AN INTRODUCTION TO HIV/AIDS http://www.worldbank.org/ AIDS (Acquired Immune Deficiency Syndrome) is caused by the Human Immunodeficiency Virus (HIV). In order for the virus to attack a person's immune system, it has to enter the bloodstream and there are three ways in which this may occur: 1.       Through sexual intercourse - this includes both heterosexual and homosexual intercourse, although most infections in the developing world are transmitted heterosexually. 2.       Directly into the bloodstream through use of contaminated blood or blood products, or sharing of intravenous drug-injecting equipment. 3.       From mother to child - it is estimated that about one third of infants born to infected mothers will be infected. This may occur prior to birth across the placenta, during birth, or via breast milk. The possible responses to the epidemic are well documented. Risk of sexual transmission can be reduced by use of condoms and/or cutting down on numbers of partners and treating other sexually transmitted infections. Blood and blood products can be made safer through screening of donors and their blood. Drug users can be encouraged to sterilise or exchange needles. Work on developing means of reducing mother to child infection is underway. One of the crucial points that has to be made about the HIV/AIDS epidemic is that it is different from most other epidemics and diseases, and consequently requires a different and much broader response - one which must encompass far more than the health sector. The factors that make it unique are: ·         It is a new epidemic. AIDS was first recognised as a specific condition only in 1981 and it was not until 1984 that the cause (and a test to detect it) was identified. ·         It has a long incubation period. Persons who are infected by the virus may have many years of productive normal life, although they can infect others during this period. It is not certain how long this latent period is; estimates range from five to fifteen years, with the shorter period being found in the developing world, where people are less healthy and well nourished. It is known that good health and nutrition, and early treatment of opportunistic infections, will extend the period of healthy and productive life. Unfortunately infected children will, for the most part, die before their fifth birthdays. ·         The prognosis for people infected with HIV is bleak. At the end of the incubation period, a person will usually experience periods of sickness increasing in severity, duration and frequency, until he/she dies. ·         The disease is found mainly in two specific age groups: children under five, and adults aged between 20-40 years. For various reasons there seem, in the developing world, to be slightly more females than males infected, and women develop the disease at a younger age. ·         The scale of the epidemic is also different from most other diseases. As Table 1 shows, in some settings, up to 30 per cent of ante-natal clinic attendees are infected. This means that between 20-25 per cent of sexually active adults may be infected. ·         HIV is mainly sexually transmitted, which means it is passed on through one of the most fundamental human activities, but one with which we are neither open nor comfortable. ·         There are links between HIV and other diseases, most notably tuberculosis, which has further implications for public health. ·         In general, the epidemic is still spreading in the developing world, although there are signs that the level of infection may have peaked in some areas. Table 1. HIV Prevalence, Selected Sites and Countries, Ante-natal Clinic Attenders (% HIV+)   1991 1992 1993 1994 1995 Gwanda, Zimbabwe [1] 16 21 NA 25 NA Nsambya, Uganda [2] 27.8 29.5 26.6 21.8 NA Francistown, Botswana [3] NA 23.7 34.2 29.7 39.6 KwaZulu-Natal, South Africa [4] 2.9 4.8 9.6 14.35 18.23   Sources: [1] Gwanda Hospital, ZIANet AIDS News, Vol. 2, No. 1 March 1994. [2] Nsambya, HIV/AIDS Surveillance Report, Ministry of Health, Kampala, March 1995. [3] AIDS Analysis Africa (Southern African Edition) 6(3), Oct/Nov. 1995. [4] AIDS Analysis Africa (Southern African Edition) 6(3). Oct/Nov. 1995. The result of infection is an increase in morbidity (sickness) and mortality (death). There are few data on increased morbidity but the effect on mortality has been predicted (see Figure 1). Attempts to predict and plan for the impact of the epidemic have foundered, firstly on the fact that nowhere has it run its course, thus we do not have examples of what might happen. Secondly, there is a paucity of good primary fieldwork and data; and thirdly, like the epidemic, the response is dynamic, thus people evolve coping mechanisms and strategies. Nonetheless, some results have been observed and predictions can be made. The effect of an infection is felt first and most immediately by the person who falls ill and their family. It then spreads like a ripple out through the household, community, and then through the country as a whole. This interaction is illustrated in Figure 2. It should be remembered that while an individual may not be a producer, he or she will always be a consumer and have social roles. Broad areas of concern for development assistance, where we expect the epidemic to have an impact, are demographic, economic and developmental. Demographic Consequences AIDS will not stop population growth, nor cause populations to fall, thus any idea that “AIDS is the solution to the population problem” is unfounded. What it will do, in some regions, is to slow the rate of population growth and alter the structure of the population. Of particular concern is the increased mortality in the 20-40 year age group. This has the effect of reducing the working age population and increasing the dependency ratio. Most women will complete their child-bearing before falling ill so the number of orphans will rise. Economic Effect AIDS will have an effect on economies at various levels. The most obvious is at the household level. A household with a infected member will find that expenditure increases as the person requires medical care, a special diet and so on. If the infected person is an adult then their labour will be lost, which may affect income if the person was in paid employment or producing goods for sale, and will reduce household welfare. At the sectoral and firm level the impact AIDS has will depend very much on how the sector or firm uses labour, what level of labour is employed, how the workers are treated in terms of benefits, and the importance of experience. In some instances the epidemic may have a significant effect on efficiency and cost, while in others the effect will be minimal. The macro-economic impact is also uncertain. It is believed that AIDS will affect national economic growth through diversion of savings to care and consumption (thus reducing investment), and through the illness and death of productive members of the society. There have been attempts to model the economic impact for specific countries. These models show that HIV will probably reduce the rate of economic growth; and, over a period of 20 years, this may be significant (up to 25 per cent lower than it would otherwise have been). The Effect on Development It is increasingly argued that development is about more than economic growth and increases in GDP per capita. It is on the development indicators that the impact of the epidemic will be felt first and worst. Particularly vulnerable are the indicators of life expectancy; infant mortality rates; child mortality rates and the crude death rate. Infant mortality rates may nearly double in Zambia and Zimbabwe and increase by 50 per cent in Kenya and Uganda. Child mortality rates will increase even more, as many children survive beyond their first birthday. Life expectancy is predicted to fall by an estimated 9 years in Zaire to more than 25 years in the worst affected countries by the year 2010 (Way and Stanecki, 1994). The effect of AIDS will be to reverse hard-won development gains and to make people and nations worse off. It is possible that these effects may last for decades. The people who fall ill and die are the parents and leaders in society, which means that a generation of children may grow up without the care and role models they would normally have. Conclusion It is clear that HIV/AIDS presents a major challenge to developing countries. The question remains as to what can be done about it. The obvious response is to reduce the number of infections. This includes 'technical solutions', such as making the blood supply safe, treating STIs, and providing condoms, but these interventions will not be successful if they are imposed without an understanding of the social and economic factors that determine both behaviour and the response to the epidemic. The sad reality is that in many countries a significant number of people are already infected. While prevention must remain a priority: - there are those who are as yet uninfected and other who are becoming sexually active - there is a need to plan for the impact of the epidemic. The number of people falling ill and requiring care will increase. The rise in mortality and its consequences will have to be accommodated. Thus while the first response is prevention, the second is to plan for and mitigate the impact of the epidemic. This is hard to do because: in most settings the impact is not visible; it is incremental rather than catastrophic; AIDS is only one of a number of problems facing policy makers; and there have been only a limited number of ideas as to what can be done. References: Lieve Fransen and Alan Whiteside, (eds.), HIV/AIDS and Development Assistance, Workshop Proceedings, Brussels, 13 June 1996. Peter O Way and Karen A Stanecki, The Impact of HIV/AIDS on World Population, US Bureau of the Census, Washington DC, 1994. World Bank, AIDS Prevention and Mitigation in Sub-Saharan Africa, An Updated World Bank Strategy, Report No. 15569-AFR, Human Resources and Poverty Division, Technical Department, Africa Region, Washington DC, April 20, 1996. DOCUMENT 2: ASSESSING THE NATIONAL IMPORTANCE OF THE HIV/AIDS EPIDEMIC One of the problems with the epidemic is that most countries are experiencing an HIV rather than an AIDS epidemic, and this is not visible. The result is that people are either not aware of the potential impact of the AIDS epidemic or do not have the data to assess it. This document presents a flow chart for deciding if HIV/AIDS is a national issue. Where they have been prepared, it should be used in conjunction with country profiles. The country profiles (which have been, or are being prepared for a number of countries) set out what the position is in a country with regard to HIV/AIDS, as well as key factors of susceptibility and vulnerability. Using the flow chart: These notes refer to the numbers in the boxes. 1. We start with available data, which in most countries are the results of surveys carried out by sampling ante-natal clinic attenders. If the level of infection is above three percent then this means that an HIV epidemic of some magnitude is likely and we need to consider HIV further. 2. If the level is below 3% in ante-natal clinic attenders, we need to look at other indicators. The prevalence of other sexually transmitted infections is a good measure, as HIV is transmitted in the same way as other STIs and there is evidence to show that these infections increase the risk of HIV transmission. If this prevalence is above 3% then there is a risk that an HIV epidemic will be experienced. 3. If HIV/AIDS is deemed to be an actual or potential problem the next step is to look at its potential impact on the development support. The first question to ask here is: is this support in a social sector? If support is in this sector then, given that HIV increases the levels of illness and death, thus increasing and changing demand for social services, the issue of HIV is one that must be considered through the use of the other tools in this toolkit. 4. If the support is not in the social sector we turn to look at what the support actually does. Here there are a number of possibilities. ·         If the sector relies on human resources (for example an agricultural project may be dependent on a supply of qualified agronomists and agricultural engineers) then HIV/AIDS needs to be considered. ·         Does the support result in increased mobility (for example a road construction project might rely on a contractor taking teams of men from camp to camp)? If so we need to consider the implication of this for the epidemic. ·         Does the project make assumptions about demographic trends? If a project makes assumptions about what the size and structure of the population will be then the impact of the epidemic on this must be considered. ·         Does the support focus on, or result in, disadvantaged groups? Examples here might be a project that provides support for refugees- risk of HIV infection is greatly increased for such groups. 5. If, when completing the flow chart, you arrive at this box it means that HIV/AIDS should be considered in the provision of development assistance and the other tools should be applied. 6. If you arrive that this box it means that HIV/AIDS is currently not a problem and does not need further consideration. However two points should be noted. ·         The flow chart looks at the national situation. There may be regional variations and these will be important for certain types of development assistance such as rural development support. For example, in Thailand the ANC prevalence is below 3 per cent yet parts of the country have a serious HIV epidemic. Obviously if data are available on a disaggregated basis the flow chart can be applied at that level. ·         The chart applies to the situation at present, and this can change. There may some virtue in reviewing the position every two years. There is a trade-off between simplicity and sensitivity. Where a country profile is available this will be appended here. DOCUMENT 3: A SECTORAL CHECKLIST What is a Sector? The term sector means different things to different people. The basic economic definition of a sector is a 'homogenous group of productive economic activities'. The most common set of sectors is found in national accounts data. Economists define sectors in terms of their output. This definition of sectors is very broad, as an examination of the transport sector shows. Transport can be divided into the following sub-sectors: maritime transport (which includes shipping and ports); railways; roads; airlines. Each of these sub-sectors could be further divided between passengers and goods, and long and short haul. The term 'sector' is used by people other than economists. The European Commission produced 24 "Fiche de Programmation Sectorielle" (sectoral notes) in 1994 and 1995 as part of the run-up to Lomˇ IV (bis). These included agriculture, livestock, fisheries, private sector, tourism, infrastructure and transport, research, education, public health, family planning, problems of drugs, potable water, rural development, urban development, tropical forestry sector, environment, women and development, population, regional integration, institutional reform, poverty alleviation, and social development. As much support is given on a sectoral basis, it is both appropriate and necessary to look at the impact AIDS might have by sector. This checklist is designed to establish points of susceptibility and vulnerability to HIV and AIDS, and point to some of the actions that may be taken to reduce this. Susceptibility may be defined as the likelihood of people being infected, while vulnerability is the likelihood of the sector being more or less affected by the epidemic. For example migrant workers in the agricultural sector may be susceptible to infection, but if they are easily replaceable and have few benefits then the sector will not be vulnerable. Addressing HIV and Sectors: a Checklist If HIV/AIDS is deemed to be a problem in the country, the next step is to look at its effect on specific sectors. There are two points where sectors are considered. The first is in the drawing up of the Sectoral Fiches, when the main areas of concern and how they are to be addressed are established. The second point is in the National Indicative Programme (the document signed by government and the EC, which identifies focal areas in which support will be given. Typically infrastructure (especially transport), rural development and human resources development receive the bulk of the funds. Objectives are identified, along with actions and measures to be taken by government, and what EC support will be available. At both stages there is a need to consider the HIV/AIDS issues and two questions are raised: 1.       Can sectors or sub-sectors be identified as being susceptible/vulnerable to HIV/AIDS? 2.       Can a sector activity or intervention be put in place? The idea of the checklist is that it should be completed as a diagnostic tool, using the notes provided. The spaces will not be completed with a simple 'yes' or 'no', but rather with a few words of explanation where necessary. Figure 1. Assessing Sector Susceptibility/Vulnerability Name of sector or sub-sector   A. LABOUR Type A 1. Availability Skilled Unskilled (i) Is there sufficient labour?     (ii) Are new recruits available?     (iii) Are there seasonal constraints?     (iv) Does the work require experience?     (v) Is there sick leave provision (how much)?     (vi) Is there compassionate leave (how much)?     A 2. Employee Benefits     (i) Are medical services or medical aid provided?     (ii) Is insurance provided?     (iii) Are death benefits provided for employees?     (iv) Other benefits (e.g. housing, transport)     (v) Is a pension provided for dependants?     A 3. Use of Labour (mobility)     (i) Does work demand travel overnight?     (ii) Are migrant workers employed? What % of work force?     (iii) Are most employees male or are they female? How are they housed?     B. POPULATION AND WEALTH     B1 Demographic Trends   (i) Is the population growth rate significant?   (ii) Is the population structure important?   (iii) Is the household size and composition important?   B2 Income and Expenditure   (i) Will changes in government budgets affect the sector?   (ii) Will changes in taxation affect the sector?   (iii) Are changes in household income and expenditure significant?   C. SECTOR SPECIFIC QUESTIONS   (i) Will AIDS affect demand?   (ii) Will AIDS affect supply?   (iii) Other issues   Notes for Completing the Checklist This checklist is designed to identify areas in which HIV/AIDS may impact on a sector or project. As it is completed areas of concern will be identified. How they are addressed falls outside the scope of the checklist. These notes assist in completing the checklist. Section A - Labour There are three key issues: will there be enough labour of the right type and at the right time?; what effect will increased morbidity and mortality have on the cost of employee benefits?; and how is the labour used? Skilled and unskilled labour should be assessed separately. A1 - Labour Availability (i) Is there sufficient labour available? (ii) Are new recruits available? Labour may be available initially, but can it be replaced? (iii) Are there seasonal constraints? Are there peaks in the supply of and demand for labour. (iv) Does the work require experience? Some jobs do not require training but are learnt through experience - this type of employee will be difficult to replace. (v) Is there sick leave provision (how much)? Although sick leave is a benefit, it will have an impact on labour availability. It is expected that employees will take all available sick leave as they fall ill - this can affect labour availability, especially if benefits are generous. (vi) Is there any compassionate leave? Increased mortality will increase demand for compassionate leave. A2 - Employee Benefits (i) Are medical services or medical aid provided? The effect of AIDS will be to increase the demand for medical care whether supplied or paid for by the sector/company/project. (ii)