professional

           and the well educated to explain their behaviours. These are clearly not behaviours which are income

           constrained (as are those of the poor) nor are they behaviours which can be simply attributed to lack of

           information on how HIV is transmitted and how it can be prevented. For these are among the educated

           elite of the region who have absorbed many years of schooling often subsidised by the State. Rather

           the explanation would seem to lie in the opportunities which are available to these groups through their

           access to income and their position in society to engage in sexual behaviours which place themselves

           and their spouses at risk of HIV infection. Such groups seem also to be characterised by patterns of

           employment which include high levels of mobility, and it would seem that this is a feature of their life

           style which provides an additional opportunity for unsafe sex. For this group it is certainly not poverty

           which explains their behaviour but the opposite; nor can behaviour be attributed to lack of access to

           education since many have achieved both secondary and often tertiary levels; but it does seem to be

           related to work and leisure patterns, and with high levels of labour mobility. There is even some

           evidence that HIV infection rises with the level of education and occupational status which is quite the

           opposite of what might have been expected given the widespread assumption that knowledge

           empowers. Typically, the spouses of men who are HIV positive are themselves often infected

           (husbands infecting wives seems the more normal case).

           In the case of the poor who are infected with the virus the evidence is less counter intuitive. Poverty will

           lead to economic strategies which expose the poor to risks of HIV infection. Thus both men and women

           will seek out livelihoods which offer the possibility of survival, and this will often require migration from

           villages to towns and cities in search of jobs. Doing so will often lead to relaxation of traditional norms

           of behaviour and in the case of men particularly will often lead to sexual activity where they have many

           partners. But poor women, especially those who head poor households who are many in Africa, will

           also engage in sexual transactions so as to support their families. This exposes such women, who

           cannot be categorised at all as being CSWs, to risks of HIV infection. For some women the pressures

           of poverty for them and their families may lead to activities which can be classed as those of a CSW,

           but even for this group of women it is not simply and only poverty which explains their actions. It should

           be recalled that HIV infection is higher amongst women than men in Africa and is very much higher

           amongst young women and girls than amongst their male counterparts. Evidence supports the

           proposition that most married women who are infected with HIV have only a single partner - their

           husband. It follows that changing the behaviour of both men and women is essential for reducing further

           HIV transmission - changes cannot be confined to only one gender.

           There are many other factors also operating in the case of the poorest. They have generally poor health

           status which is the outcome of their poverty and their lack of access since childhood to those things

           which determine health status. In part, this is a matter of access to formal sector health services but it

           is much more a matter of environmental conditions (such as poor housing, clean water and poor

           nutrition). Addressing these environmental aspects of the life of the poorest will have significant effects

           both on health status as well as on their labour productivity, for low output per person is often related to

           poor health. These conditions are true irrespective of gender but seem to be severest for girls and

           women which may in part explain their greater susceptibility to HIV infection than males. What is

           undoubtedly clear is that women receive less health care than men generally and the failure to treat

           STDs in women is indeed a major problem given the link between STDs and HIV transmission. Poor

           health status of both men and women in part explains the more rapid progression from HIV infection to

           death for those who are HIV positive in Africa compared with rich countries - compounded in the case of

           women by excessive numbers of pregnancies. This evidence leads to important policy conclusions for

           Namibia which are summarised below.

           Finally, there is the issue of access to and the quality of the education received by the poorest. In spite

           of major efforts by many countries in Africa, there still remains a major educational deficit. The recent

           decade has seen a worsening of the effective education received by the poorest in many countries,

           which reflects public policy decisions under conditions of constrained resources. Particularly severe in

           countries following structural adjustment policies, but also reflecting increasing demands caused by a

           rapidly increasing and youthful population. One consequence is a perpetuation of poverty associated

           with little or no education, and another is illiteracy for many Africans, which compounds their problems

           of full participation in civil society.

           2. Economic Organisation and Public Policy

           This is a categorisation which covers many factors which seem to have had an influence on the

           dynamics of the HIV epidemic. Their particular role is difficult to identify and assess but they have

           some importance. Thus it is evident that patterns of labour mobility and migration are affected by

           particular economic strategies, and that mobility of labour plays an important role in the transmission of

           HIV throughout the region. But economic strategies can be modified and be different and in a world of

           HIV it is important to re-examine those being followed by a country. Thus most countries in Africa have

           pursued economic and social policies which are urban biased - favouring those who live and work in

           cities to the disadvantage of rural populations. These biases in policies and in access to public services

           are factors in the transmission of HIV and thus the spread of the epidemic.

           Rural to urban migration has been in part the consequence of the imbalance between living standards,

           access to education and health and to employment that exists. Different allocations of public resources

           in favour of poorer rural populations, especially in education and health, and different pro-agricultural

           strategies (different exchange rate policies, improved access to credit, better transport infrastructure,

           rural development, and so on) would have major effects on the mobility of labour and on rural poverty. Of

           particular importance is the need to improve employment opportunities for adolescent youth - both boys

           and girls in rural and urban settings. There are many instruments of public policy which can be used to

           raise employment for young people and this could be a potent force for affecting positively their sexual

           and other behaviours.

           Many countries in the region have followed policies of structural adjustment which have had the effect of

           generating additional unemployment, particularly for workers in the public sector. These policies have

           disproportionately reduced expenditures on health and education along with other social sector

           spending. As such, the SAPs have added to more general forces at work over the past two decades

           which have caused widespread social distress and rising unemployment together with reduced access

           to essential social services. Governments have had few degrees of freedom to change some of the

           factors at work (such as an adverse external environment for trade) but that is not to say that they have

           no independence of policy making.

           In particular, they have had the capacity to change public expenditure allocations in ways that would

           have prevented much of the deterioration in essential public services such as education and health.

           They have also had choices in terms of the allocation of expenditure within broad functional categories,

           and could at any time have redistributed expenditure to primary health (away from acute/hospital care),

           and to primary and secondary education (with less for very expensive and highly subsidised tertiary

           education). More broadly, there has always existed the choice of using public services as a vehicle for

           redistribution in favour of the poor and away from the rich. This they have failed to accomplish and they

           have through their policies helped to maintain and to expand those underlying factors which have

           contributed to the epidemic - such as poverty, poor and unequal access to key public services, and too

           little provision for primary health and basic education for all.

           In part, economic development in the region has been dependent for far too long on families being

           disrupted through the migration of family members in search of employment. This is most evident in the

           case of mining where recruitment of male workers without their families has been only too typical.

           These employment practices have been important in the spread of HIV not only for the miners but also

           to their wives and their rural communities. But what is most obviously true of mining is only an example

           of the more general problem with development which is a failure to locate employment closer to where

           people live. This is not inevitable, and in a world of HIV and AIDS it is necessary to revisit policies for

           industrial and agricultural development. This is also true for large scale infrastructure developments

           which have the effect of generating localised flows of migrant labour with consequences in terms of HIV

           transmission which are only too evident. It is possible to build into such developments an awareness of

           their effects on the epidemic, and to design appropriate interventions to limit the spread of infection

           within the work force and local communities.

           3. Social Organisation, Gender and Public Policy

           This is a massive topic and the following represents only a few but important observations on issues

           which are not generally well documented. The easiest is Gender where there now exists considerable

           evidence on the role that male and female relationships play in the epidemic. As has been noted

           several times already, women now outnumber men in terms of HIV infection in Africa; young women

           have rates of HIV infection several orders of magnitude higher than their male counterparts, and most

           married women in Africa who are infected with HIV say that they have only had a single partner - their

           spouse. At the heart of this heartrending picture are relationships between men and women - not

           simply sexual relationships important though these are in terms of the epidemic. Evidence suggests

           that where women are not valued, and where they are largely excluded from protection of their rights as

           full members of society that the epidemic flourishes. This is often reflected in unequal access to

           education for women, unequal access to credit, a lack of protection under the law for women's property,

           the continuing treatment of women as chattels to be disposed of at the will of their husbands,

           discrimination in access to health services, and so on. All of these matters can be remedied by

           appropriate public policy although to achieve this there may have to be firstly changes in women's

           access to political power. This is itself amenable to policy and is unlikely to happen unless there is

           action by men to include women in the processes of civil society. But happen they must if the present

           rates of HIV infection of both men and women are to be reduced.

           Related to the foregoing are issues of inequality between men and women and between different social

           classes. It appears that HIV infection is higher where the economic gaps separating men and women

           are greatest. Addressing these sources of gender inequality thus becomes an important area for social

           and economic policy. It is also the case that social stratification can be a source of inactive social and

           economic policy as those with power (the rich) follow policies in their own interest to the neglect of the

           rest of the population. Thus policies will be followed that are to the benefit of the rich (in economic

           matters generally, in access to credit, in employment, in education and in health provision, and so on).

           The exercise of such powers often continued after the formal passing of power to the rest of the

           population as democratisation has occurred in Africa, with the old elites continuing to set the policy

           agenda in their own interest.

           The power of self-interest in combination with continuing misconceptions about the HIV epidemic have

           been part of the problem in sub-Saharan Africa. One explanation of the rapid process of transmission in

           South Africa was that the former colonial government was simply uninterested in taking appropriate

           responses to the epidemic as it emerged. It seemed to the government to be an irrelevance given their

           particular class interests and so they failed to institute effective policies and programmes at the time

           that it was essential that they do so. This legacy is apparent both in RSA and in Namibia, and through

           relationships with other "dependent" economies in the region in other countries as well. Once the

           epidemic reaches a prevalence rate of 3-4% it is then exceedingly difficult to rein-in the subsequent rise

           in HIV infection. All the countries in the region are having to live with the consequences of the initial

           failures of Government in RSA to act decisively and early in relation to the epidemic. It should be noted

           that class economic interests can continue to prevent effective policy and programme responses, for

           the latter will often require fundamental changes in relations within civil society.

           4. Social Learning

           This can be brief although it is at the heart of an effective response to the epidemic. In the early days of

           the HIV epidemic in Africa, it was assumed that HIV infection was confined to core groups in the

           population - to those with immoral behaviours such as CSWs and their clients. In time, this perception

           of the epidemic has changed, although not everywhere. Clearly it does not make sense to think of the

           HIV epidemic in terms of "high risk groups" where 20, 30 or 40% of adults are infected as is now

           unfortunately the case in many countries and cities in the region. The HIV epidemic needs to be

           perceived as the responsibility of all - young and old, the poor and the rich, the governors and the

           governed, and men and women. But this recognition that a social partnership is required has been very

           slow in emerging and the question arises as to why this is so. It is also the case that many

           governments still do not perceive the risk that the HIV epidemic poses for all aspects of social and

           economic development. Again, how can this be explained and what needs to change?

           It may be useful to distinguish between "endogenous change" and "exogenous change". In the case of

           the former, one is interested in those processes of change which are internal to a society or

           community, or other social group, or within a family. What brings change about? More specifically,

           what are the forces which lead to changes in behaviours and attitudes such that those who are

           excluded (those living with HIV and their families) are accepted by society? So that people are enabled

           to understand the epidemic and are able to perceive what needs to change in their own behaviour and in

           social norms and conventions. The initial presumption of experts was that these changes would be

           brought about over time as societies experienced the illness and the deaths of their friends and loved

           ones. That there would indeed be Social Learning so that societies would adjust to the issues raised by

           the epidemic, become more socially inclusive, be reforming, and be generally capable of those social

           changes necessary for responding to the epidemic.

           There are examples within countries where this transformation has taken place, e.g., in some areas of

           Uganda. But generally the processes of social learning have been slow to operate with the result that

           social, economic and political changes have been slow in coming about. A consequence of this has

           been that the HIV epidemic has developed a severity in terms of the size of the populations infected

           which far exceeds original projections. Unless these processes of Social Learning occur it is difficult to

           see what can prevent the epidemic from continuing to effect the lives of everyone from one generation to

           the next.

           Unless there can be "exogenous changes" which can be imported from outside a society. Examples of

           this are condoms as also would be a vaccine where the technologies come from outside a society, or

           forms of social organisation which have been successful elsewhere. At the present time there seems

           little hope that a vaccine will be available and in any case when one does there will have to be an

           infrastructure to deliver it. Condoms have been more or less unpopular in most settings and it seems

           obvious that social attitudes and behaviours need to change first if they are to become widely used.

           Organisations which have had some success elsewhere can rarely be transplanted to other settings -

           although some of the concepts may be transferable.

           So what can be concluded from the evidence? It seems that Social Learning is central to the processes

           of both endogenous and exogenous change. New technologies are unlikely to be successful unless

           these are accompanied by other changes which are derived from social learning. It is an aim of public

           policy to help this social learning take place through building frameworks of laws and ethics, and

           respect for human rights, and through ensuring that everyone perceives the risks that the epidemic

           poses to society. In a word society will have to find ways of strengthening partnerships across gender,

           economic, class and ethnic divides.

           Part 2: ESTIMATINGDEMOGRAPHIC AND DEVELOPMENTAL IMPACTS - A CASE STUDY OF

           NAMIBIA

           Most of the lessons to be drawn from the foregoing are more or less self-evident. Nevertheless, it is

           probably worthwhile spelling out some of the more obvious conclusions and relating these to

           socio-economic conditions in Namibia. Data and information which are very relevant to analysis of the

           socio-economic factors affecting the HIV epidemic are contained in the Namibia Human Development

           Report, UNDP 1996.

                Poverty is obviously a factor in explaining who gets infected with HIV although, as noted above,

                there is no simple causal relationship, and the non-poor are also engaged in risk behaviours

                which expose them to infection. The evidence on poverty in Namibia is unambiguous C some

                40% of households were classified as poor in 1994. There are essentially two nations; the white

                population (5% of the total), and an emerging black elite (1%), who have average annual per

                capita incomes of US$16,500, while blacks in the modern sector (39%) have incomes of

                US$750 and the rest of the population have an estimated annual income of US$85.

                Namibian society is also highly unequal. The World Bank concluded that, "There are at least 2

                Namibias. The white population...is mostly urban and enjoys the incomes and amenities of a

                Western European country. The black population, mostly rural, lives in abject poverty". The

                result is that 65% of national income is received by 10% of the population, with the remaining

                90% receiving the remaining 35% of the national pie. But it is not only inequality of income, it is

                also inequality of the ownership of assets, with most of the financial and business assets held

                by a small minority, and with ownership of the most valuable land and mining resources also

                concentrated in their ownership. Namibia is without doubt one of the most unequal countries

                both in the distribution of income and in the ownership of productive assets.

                Inequality of income and assets have effects which transcend issues of economic and political

                power. They have consequences also for patterns of demand and for employment, and have

                effects on the distribution of labour both within sectors as well as spatially. Thus an element in

                rural to urban labour migration is the demand for largely unskilled and often poorly educated

                labour to serve the needs of the urban elite. They come partly in search of jobs and to escape

                rural poverty, and in part they are attracted by the lifestyles of urban society. But once in the

                cities they engage often in behaviours which expose them to risk of HIV infection, and then on

                their return to their rural communities they further transmit the virus to their spouses. The urban

                population has been increasing at something like twice the national rate which in part reflects

                the gap between rural and urban incomes - rural households have on average about one third of

                the income of their urban counterparts.

                Inequality extends well beyond incomes and assets and differences in life styles. They are

                embedded in more or less all aspects of Namibian life. All of the social indicators for Namibia

                point to a situation of great inequality in access to schooling, in access to health care, in the

                provision of housing, electricity, water and sanitation. Thus 95% of rural households have no

                access to electricity and 35% have no ready access to piped water. While 66% of the

                population is literate, only 58% of those in the rural areas can read compared to 83% in urban

                areas. There are deep ethnic, regional and rural/urban differences in most of the aspects of life

                which determine the standard of living.

                These differences have great implications for the HIV epidemic both in terms of what they imply

                for risk behaviours but also in terms of what can be achieved through HIV-related programme

                activities. It becomes immensely difficult to reach largely illiterate rural populations through IEC

                programmes - whether these are targeted at adults or at children/youth. The ethnic diversity of

                the population and the use of multiple languages makes all programming that much more

                difficult for it has to be appropriate for the particular group. The lack of access to water will pose

                great problems for those who care for HIV infected persons at home, mainly women, given that

                access to water is absolutely essential given that many patients suffer from diarrhea.

                Many studies point to vast inequalities in Namibia in nutritional status with the poor, and

                especially poor children, particularly affected. This again has importance in terms of the

                epidemic since it is clear that nutritional status is a factor in the ability of HIV positive persons to

                deal with opportunistic infections.

                Many more women than men are infected with HIV and many more young women than young

                men. In part, this reflects the inequalities that women continue to endure in Namibia - in all

                aspects of economic and social life. Their health status is worse than for men; and they have

                much lower labour force participation rates than men. As the NHIES concluded, "About 40% of

                Namibian private households are headed by females. The private consumption level in female

                headed households is about half the consumption level in male headed households." While there

                has undoubtedly been progress in girls access to education and in improvements in the legal

                position of women (at least on paper but less so in implementation) there is still a long distance

                to travel in Namibia. As the UNDP HDR for Namibia concluded in 1996, "In many

                communities...attitudes to women are at best outdated and at worst abominable, as evidenced

                by the high rate of rape and violent crimes against women." In a world of HIV and of AIDS the

                lives of women have to be changed or there can be no progress in addressing the fundamental

                factors which are driving the epidemic in Namibia.

                Agriculture continues to be the base for most of the country's population and there is a clear

                duality in this sector with high productivity and incomes for commercial farmers and low

                productivity and basic subsistence for the mass of traditional farmers. Since the traditional

                farming sector is where most of the poor are concentrated, it follows that efforts need to be

                intensified to raise productivity and incomes. This is crucial if rural to urban migration is to be

                slowed. Similarly, there is a need to re-examine industrial development strategies so as to

                minimise the mobility of labour within Namibia. It is well known that Tourism can be a factor in

                HIV transmission, and while no one would suggest that development not take place in this

                sector, there is nevertheless a need to ensure that structures and programmes are in place to

                minimise the possibilities of HIV transmission. In the aggregate all areas of development

                strategy should be assessed so as to address the ways in which planned developments have

                adverse effects on the growth of HIV in the population.

           Namibia is a fractured society. How could it be otherwise given its recent history of colonialism and war

           of independence? It is divided on ethnic grounds, on the basis of income and wealth, on social class,

           and on gender. But the HIV epidemic requires that society perceive the risks to its continuation and its

           prosperity posed by the epidemic. As such, the whole of civil society - not just Government and one or

           two large private employers - have to understand that all are threatened in one way or the other by the

           epidemic. The challenge for Namibia is how under conditions of social and economic differentiation to

           build a partnership of all Namibians. There are no blueprints for how to do this but an attempt must be

           made, nevertheless. The changes in social policy of recent years with a better distribution and higher

           levels of expenditure on health and education are a start. But the depth of the social deprivation and

           inequalities - especially those that are gender based - are what is driving HIV transmission in Namibia.

           Unless there is a more intensive attack on many aspects of the things that make up the lives of the

           poor, including access to employment and better social services, there will be little that can be

           achieved in reining back the HIV epidemic.

           Epidemiological Situation in Southern Africa

           As noted above sub-Saharan Africa has some 70% of the global total of 30 million people living with

           HIV, with Southern Africa the worst affected region on the continent. Adult HIV infection rates of

           20-25% are seen in countries with the highest prevalence, with urban rates in some cities double the

           average for the total adult population. In 1997 it was estimated that 2.4 million South Africans were

           living with HIV - an increase of more than a third compared with 1996. In Botswana the proportion of the

           adult population living with HIV has doubled over the past five years (to an estimated 25% in 1997). In

           Francistown the second largest city in Botswana the rate of HIV for pregnant women is now almost

           50% (1997). In Zimbabwe the adult rate of HIV infection in 1996 was 20% - one in five of all adults in the

           population. With 32% of pregnant women testing HIV positive in Harare in 1995, and a staggering 59%

           in Beit Bridge (1996). Throughout the region HIV prevalence continues to increase with rates in cities

           increasingly being mirrored by those in rural areas.

           The majority of new infections are in young people - those between the ages of 15 and 24 (sometimes

           younger). Thus in Zambia in one recent study over 12% of the 15-16 year olds seen at an ANC were

           HIV positive. In South Africa the % of pregnant 15-19 year olds infected with HIV rose to 13% in 1996

           from about half that level two years earlier. In Botswana the HIV rate for the same age group stood at

           28% in 1997. Infection rates in girls and young women are significantly higher than they are for boys

           and young men of the same age - thus in Malawi it is reported that HIV infection rates of young women

           are 5 to 6 times higher than for young men in the age range 15-20. The explanation of these differential

           rates of infection are complex, partly physiological and partly socio-economic. Whatever the causes

           the differentials both create gender biased socio-economic consequences, and at the same time call

           for programme responses which specifically address the problems of young men and young women.

           The epidemiological situation in Namibia reflects that common to other countries in the Region. Data on

           HIV for pregnant women attending ANCs suggest an average rate for the country as a whole of 15.4%

           in 1996 - this is a tripling of the level of HIV nationwide in the 4 years since 1992. HIV prevalence for

           women ranges from just over 3% to more than 24% in the different districts; is higher in urban than in

           rural areas (17.6% and 10.9% respectively), and reaches its peak in the age range 20-34. While AIDS

           deaths are widely under-reported it is still the case that it is now the leading cause of death for all age

           groups in Namibia. For AIDS to have become the leading cause of death by 1996 it follows that the

           present estimates of HIV prevalence must be serious under-estimates of the actual situation in the

           country. It is thus much more probable that HIV rates are closer to those in neighboring countries such

           as Botswana and Zimbabwe.

           Chart I is a summary representation of seroprevalence for pregnant women in Southern Africa C it is the

           best proxy available for measuring adult HIV infection. The visual picture is bleak: the realities of the

           lives of people even bleaker. The epidemic is without a doubt the greatest threat to sustained

           development facing the Region.

           Demographic Effects of HIV and AIDS

           No specific studies have been undertaken in Namibia into the demographic effects of HIV and AIDS and

           it is thus necessary to present data which relates to other high prevalence countries in sub-Saharan

           Africa. These have obvious relevance for Namibia given that HIV prevalence rates here are similar to

           other countries in the region and that demographic structures are also sufficiently similar as to make

           comparisons possible. The US Census Bureau has recently published its estimates of the

           demographic effects of HIV and AIDS on Africa and these are the most up to date and consistent

           estimates and projections currently available. In what follows the Census Bureau's estimates and

           projections are presented in the form of a commentary for the main aggregates under discussion,

           together with Charts to illustrate their projections which compare states with and without AIDS for the

           Southern Africa region. The following key outcomes are presented below:

                - crude death rates

                - infant mortality rates

                - child mortality rates

                - population growth rates

                - life expectancy

           1. The most immediate effect of the HIV epidemic is to increase the crude death rate for the

           populations affected. These will be higher where HIV prevalence is higher, which in sub-Saharan Africa

           is in the Eastern and Southern regions where the epidemic is most mature. Within these regions HIV is

           highest generally everywhere in urban settings and so also will be observable and predicted mortality.

           Chart 1 presents data on crude death rates for Southern Africa for the year 2010. Since crude death

           rates are generally lower in this region that elsewhere in sub-Saharan Africa so the increases will be

           relatively greater. By the year 2010 the crude death rate is projected to be 6 times higher in Zimbabwe,

           4 time higher in Botswana and 3 time greater in Zambia than it would have been in the absence of AIDS

           (Chart 2).

           2. Infant mortality rates are already rising sharply in countries with mature epidemics. Children borne to

           mothers who are HIV positive have a 30-60% chance of becoming positive themselves. In 1996 infant

           mortality rates in Zambia and Zimbabwe are estimated as being already 25% higher than they would

           have been in the absence of AIDS. In Southern Africa projections for 2010 are that deaths due to AIDS

           will more than double infant mortality rates in Botswana and Zimbabwe, and be more than 40% higher

           in Malawi (where rates are currently higher than elsewhere in the Region) and 60% higher in Zambia

           (Chart 3).

           3. It is estimated that two-thirds of AIDS-deaths will occur in children aged 1-4 years. These rates will

           increase since many children who are positive survive past their first birthday. Child mortality rates are

           already higher today than they would have been without AIDS in some high prevalence countries. Thus

           child mortality rates are estimated as being 75% higher in Botswana in 1996. By the year 2010 child

           mortality rates are expected to be twice as high in Botswana, 4 times greater in Zimbabwe and about

           twice as high in Zambia and Malawi (Chart 4).

           4. Projecting the overall effects on population growth is difficult in part because it depends on fertility

           decisions which are themselves partly the outcome of the effects of AIDS, and on decisions made in

           the knowledge of the effects of AIDS. Almost all past projections have supported the proposition that in

           spite of AIDS most countries will continue to experience positive population growth. Nevertheless the

           Census Bureau estimates suggest that 2 countries in sub-Saharan Africa will experience negative

           population growth by the year 2010 - in Botswana the rate is estimated to be minus 0.4 %(compared to

           a without AIDS rate of 1.9%), in Zimbabwe minus 0.5% (compared to 1.8%), and in Zambia 1.2%

           (compared to 3.1%), and in Malawi 0.1% (compared to 2.2%), see Chart 5.

           5. The most striking demographic effects are on life expectancy (Chart 6). Without AIDS all countries

           in the region would have been expected to have increased life expectancy as has been the case in

           recent decades more or less everywhere in sub-Saharan Africa. The effects of AIDS will be to increase

           mortality for children and young adults where mortality would otherwise have been low (and falling). The

           result is that AIDS will have the greatest impact on life expectancy, which other things being equal is

           one of the most important ways in which improvements in the standard of living are achieved and

           measured. It is indeed one of the three important elements in the UNDP HDI because of its value in

           summarising the benefits to individuals (societies) of sustainable human development.

           The estimates suggest that life expectancy has already been reduced from 64.1 years in Zimbabwe to

           41.9. But the situation in Zimbabwe is projected to deteriorate even further; without AIDS life

           expectancy in 2010 would have been an estimated 70 years but with AIDS it falls to less than 35 years.

           A disastrous decline and the worst projected for any country in sub-Saharan Africa. All of the countries

           in the Southern Africa Region are projected to suffer major declines in life expectancy caused by AIDS

           by the year 2010 -- for Botswana from 66.3 to 33.4; for Malawi from 56.8 to 29.5; for South Africa from

           67.9 to 47.8, and for Zambia from 60.1 to 30.3 years.

           Estimating the Impact of HIV and AIDS on Human Development

           It is now generally accepted that the HIV epidemic has multiple and complex effects on sustainable

           human development. These impacts have their origins in the effects of HIV and AIDS on the growth in

           the labour force and on the productivity of labour and capital. It also has effects on demographic factors

           in ways which have been identified above, with the probability that labour losses due to HIV and AIDS

           will ero