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HIV/AIDS:
A threat to decent work,
productivity and
development
Document for discussion at the
Special
High-Level Meeting on HIV/AIDS and
the
World of Work
Geneva, 8 June 2000
International Labour Office
Geneva
Copyright © International Labour Organization 2000
First published 2000
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ISBN 92-2-112167-4
Also published in French: VIH/SIDA: Une menace pour
le travail décent, la productivité et le developpement
(ISBN 92-2-212167-8) Spanish: VIH/SIDA: Una amenaza para
el trabajo decente, la productividad y el desarrollo (ISBN
92-2-312167-1)
Designed by: Enzo Fortarezza • Photos: Paolo
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Executive summary
The figures speak for themselves. With
an estimated 33 million persons living with HIV in 1999,
two-thirds of them in sub-Saharan Africa, and over 5
million newly infected in 1999 alone, HIV/AIDS is an
immense human and social tragedy. It is also now beginning
to be more widely, if belatedly understood that HIV/AIDS
is a major threat to the world of work. HIV/AIDS is a
threat to workers’ rights. People with HIV/AIDS are
subject to stigmatization, discrimination or even
hostility in the community and at work. The rights of
people living with HIV/AIDS, such as the right to
non-discrimination, equal protection and equality before
the law, to privacy, liberty of movement, work, equal
access to education, housing, health care, social
security, assistance and welfare, are often violated on
the sole basis of their known or presumed HIV/AIDS status.
Individuals who suffer discrimination and lack of human
rights protection are both more vulnerable to becoming
infected and less able to cope with the burdens of
HIV/AIDS. HIV/AIDS is a threat to development. The
pandemic has profound negative impacts on the economy, the
workforce, the business, individual workers and their
families. Economic growth could be as much as 25 per cent
lower than it might otherwise have been over a 20-year
period in high prevalence countries. Their populations
will be about 20 per cent lower by the year 2015 than they
would have been without HIV/AIDS, and their labour forces
in the year 2020 will be between 10 to 22 per cent
smaller. HIV/AIDS also has a significant impact on the
composition of the labour force in terms of age, skills
and experience.
HIV/AIDS is a threat to enterprise
performance. The world of work is affected by increasing
costs due to health care, absenteeism, burial fees,
recruitment, training and re-training. For smaller firms
in both the formal and informal sectors, the loss of
employees has major implications. In the rural sector,
losses due to HIV/AIDS may reduce food production and food
security. Enterprises in sectors such as transportation,
tourism and mining are the most vulnerable. Overall, there
will be a reduction of growth if rapid measures are not
taken to prevent the impact of HIV/AIDS.
HIV/AIDS is a threat to gender
equality. Women are highly vulnerable to HIV/AIDS for both
biological and cultural reasons. They are particularly
affected by HIV/AIDS when a male head of household falls
ill. The burden of caring for children orphaned as a
result of the pandemic is borne mainly by women. Loss of
income from a male income-earner may compel them to seek
other sources of income, putting them at risk of sexual
exploitation.
HIV/AIDS increases child labour. The
tremendous pressure on households and families often
forces children to work. As a result, it is difficult for
them to attend school, they do not receive proper care and
guidance, and easily fall victim to all kinds of
exploitation. For all these reasons, HIV/AIDS is a major
factor undermining the ILO’s guiding principle of decent
work. People living with HIV/AIDS are often forced to
leave their jobs and are isolated in their communities,
with minimal opportunities to earn an income. In the
absence of adequate public support systems, especially in
the developing countries, families have to bear the full
cost of the disease, pushing them deeper into poverty.
HIV/AIDS prevention is poverty alleviation.
Yet, in so many countries, even those
which are worst affected, prevention and care are impeded
by a persistent culture of denial, both in society and the
world of work.
The ILO has to play a pivotal role in
overcoming this culture of denial and in addressing
HIV/AIDS in the world of work. A global partnership is
required to develop a comprehensive response to the impact
of HIV/AIDS on the world of work. Although governments and
employers’ and workers’ organizations have started to
respond to the effects of the pandemic on the world of
work, the complexity and extent of the pandemic require
global initiatives by the ILO and support for action at
the national and enterprise levels. The ILO has the
expertise in this area and, through its long history, has
established the necessary relations with the social
partners all over the world. In particular, the large
numbers of members of employers’ and workers’
organizations offer an ideal channel for
awareness-raising, prevention and support initiatives at
all levels.
2Introduction
From medical problem .....
In the early years of the pandemic, HIV/AIDS was regarded
almost exclusively as a medical problem. Since then, as
the scale of the human tragedy has become clear,
particularly in the most affected countries, it has become
evident that HIV/AIDS is a major development problem which
is threatening to reverse a generation of achievements in
human development. HIV/AIDS is also rapidly emerging as a
serious issue in the world of work and a major threat to
the ILO’s guiding principle of decent work. As
participants from 20 African countries meeting in
Windhoek in October 1999, put it:
....to development issue......
“The pandemic has manifested itself in
the world of work – the area of the ILO’s mandate – in the
following ways: discrimination in employment, social
exclusion of persons living with HIV/AIDS, additional
distortion of gender inequalities, increased numbers of
AIDS orphans, and increased incidence of child labour. It
has also disrupted the performance of the informal sector
and small and medium enterprises. Other manifestations are
low productivity, depleted human capital, challenged
social security systems and threatened occupational safety
and health, especially among certain groups at risk such
as migrant workers and their communities and workers in
the medical and transport sectors.”
......but the potential of the world of work to combat
HIV/AIDS is untapped
Much has been learned about the pandemic and how it should
be addressed — and in particular that AIDS prevention and
care are complex issues requiring a multi-sectoral
approach. However, the full potential role of the world of
work as a major venue for partnerships and interventions
to prevent HIV/AIDS, protect workers and reduce its impact
on business remains untapped. It is therefore the purpose
of this paper to examine the social and labour
implications of HIV/AIDS, as well as current practices and
approaches to addressing the problem. Based on a
preliminary assessment of impact, constraints and
opportunities, the paper goes on to explore the policy and
programme elements of an ILO response to the tragedy.
I. The nature and magnitude of the pandemic
A. HIV/AIDS: the global picture
Recent estimates indicate that 33.6
million persons were living with HIV by the end of 1999,
of whom 32.4 million are in their most productive years,
that is between the ages of 15 and 49, while 1.2 million
are children aged 15 years and younger. In 1999 alone, 5.6
million people (570,000 children) became infected with HIV
and 2.6 million died from AIDS (see Table 1). With the
HIV-positive population still expanding, the annual number
of AIDS deaths worldwide can be expected to increase.
95 per cent of persons living with HIV/AIDS are in developing
countries
Around half of all people with
HIV become infected before the age of 25 and die
approximately ten years later. By the end of 1999, there
was a cumulative total of 11.2 million AIDS orphans,
defined as children who have lost their mother before
reaching the age of 15. Many of these maternal orphans
have also lost their fathers. Approximately 95 per cent of
the global number of people with HIV/AIDS live in
developing countries. Due to poverty, poor health systems
and limited resources for prevention and care, it is
expected that this proportion will rise further.
Table 1: The AIDS pandemic at the end of 1999
1
People newly infected
Total 5.6 million
With HIV in 1999
Adults 5 million
Women 2.3 million
Children <15 years 570 000
Number of people living Total
33.6 million
With HIV/AIDS
Adults 32.4 million
Women
14.8 million
Children<15 years 1.2 million
AIDS deaths in
Total 2.6 million
1999
Adults 2.1 million
Women 1.1 million
Children <15 years 470 000
Total number of AIDS Total
16.3 million
Deaths since the
Adults 12.7 million
Beginning of the
Women 6.2 million
Pandemic Children
<15 years 3.6 million
1 UNAIDS: AIDS
epidemic update, December 1999.
4B. Regional features
The pandemic has taken on different
forms in the various parts of the world. In some areas,
HIV has spread rapidly to the general population, while in
others certain sub-populations have been particularly
affected, including sex workers and their customers, men
who have sex with men (MSN), and injecting drug users.
Table 2 provides an overview of the regional features of
the HIV/AIDS pandemic, the adult prevalence rate and the
main mode(s) of transmission. In global terms, the adult
prevalence rate is 1.1 per cent of the population as a
whole, of whom 46 per cent are women.
Region People living
New Adult prevalence
HIV-positive Main mode(s)
With HIV/AIDS
Infections rate as % women
as of
Of total % of total
transmission
Population HIV-positive
Population
Sub-Saharan Africa 23.3 million 3.8
mil
8.0 55
heterosexual
North
Africa & 220,000
19,000 0.13
20 injecting drug use
Middle
East
and heterosexual
South
& 6 million 1.3
mil 0.69
30 heterosexual
South-East Asia
East
Asia & 530,000
120,000 0.068
15 injecting drug use,
Pacific
heterosexual, men
Having sex with men
Latin
America 1.3 million 150,000
0.57 20
men having sex
with men,
injecting drug use,
heterosexual
Caribbean 360,000
57,000 1.96
35 heterosexual,
men
having sex
with men
Eastern Europe 360,000
95,000 0.14
20 injecting drug use,
&
Central
Asia
men having sex
with men
Western Europe 520,000
30,000 0.25
20 men having sex
with men,
injecting drug use
North
America 920,000
44,000 0.56
20 men having sex
with men,
injecting
drug use,
Heterosexual
Australia & 12,000
500 0.1
10 men having sex
New
Zealand
with men, injecting
Drug use
TOTAL 33.6 million 5.6
mil 1.1
46
5Two-thirds of all people living with
HIV/AIDS are in sub-Saharan Africa
Over 23 million people in sub-Saharan
Africa are reported to have HIV infection or AIDS. This
figure amounts to almost 70 per cent of the global total
of persons living with HIV/AIDS in a region inhabited by
around 10 per cent of the world’s population. Table 3
provides estimates for the end of 1997 of the numbers of
people in Africa living with
HIV/AIDS and the percentage of
HIV-positive adults in the 15 to 49 age bracket. In nine
African countries, the rate of adults living with HIV/AIDS
was 10 per cent or more, while two countries have rates of
more than 20 per cent, meaning that approximately every
fifth person between 15 and 49 years of age is
HIV-positive and will, in all likelihood, die in the
course of the next 10 years.
HIV/AIDS in other regions
For the Asian and Pacific Region, it is
estimated that 6.5 million people were living with HIV at
the end of 1999. It has been estimated that around 4
million persons in India are infected with HIV. In China,
half a million people are estimated to be HIV-positive.
Estimates from Thailand indicate that 780,000 people were
living with HIV/AIDS in 1997, that the adult infection
rate was 2.2 per cent, of whom 260,000 had AIDS and the
cumulative number of AIDS deaths was 230,000. In Viet Nam,
the HIV surveillance system indicates that HIV prevalence
in pregnant women increased more than ten-fold between
1994 and 1998.
Among injecting drug users, HIV
prevalence remained stable at 18 per cent over the same
period. In Cambodia, 3.7 per cent of married women of
reproductive age were living with HIV in 1998 and 4.5 per
cent of male blood donors were infected with HIV, compared
with 2.5 per cent of female donors.
Approximately 1.7 million people in
Latin America and the Caribbean are living with HIV/AIDS.
In Guatemala in 1999, up to 4 per cent of pregnant women
tested at antenatal clinics in major urban areas were
found to be HIV-positive. In Guyana, HIV prevalence was
recorded at 3.2 per cent in blood donors, while
surveillance of urban sex workers in 1997 showed that 46
per cent were infected. HIV surveillance among pregnant
women in Haiti in 1996 found close to 6 per cent to be
positive.
Republic 170,000 8.6 Liberia 42,000 3.0
Country Est. number
of
Adults prevalence
Persons
living
rate (per cent)
With
AIDS/HIV
Botswana
190,000
22.1
Burundi
242,000
7.0
Zimbabwe
1,400,000
21.5
Togo
160,000
6.9
Zambia
730,000
16.6
Lesotho
82,000
6.7
Namibia
150,000
16.1
Congo
95,000
6.4
Malawi
670,000
12.5
Burkina
Faso
350,000
6.0
Mozambique
1,200,000
11.9
Cameroon
310,000
4.0
South
Africa
2,800,000
11.8
Democratic Republic
900,000
3.6
Of the Congo
Rwanda
350,000
11.2
Nigeria
2,200,000
3.4
Kenya
1,600,000
10.4
Gabon
22,000
3.1
Central African
170,000
8.6
Republic
Liberia
42,000
3.0
Cote d’lvoire
670,000
8.5
Eritrea
49,000
2.6
United
Republic
1,400,000
8.2
Of Tanzania
Sierra
Leone
64,000
2.6
Uganda
870,000
8.1
Chad
83,000
2.2
Ethiopia
2,500,000
7.7
Benin
52,000
1.8
Guinea-Bissau
11,000
1.7
C. Risk and vulnerability
In the context of HIV/AIDS, risk is
defined as the probability that a person may acquire HIV
infection. Certain types of behaviour create, enhance and
perpetuate this risk. High-risk behaviour includes for
example, unprotected sex with a partner whose HIV status
is unknown, multiple unprotected sexual partnerships, lack
of adherence to infection-control guidelines by
health-care personnel, repeated blood transfusions,
especially using untested blood, and injecting drug use
with shared needles.
Women are infected younger than men
The current information available on
the pandemic indicates that women tend to become infected
far younger than men, for both biological and cultural
reasons. According to recent studies of several African
populations, girls aged 15-19 are five to six times more
likely to be HIV-positive than boys at that age. A number
of gender-related risk factors increase women’s exposure
to HIV and sexually transmitted infections, and impair
their ability to protect themselves from infection.
4 Source: UNAIDS, 1998: United Nations, World population
prospects: The 1998 revision.
7These
include:
_
behavioural factors, such as the inability to negotiate use of condoms, refuse
sexual intercourse or demand divorce, because of adverse
economic, social or legal consequences;
_
gender-related cultural factors,
such as different expectations regarding sexual roles,
fidelity and mariage or harmful traditional practices; and
_
socio-economic factors, such as inadequate access to health care and unequal
educational and economic opportunities, which may promote
dependency on a male partner, or even lead to commercial
sex.
Vulnerable populations
Mobile workers, including migrants, are
another vulnerable group. A great number of persons
working in the transport, fishing and tourism industry
belong to this group. Mobile populations tend to be more
vulnerable to infection than local populations for reasons
which may include lack of hygiene, poverty, powerlessness
and the precarious family situations which accompany their
status. One significant source of HIV transmission is sex
between men who, through their work, spend long periods
away from their families in predominantly or exclusively
male environments.
Higher risk for drug and alcohol abusers
Drug and alcohol use is related to a
higher risk of HIV infection for at least two reasons. In
the first place, the sharing of needles, syringes and
other equipment in a group in which one or more persons
are HIV-positive significantly increases the risk of HIV
transmission. Secondly, the effect of psychoactive
substances, such as alcohol and stimulants, can
significantly lower the threshold of engaging in high-risk
behaviour. Substance abuse prevention is HIV/AIDS
prevention. Military personnel are a population group at
special risk of exposure to sexually transmitted
infections, including HIV. Recent figures from Zimbabwe
and Cameroon show that military HIV infection rates are 3
to 4 times higher than in the civilian population in peace
time. In times of conflict, the difference can be over 50
times higher.
D. The impact on the individual and the household
HIV/AIDS has an enormous impact on
infected individuals and their families, as well as on
their extended family and the community at large. The
impact at the individual and the household level is
mirrored at the enterprise level in the case of
family-businesses, micro-enterprises and self-employment.
The impact begins as soon as the HIV status of a member of
the household is known and is aggravated when he or she
starts to suffer from HIV-related illnesses.
Stigmatization, Discrimination and hostility
Where a person is known to be
HIV-positive, he or she is frequently the subject of
stigmatization, discrimination or even hostility in the
community and at work, particularly where community
members and colleagues have little understanding of
HIV/AIDS. As a consequence, people living with HIV/AIDS
are often forced to leave their jobs and are isolated in
their communities. Some of them prefer to leave their
community and try to make a new beginning where they are
not known. They hide their HIV status as long as they can
to avoid stigma and discrimination. In such an
environment, it is very difficult to provide people living
with HIV/AIDS with the necessary assistance and support,
or to enable them to work in conditions of freedom,
equity, security and human dignity. Persons with HIV
infection or AIDS-related illnesses frequently have no
opportunity to obtain decent jobs. Their economic
situation often obliges them to take any work they can
find, which may be far below their qualifications, in
order to survive. The effect on the family is generally a
loss of income and increased expenditure on medical care
and funeral costs. As a consequence, savings are used,
assets are sold and money may be borrowed. In many cases,
the health costs associated with HIV/AIDS eat up all the
savings of a family or family business, leaving no
reserves to cope with the actual loss of the person
(breadwinner, business owner, etc). This directly affects
the “risk management capacity” of the other persons
involved.
Children have to work
Other family members, including
children, are often forced to work. As a consequence, the
number of children engaged in income-earning activities in
high prevalence countries increases significantly. Those
children, in turn, are not able to attend school and do
not receive proper care and guidance. The family
composition and role distribution change dramatically. The
tremendous pressure on the household frequently prevents
family members from finding decent work, and they often
have to migrate, or may be forced into homelessness and
living in the streets.
Role of the extended family
The role played by the extended family
as a safety net is by far the most effective community
response to the AIDS crisis. Affected households in need
of food send their children to live with relatives.
Relatives are then responsible for meeting the children’s
food and other requirements. The preparation of food and
agricultural work on the affected household’s land or
overseeing its livestock may well be carried out by
another family member or neighbour, in addition to their
own tasks. However, as the number of multi-generational
households which lack a middle generation increases, the
ability of families and social networks to absorb these
demands is bound to decline.
9Women are particularly affected by
HIV/AIDS in cases where a male head of household falls
ill. The women may themselves become infected. The burden
of caring for children orphaned as a result of the
pandemic is borne mainly by women. Loss of income from a
male income-earner may compel women and children to seek
other sources of income, putting them at risk of sexual
exploitation. If a woman living in an agriculture
community in which women are responsible for subsistence
farming becomes infected and falls ill, the cultivation of
subsistence crops will fall, resulting in an overall
reduction in the food available to the household.
HIV/AIDS prevention is poverty
alleviation
In the industrialized countries, HIV/AIDS places a heavy burden
on the social security systems. However, such systems are
practically non-existent in developing countries. As a
consequence, the affected families have to cope with the
full impact of HIV/AIDS, with the effect that their
residual assets are wiped out and they are pushed deeper
into poverty. HIV/AIDS prevention is an important aspect
of poverty alleviation.
E. Human rights implications
Human rights issues become more
critical in crisis situations. The HIV/AIDS crisis is no
exception. A lack of respect for human rights fuels the
pandemic in at least three ways:
_
discrimination increases the impact of
the disease on people living with HIV/AIDS and those
presumed to be infected, as well as on their families and
associates;
_
people are more vulnerable to infection
when their economic, social or cultural rights are not
respected; and
_
where civil and political rights are
not respected, it is difficult for civil society to
respond effectively to the epidemic.
Human rights are vital for HIV/AIDS
prevention
Protection of human rights, and particularly protection against
discrimination, as the core principle in the prevention of
HIV/AIDS, was first stressed by the World Health Assembly
in May 1988 in the resolution entitled
“Avoidance of discrimination in relation to HIV-infected people
and people with AIDS”. The resolution emphasized that respect for human
rights is vital for the success of national AIDS
prevention programmes, and urged member States to avoid
discriminatory action in the provision of services,
employment and travel. The Joint WHO/ILO Statement adopted
at the Consultation on AIDS and the Workplace (Geneva,
1988) also came to the conclusion that protection of human
rights and the dignity of HIV-infected persons, including
persons with AIDS, is essential to the prevention and
control of HIV/AIDS. In September 1996, the Office of the
United Nations High Commissioner for Human Rights and the
Joint United Nations
10Programme on HIV/AIDS convened the
Second International Consultation on HIV/AIDS and Human
Rights, which adopted a set of 12 International Guidelines
on HIV/AIDS and Human Rights, which clarify the
obligations contained in existing human rights
instruments, including various ILO Conventions and
Recommendations.
The rights of persons living with
HIV/AIDS are vital to protecting the uninfected majority
From an ILO perspective, discrimination – especially
discrimination in the world of work – is one of the most
significant human rights abuses in the area of HIV/AIDS.
The rights of people living with HIV/AIDS, such as the
right to non-discrimination, equal protection and equality
before the law, privacy, liberty of movement, work, equal
access to education, housing, health care, social
security, assistance and welfare, etc., are often violated
on the sole basis of their known or presumed HIV/AIDS
status. Moreover, individuals who suffer discrimination
and lack of respect for their human rights are both more
vulnerable to becoming infected and less able to cope with
the burdens of HIV/AIDS. People exposed to HIV will not
seek testing, counselling, treatment or support if this
means facing discrimination, lack of confidentiality, loss
of employment or other negative consequences. Several
years of experience in addressing the HIV/AIDS epidemic
have confirmed that the promotion and protection of human
rights constitute an essential component in preventing
transmission of HIV and reducing the impact of HIV/AIDS.
Experience has also shown that the incidence and spread of
HIV/AIDS is significantly higher among groups which
already suffer from a lack of respect of their human
rights and from discrimination, or which are marginalized
because of their legal status. These include women,
children, people living in poverty, minorities, indigenous
peoples, migrants, people with disabilities, sex workers,
homosexuals, injecting drug users and prisoners. These
populations often have less access to education,
information and health care because of the discrimination
they face in relation to their economic opportunities,
political and social influence, or gender and sexual
relations. Without a rights-based response, the impact of
HIV/AIDS and vulnerability to the disease will inevitably
increase. As often highlighted by the late Jonathan Mann,
the protection of the uninfected majority is inextricably
bound up with upholding the rights of people living with
HIV/AIDS.
II. The social and economic implications of HIV/AIDS
A. The social and economic impact at the national
level
There are several mechanisms by which
HIV/AIDS affects macroeconomic performance:
_
AIDS deaths lead directly to a
reduction in the number of workers available, and
particularly workers in their most productive years. As
experienced workers are replaced by younger, less
experienced persons, productivity is reduced.
_
A shortage of skilled workers leads to
higher production costs and a loss of international
competitiveness.
_
Lower government revenues and reduced
private savings (because of greater health care costs and
a loss of income for workers) can lead to slower
employment creation in the formal sector, which is
particularly capital intensive. As a result, some workers
will be pushed into lower paying jobs in the informal
sector.
_
Expenditure increases on the monitoring
of high-risk groups, the establishment of prevention
strategies, the provision of health care and welfare.
_
Pressure increases on the social
security system, as illustrated in Figure 1, including
life insurance and pension funds, which are important
sources of capital for both the government and the private
sector.
The macroeconomic impacts of HIV/AIDS
are sensitive to assumptions about how AIDS affects
savings and investment rates, and whether AIDS affects the
best-educated employees more than others. Studies in
Tanzania, Cameroon, Zambia, Sw |
