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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”





A threat to decent work,

productivity and


Document for discussion at the Special

High-Level Meeting on HIV/AIDS and the

World of Work

Geneva, 8 June 2000

International Labour Office


Copyright © International Labour Organization 2000

First published 2000

Publications of the International Labour Office enjoy copyright under Protocol 2 of the Universal Copyright Convention. Nevertheless, short excerpts from them may be reproduced without authorization, on condition that the source is indicated. For rights of reproduction or translation, application should be made to the Publications Bureau (Rights and Permissions), International Labour Office, CH-1211 Geneva 22, Switzerland. The International Labour Office welcomes such applications. Libraries, institutions and other users registered in the United Kingdom with the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P OLP (Fax: + 44 (0)171 631 5500), in the United States with the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923 (Fax: + 1 508 750 4470) or in other countries with associated Reproduction Rights Organizations, may make photocopies in accordance with the licences issued to them for this purpose.

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 Pellegrin, Agenzia Grazia Neri The designations employed in ILO publications, which are in conformity with United Nations practice, and the presentation of material therein do not imply the expression of any opinion whatsoever on the part of the International Labour Office concerning the legal status of any country, area or territory or of its authorities, or concerning the delimitation of its frontiers. The responsibility for opinions expressed in signed articles, studies and other contributions rests solely with their authors, and publication does not constitute an endorsement by the International Labour Office of the opinions expressed in them.

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Printed in Italy  

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.


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: 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


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


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,


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,                        



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


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