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


Which is the

The Debt


By Osborne Wanyama, Young Professional at the World Alliance of YMCAs in 2000




1. Asia (India)
1.1. HIV/Aids current status - ASIA
1.2. India (snap-view)
1.3. Socio-economic impacts - Focusing India
1.4. Initiatives from local community and NGOs (YMCA)

2. Latin America and the Caribbean
2.1. HIV/AIDs current status
2.2. Socio-economic impacts ( Jamaica, Trinidad/Tobago)
2.3. Comparing efforts in the Caribbean, Uganda and Thailand

3. Sub-Saharan Africa (A general view)
3.1. HIV/AIDs current status
3.2. Socio-economic impacts
3.3. Initiatives from the local community
- Better Life Options (BLO) - South Africa YMCA
- Learning by doing - Busia YMCA

4. Critical analysis of findings from the three regions

5. Transition to the PRS and grassroots initiatives

6. Case study (Kenya and Uganda)
6.1. Kenya's Poverty reduction Strategy Paper (PRSP)
6.2. A model Approach - Uganda
(a) Snap View of HIV/AIDS situation in Uganda
(b) Planning HIV/AIDS interventions for Youth Programmes
(c) Key areas to focus on for intended initiatives

7. Strategies for the YMCA


This booklet could not have been researched and written without support from the WHO's Department of Child and Adolescent health and development and UNAIDS for their first hard information on 'Getting the Priorities Right'.

We are entirely grateful to Ms. Jane Ferguson and her technical team, Mr. Robert Thomson and Mr. Paul Bloem for their time and support through the whole process. I also want to thank my extended family at the World Alliance of YMCAs especially Nick Nightingale, the Secretary General for his generous contributions. You all have made the experience of marrying theory and practice worthwhile.

To my Supervisor Ranjan Solomon 'My Greatest Teacher and Friend', I say thank you for always willing to advice, criticize, suggest and most of all sacrifice your precious time to decipher my expressions and opinions - Thank you so much!

Finally in a work of this nature, which is neither a theoretical discourse nor simplified guidebook, it is impossible not to reflect, echo, or recall what others have said or written before. And at that extent and purpose I have taken a reasonable liberty to quote, paraphraseor expound on what past- masters in this area have said before. All other faults and weaknesses remain mine.

Osborne Okumu Wanyama
December 2000
Geneva - Switzerland

Understanding the twin challenges of globalisation and HIV/AIDs is becoming an imperative for YMCA people in each of the 127 countries where the YMCA is present around the world. As we increase our knowledge and experience of the pandemic and its effects on young people, the YMCA must add its voice to the ethical and
moral issues which are raised.

The YMCA is at its strongest when in action, however, and this excellent paper, "Which is the Scourge? The Debt or HIV/AIDS?", points to some ideas for programme work. It is also a thorough analysis of some specific aspects of the impact of global economic injustice. Until we see this injustice addressed, our aspirations for a peaceful world will remain pipe dreams.

Osborne Wanyama has drawn on the views of several international organisations based here in Geneva, but is himself responsible for raising some provocative questions. For that and the information he has gathered together, I for one am appreciative and very grateful for his valuable new resource for the Movement.

Nicholas J. Nightingale
Secretary General
World Alliance of YMCAs
1st December 2000
World Aids Day

Developing countries cannot simply ignore the HIV/AIDs pandemic. According to UNAIDS, about 1.5 million people died from AIDs in 1996. Each day about 8,500 people including 1000 children, become newly infected. About 90% of these infections occur in developing countries, where the disease is likely to exacerbate poverty.

But HIV/AIDs is not the only problem demanding government attention. In the poorest countries especially, confronting AIDs can consume scarce resources that could be used for other pressing needs. Most of the countries worst affected by HIV virus are already buckling under the heavy burden of international debt. The requirement that Third World countries ravaged by AIDs have to divert their scarce resources away from the immediate and desperate needs of their impoverished populations to repay their debts is now finally recognised as scandalous. Debt relief is urgently needed to allow indebted countries to target their spending where it is most needed. These are diverted to repaying debts that these countries owe the IMF and World Bank.

But in order to qualify for debt relief under the HIPC initiative, debtor countries had until recently to implement six years Structural Adjustment Programmes (SAPs) designed by IMF. In an effort to ensure that the potential of benefits of debt relief are maximised, SAPs are a package of neo-liberal policies, intended to stabilise poor country economies by creating economic growth which will in time have repercussions for the poor.

In 1983 when the HIV virus was first identified as the cause of AIDs, the disease has been reported in nearly all developing and industrial countries.

UNAIDS, the UN's joint programmes towards fighting the AIDs epidemic, estimated that at the end of 1996 about 23 million people world-wide were infected with HIV and more than 6 million had already died of AIDs. More than 90% of adult HIV infections are in developing countries. About 800,000 children in the developing world are living with HIV. At least 43% of all infected adults in developing countries are women.

Globally, the HIV pandemic has affected regional areas differently. The rates or forms of HIV transmission are said to differ according to geography. In the more developed socio-economic countries, HIV transmission has occurred mainly between men who have sex with men, bisexuals and people who use street drugs intravenously. In the lower socio-economically-developed countries, HIV transmission is usually through heterosexuals, with women being the most at risk, and mother to child transmission being high.

In major cities of India and Thailand for example, 2% of pregnant women, carry HIV. These levels are similar to those found in such African countries as Zambia and Malawi, where more than one in four pregnant women are now infected. While new infections are thought to be levelling off in Sub-Saharan Africa as a whole, in some countries, military conflict and civil unrest maybe spreading the pandemic.

Meanwhile, the disease is spreading rapidly in Asia. Asia may already have surpassed Africa in the number of new infections per year.

In Latin America and the Caribbean countries, the number of new infections has been steady at 200,000 per year for several years. AIDs is clearly taking an immense growing toll. The disease is catastrophic for millions of people who become infected, get sick and eventually die. Because AIDs kills mostly prime-age adults, it increases the number of children who lose one or both parents.

India, Sub-Saharan African and some countries of Latin America and the Caribbean are depleted of resources generally and therefore have fewer for the provision of comprehensive health care. International debt increased due to unfavourable economic events of the 70s. In the 1980s debt in Latin America and Sub-Saharan Africa, particularly had become so large that these countries were not able to service their debt.

As the debts increased for many developing countries, so the option of default increased. In response to this, the World Bank together with the IMF introduced Structural Adjustment Programmes (SAPs) to enable developing countries to borrow money from funds via the World Bank. Despite the huge national debt and borrowing levels, money was given under certain conditions.

These Macro-economic policies however, have failed to alleviate poverty, and in some cases contributed to greater inequities. At the same time, while development programs have made some headway in ameliorating the conditions in which poor people live, they remain fragmented in vertical programming streams. Overall, policies and actions of IFIs, donors and many southern governments themselves neglect the "agency" of poor people to create lasting social change; fail to promote participation of the poor in agenda-setting; and stifle systems of public accountability. This paper argues that economic, gender, health and other inequities are bound to persist if these basic criteria for participation, decision-making and accountability are overlooked.

Structural Adjustment Programmes were focused to control inflation, control interest rates and money flow, and prune public spending whilst building upon an economic policy of comparative advantage. For many developing countries, this has led to fewer resources (gained through public expenditure cuts) to fund uniform comprehensive health provision. HIPC have high unemployment levels, which means the majority of people live in poverty. Many of these people participate in informal sector activities, such as prostitution and intra-venous drug-use, which has implications for HIV. Government resources are very scarcely spread, the cost of medically testing HIV/AIDs within the community and in hospital is high and very much beyond providing universal care. In terms of health prevention, training local personnel and providing safer sex tools, such as condoms, may also be impossible to supply universally due to the high cost. HIV being contracted through blood can also expose inadequate screening and testing facilities in developing countries, where screening for the virus is often not done due to no equipment in which to store and save blood, i.e. refrigerators and facilities for the blot test.

We should however not attribute the failure of service systems like health to the policies made by International finance Institutions (IFIs). The predominant pattern of unequal distribution of public resources for health in developing countries could also be linked to political powers in these countries. This is no mere accident, current terms and conditions demanded by IFIs such as IMF in return for aid and debt relief are making corruption worse. The money released through the HIPC debt relief initiative should be used in the interest of the poor.

The challenge of organisations like the YMCA and others is to advocate for mechanisms to check the appropriation of such funds. But corruption should not be used as an excuse to slow down debt relief-no society is corrupt free. If debt cancellation is done with sensitivity and local control, it can help countries that have a problem corruption become less corrupt what is needed is to put pressure especially on democratic governance, while at the same time relief is worked on. AIDs is not alone in causing human suffering, however. In low-income countries and those heavily laden by the debt crisis in particular, many urgent problems compete for scarce skills and resources. For example, at the beginning of this millennium, malnutrition and childhood diseases that can be prevented or treated much more easily than AIDs are expected to kill 1.8 million children in the developing world. TB is expected to kill more than 2 million people; and malaria, about 740,000 world-wide. Annual deaths from smokers are expected to increase from 3 million in 1990 to 9.4 million in 2020, and nearly all these is expected to occur in developing nations.

Given these many pressing problems, how much time, effort and resources should governments, NGOs and civil society devote to fighting AIDs not forgetting their present concentration on now christened SAPs to Poverty Reduction Strategies (PRS) imposed by the World Bank and IMF?

PRS profoundly alter the nature of a country's economy and the role of its government. PRS have sometimes succeeded in improving government balance sheets, by shrinking budget deficits, eliminating hyperinflation, and maintaining debt payment schedules. However, the types of structural adjustment measures that the World Bank and the IMF require all too often fail to promote sustainable economy. Instead, they have frequently led to
environmental degradation. Once again the poor are the most affected. This kind of scenario is very conducive to factors that contribute the growth and progression of the HIV/AIDs pandemic. Countries can be classified according to two broad criteria: first, the extent of HIV infection among groups of people often found to engage in high-risk behaviour and second, whether the infection has spread to populations assumed to practice lower-risk behaviour. The typology includes three stages of the HIV/AIDS epidemic:

HIV prevalence is less than 5 percent in all known subpopulations presumed to practice high-risk behaviour for which information is available.
HIV prevalence has surpassed 5 percent in one or more subpopulations presumed to practice high-risk behaviour
, but prevalence among women attending urban antenatal clinics is till less than 5 percent.
HIV has spread far beyond the original subpopulations with high-risk behaviour, which are now heavily infected. Prevalence among women attending urban antenatal clinics is 5 percent or more.


In most Asian countries, the epidemic has reached a concentrated stage either nation-wide or at least in some states or provinces. This includes regions of the world's two most populous countries, China and India, most of Indochina, and Malaysia.

In the remaining Asian countries, the epidemic is nascent; infection among those presumed to practice high-risk behaviour is less than 5 percent. Patterns of infection in east, south, and Southeast Asia have been greatly influenced by the proximity of many countries to the Golden Triangle of heroin production, located at the border between Lao
PDR, Myanmar, and Thailand, and to its distribution routes. HIV infection was first detected among those who inject drugs in Bangkok in 1987; during the following year it spread rapidly among injecting drug users in the Thai capital. The pattern was quickly repeated among injecting drug users in northern Thailand and along the border areas between southern Thailand and northern Malaysia.

In 1989, HIV infection was identified in Myanmar, Yunnan Province in China, and in Manipur State in India. HIV was detected among injecting drug users in Singapore in 1990. Injecting drug use has been the main transmission mode in China, where the most highly infected province, Yunnan, is adjacent to international drug routes. Male injecting drug users in Yunnan account for 78 percent of HIV infections in China. In other Chinese provinces, infection rates are thought to be low, even among those who practice high-risk behaviour.

Economic reforms that have helped to reduce the number of people in poverty in China by more than half since the late 1970s have also resulted in large increases in internal migration that could generate conditions conducive to the spread of HIV. Studies have estimated that nearly 100 million people, roughly one in twelve people in China, have moved either temporarily or permanently from their registered residences. Much of the movement involves migration within provinces, but an estimated 20 million migrants have moved from poor areas of western China to eastern provinces.
Most migrants are young, single, and male, but many women have also migrated; some have reportedly become involved in prostitution. Sexually Transmitted Diseases (STDs), which were all but eliminated in China in the 1960s, are rising rapidly.

Early preventive interventions for migrants and sex workers in areas receiving migrants could reduce the likelihood of an epidemic of HIV and other STDs among these mobile groups. Among the nations of South Asia, the epidemic is believed to be spreading most rapidly in India and Pakistan. In India, HIV is widespread among injecting drug users in the north-eastern states of Manipur and Mizoram and is spreading to their sexual partners; prevalence in antenatal clinics in Manipur has reached 2 percent.

HIV is well established among sex workers and STD patients in much of southern India, including populous Maharashtra and Tamil Nerd states. In the city of Mumbai formerly Bombay, HIV prevalence among pregnant women has reached 1.5 to 2.5 percent. In Pakistan, the infection rate among injecting drug users in Lahore was 12 percent; as of 1998, HIV infection among women attending antenatal clinics was still extremely low.
Transmission by those who inject drugs also may be a factor near a second major heroin-producing area, the Golden Crescent where Pakistanis Northwest Frontier meets the Badakhshan area of Afghanistan and the Baluchistan area of Iran. Bangladeshis HIV epidemic is still nascent, but, without behaviour change, HIV could spread quickly among a population of brothel-based sex workers and their clients.

In most of south-east Asia, with the significant exceptions of Indonesia, Lao PDR, the Philippines, and Papua New Guinea, the HIV epidemic is at the concentrated stage. Injecting drug use has played a central role in the launching of HIV, often in conjunction with commercial sex, but heterosexual transmission is now thepredominant mode of transmission. HIV is firmly established among injecting drug users and sex workers in Cambodia, Myanmar, and Thailand, and 1 to 3 percent of pregnant women are HIV-positive in those countries.

In Thailand, HIV prevalence peaked at 4 percent among military conscripts in 1998, but has recently been declining following a national campaign to reduce sexual transmission of HIV through greater condom use and a reduction in commercial sex. In Cambodia, however, infection levels in the military have reached nearly 7 percent. In Malaysia and Vietnam, more than three-quarters of HIV infections are attributed to transmission through injecting drug use. Yet sexual transmission in Malaysia is clearly on the rise; nearly 40 percent of HIV/AIDS cases seen at the University of Malaya Medical Centre since 1986 were thought to be due to heterosexual transmission. In contrast, although HIV has been detected sporadically for some time among sex workers in the Philippines and Indonesia, it has not spread rapidly, even within that group; as of mid-1996 these two populous countries remained at the nascent stage.

By the turn of the century, the year by which health for all was to be achieved, India is expected to have the highest incidence of HIV/AIDs between five and eight million cases. The HIV virus that causes AIDs is spreading to previously untouched populations. The virus is moving from urban to rural areas and from high-risk groups to the general population.

Sero-positivity is a high 25.84 per thousand, and most case of HIV infection have been detected in men and women between the ages 20 and 45, which would mean the untimely loss of a large number of adults in the prime of their economic life in India.

Apart from heterosexual contact, followed by intravenous drug use and infected blood products, other factors are attributed to the rocketing increase in infection.

It is hard to explain the dramatic shift in the sexual behaviour of the middle class. Changes in the workplace are cited as a major reason. Industrial growth has spawned a breed of travelling executives who spend nearly half their working lives away from home. At the same time, women have become an increasingly visible part of the professional workforce. Put these factors together and you have the settings for an increasing number of casual relationships.

Roshan dreamt that it was so easy. Last year as a chief executive of a motor company, he went to Delhi for an official engagement with Neetu, a junior colleague. They completed their work, had a drink and dined together. Neetu invited Roshan to her room for a nightcap. Roshan hesitated, Neetu insisted and Roshan ignored the fact that he was married. After all, they were two consenting adults in a strange city, no one would ever know.They spent the next three nights in her hotel room. A month later, Neetu left to join another company. Roshan forgot their little affair until an uncle asked him to donate blood for his bypass surgery. When the blood bank pronounced him positive, Roshan was furious. They offered to retest. The result was the same. Frantic Roshan went to another diagnostic centre. The reply was no different. While exchange of genital fluids during sexual intercourse is the most common cause of transmission, the rates can be as low as one for every 100 such episodes with infected persons. Too bad Roshanís brief alliance with Neetu had been dead on target. Roshan is now on anti-depressant drugs.

In every country with a serious AIDS epidemic today, people once said: "It can't happen here. We don't have the behaviours that spread AIDS." They were wrong. It is too easy to be complacent, when no one appears visibly sick with AIDS. It is too easy to look the other way, when thousands are dying of other afflictions.

HIV/AIDS respects no international borders. It does not discriminate by nationality, race, gender, or religion. Human behaviours and social conditions that spread the virus are present in all countries. Internal and international migration, or political and social upheavals also facilitate the spread of the virus. By the time hospitals are filled with AIDS patients, it is too late. The virus will already have spread to epidemic proportions.

The growing affluence of the middle class and Hollywood films could have something to do with changing moral values. The influence of the west is an inescapable factor. Unfortunately, people have borrowed the gloss but not the ability to react swiftly to a crisis. While in Europe and North America, having a multiple sexual partner is now considered high risk behaviour in India it has just become fashionable; a symbol of liberation and upward mobility. Everyone wants to be James Bond ,women are shedding their inhibitions as it were, and sexual expectations are running high.

With the premarital sex gaining increasing acceptance among the new generation, the incidence of sexually transmitted diseases including HIV/AIDs has risen. Teenagers and those in the early 20s now constitute a third of the cases testing HIV-positive. But therein lies the paradox. The question is, if students can get sex on campus, why would they opt for loose sleaze bazaars (immoral expeditions) without.

"Because it is easier", admits 20 year old Kunjan reluctantly. "Peer pressure made me desperate for sex". Nevertheless, he was too shy to make a first move. When his friend Deepak suggested the brothels of Kamathipura, he agreed. "They went only a couple of times but I hated the experience". Two years later, Kunjan was diagnosed with TB. A mandatory AIDs test followed, and Kunjan's family was told the worst.

Teenagers and young men from a third of HIV cases, prostitutes are the main source of infection.

Prostitutes top the list of premarital sexual partners, among men. For researchers, these are danger signals because prostitutes are a major reservoir for the AIDS virus and the border between this original reservoir and the general population is quickly getting porous."

Dinesh got a job with a foreign bank in Mumbai. He was given a flat with three other colleagues all male and more money than his father earned after 20 years of government service. This was a taste of independence for Dinesh.

Last year, his roommate Ranjan took him to an exclusive brothel downtown.
'Time to lose your virginity', he grinned. Rajula was about 40 and very kind.
"Don't worry," she said when he admitted he had never worn a condom. "You are safe."
The following week Dinesh was back at the same time, alone. Soon he was a regular. Six months later, the young executive went home to Jaipur for holiday. When he returned, Rajula had vanished. "The doctor said she had AIDS", the receptionist explained. Dinesh felt a knot in his stomach. An Aids test confirmed what he feared.

While Dinesh learnt his plight accidentally, the real problem is that few go in for blood test unless the symptoms begin to show. The virus can lie dormant in the body for anything between six months and over ten years and then strike the immune system down.
So in many cases people who are infected get married and pass on the virus to their wives and children unknowingly.

The changes in economic policy have been standard in structural adjustment packages prescribed by the World Bank and the International Monetary Fund universally, regardless of the needs of individual countries. These recommendations include the devaluation of the rupee, increase in interest rates, reduction in public investment and expenditure, reduction in public sector food and fertiliser subsidies, increase in imports and foreign investment in capital-intensive and high-tech activities and abolition of the cash compensatory support for exports. Additionally, it includes massive privatisation of major national industries including power generation, telecommunications, toll roads and bridges, making those with less economic power having to pay equal to those with more economic power for essential utilities in an industrialised nation. When a country begins to denationalise, it is usually the most lucrative businesses that get sold first, leaving only unprofitable industries in the public sector. The effect is that the public sector has fewer sources of income generation, leaving fewer profits available for the government to pay for food and health subsidies. The Bretton Woods institutions promote these policies for their long term benefits, while ignoring that in the shorter term, they are likely to put further strain on the poor.

Changes in industry
In fiscal year 1998-1999, the economy has a healthy GDP growth level of 5.8 percent. Liberalisation policies made it easier for large foreign corporations to set up in the country. Large cities, that would be more hospitable to new technology, disproportionately attracted the majority of the industries. Some cities were favoured more than others: 37 percent of industrial investments between August 1991 and October 1994 were concentrated in the two states of Gujarat and Maharastra, both in proximity to the city of Bombay. This can be compared to the combined share of all the eastern and north-eastern states which attracted a meagre 5.14 percent. It is precisely those regions that received the most foreign direct investment that the number of commercial sex workers (CSWs) are highest and incidence of the HIV is increasing most rapidly.

Changes in Employment
Changes in industry have created new employment prospects for some, while destroying economic situations for others. Studies show that in each period, 1992-1993, 1993-1 994, 1994-1995, six million jobs were generated. Employment generation has grown 2.1 percent between 1992-1993 and 1994-1995, translating into an increase in disposable income among middle classes. However these jobs are mainly for skilled labourers and middle and upper managerial positions, most frequently held by men who have received some form of education or training. This discrimination in the labour market contributes to an unequal human capital investment in men and women. Lacking appropriate skills, women tend to get easily displaced by new technologies and are either pushed out or pushed down when job requirements call for skilled and trained personnel. Surveys show that female urban
unemployment increased from 4.3 percent in 1991 to 5.8 percent in 1992 (Anuradha Chenoy 1995). Such marginalisation of female workers in the face of globalisation has been documented extensively.

It is estimated that 94 percent of the Indian female labour force exists in the informal sector. Women working in the informal sector are not protected by any labour laws such as the Employees State Insurance Scheme, the Factories Act or the Equal Remuneration Act.

Decreases in Public Sector Subsidies
Another direct consequence of the New Economic Policies is the reduction of subsidies for health, education, housing and welfare. Such cuts in spending results in diminished support for services previously available to women. Without government assistance, fees for education and costs for health care increase. Reduced social spending also means less funding is available for prevention and treatment programs for the many opportunistic diseases caused by HIV.
With the cuts in subsidies to small farm owners, grains become more expensive to cultivate. The decline of the rural subsistence economy accelerated, causing food prices to increase. The per capita daily availability of cereals and pulses averaged 469 grams in the years 1992-1994, down from 473 grams in 1988-1990. With the advent of the NEP fertiliser prices have doubled and seed and other input costs have increased.
The deterioration of social services has weighed heavily on low-income groups, of whom women constitute the majority. The gender dimensions of liberalisation policies are not easily measured or counted in macroeconomic indicators. Changes in income, food prices and public expenditure do not affect all members of the household in the same way. Macroeconomic indicators, too often focus on gross national product (GNP), imports and exports, balance of payments, and efficiency and productivity. Effects of economic policy on everyday microeconomic transactions are rarely examined. How a family will be able to pay for health costs or rising food prices is not the concern of the national and international economic reformers.
The share of government spending on medical and health services for the year 1990-1991 to 1994-1995 shows the decline in seven states. It remained stagnant in four states. Only in five states did an increase in spending register. The share of expenditure on public health declined in the states where health status is the lowest in the country. Trends like the introduction of user fees for outpatient and inpatient care have started in several states. Kenya's experience shows us that this has severe consequences: when the World Bank required the country to charge $2.15 for sexually transmitted disease (STD) clinic services, visits fell 35-65 percent. Privatisation of the pharmaceutical industry has done away with cost-controlled drugs, making medications more expensive. Thus decreases in public sector subsidies also lend to increased urbanisation. The poor already living in the cities had few choices and were left economically powerless.

Devaluation of the Rupee
Most Structural Adjustment packages include measures to devalue the currency, a direct result of which is inflation. The devaluation of the rupee increases prices across the board: items that are most difficult to do without include grains and sugar, and freight and passenger fares, both by rail and by road, basic necessities used by rich and poor alike. Inflation rates during the 1991-1995 fiscal year were higher then pre-reform rates. The effect was a changed economy that further widened the gap between rich and poor and men and women. There has not been such a continuous high rate of inflation since India's independence.

To supply food-processing industries being set up with foreign collaboration, there has been a major shift from subsistence farming of rice, millet, corn and wheat to cash-crop production of fruits, mushrooms, flowers and vegetables. This shift has led women to lose jobs. The process of mechanisation of agricultural activities has also brought in gender discrimination by replacing women with men. As the economic policies in India cut subsidies on fertilisers and grain transport which assist small farmers, life in rural areas has become more difficult.
Migration motivated by wage differentials apply to families, single men and also single women; in fact, anyone who needs additional income considers moving into the cities. It has been demonstrated that increased migration exacerbates the spread of HIV. More men in large cities, most often without their families suggests that demand for commercial sex would increase, especially with potential clients with higher disposable incomes. As women move into the cities, they find fewer job opportunities than men.
Prostitution has always been associated with migration. It is found where religious and mercantile centres are found and any type of festival which brings people from far off. Prostitution always has been, and probably always will be, one of the adaptive strategies to cope with the stress and dislocation of migration.

World poverty is increasing as a result of globalisation, the lack of accountability of multinational corporations and increasing over-consumption. In India, evidence shows that between fiscal years 1989-1990 and 1992-1993, the proportion of the population living below the poverty line (defined as a nutritional minimum in terms of calories per day) increased from 34 percent to 41 percent. The number of people living below the poverty line rose from 282 million to 355 million, mostly in rural areas. Another source finds that in 1995 there were 300 million people in India under the poverty line compared to 200 million in the middle class. The budgetary provision for poverty alleviation programs and welfare and economic security schemes for the poor has been cut by 12 percent These reductions hit women and their children the hardest in terms of access to food, health care and energy expenditure on work.
Unskilled women who find themselves in financial difficulties, without access to any economically secure household have few options in India. Legally, women have rights to a share of parental property, or that of their husbands', be it a house or a piece of land. In practice though, they rarely benefit from it.
They are also prevented from doing some types of agricultural labour and are thus excluded from the majority of the work in rural areas. Women therefore experience poverty differently from men. It is in the face of economic
crises that many women are forced to join the sex trade.

Demand for Commercial Sex
Truck drivers make up a major clientele group for sex workers. With increased market activity comes increased transport of goods. Truck drivers are instrumental in transporting the bounty of new goods flooding India's markets. Truck drivers have been found to be one of the largest causes of transmission of the virus in India. Recent surveys of truckers in and around Calcutta found that more than 5 percent of the drivers had HIV, more than 90 percent visited at least one prostitute a week, having an average of 200 sexual encounters per year, and 68 percent never used a condom. Truckers are the main channels through which HIV migrates from urban to rural areas.
Studies have also found an increase in HIV among truck drivers in Madras. Truck drivers requesting HIV testing, because of increased rates of other STDs have increased from almost 60 percent in 1993 to 91 percent in 1995. Surveys show that almost 33 percent were infected with HIV in 1995.
Also included in the category of men more likely to visit sex workers are non-skilled and low-skilled workers in manufacturing industries located in urban areas; low level workers in various types of transport industry such as rickshaw drivers, taxi drivers and bus drivers; construction workers; and traders and customers in periodic markets in both rural and urban regions. Numbers of people in all of these categories have increased as a result of increased industrialisation and economic activity in the larger cities.

Increase in Commercial Sex Work
Effects of structural adjustment are most severely felt by the poor, especially women. Their reduced economic power, caused by changes in industry, reduction in public sector subsidies and the devaluation of currency. This justifies resorting to prostitution for lack of better alternatives. An activist from an Indian NGO said that some 200 Indian women and girls go into prostitution each day and 75,000 enter the trade each year. She adds that between 1954 and 1992, the population of commercial sex workers has increased fourfold. She explains "the pressures of liberalisation, urbanisation, and migration are stimulating the sex trade" Data on the actual number of commercial sex workers in India is sparse. It is extremely difficult to obtain reliable quantitative data since prostitution is illegal and women distrust the motives of the surveyors. In 1990, it is estimated there were 50, 000 CSWs in Mumbai and 2 million in all of India.
Over a third of the world's households are headed by women who are solely responsible for all the household production and needs. Official estimates of female-headed families in India are around 10 percent, but these are probably grossly underestimated; actual figures could be as high as 30, especially when taking rural areas into account. Poor and lower caste families are more likely to have a tradition of female employment which sex-work is merely continuing. Many families often depend on income sent to them by female family members who send home money made from their sex work.

Earning Capacity
Working in the sex industry can be lucrative and financially attractive, in an environment of economic despair.
A program in Calcutta conducted a study to find out how much the sex workers earn. They categorised the sex workers into three categories: High-income, receiving over Rs.100 per single act, middle-income, receiving Rs 50-100, and low-income receiving less than Rs 50. Proportionately, the high-income group made up 21.5 percent of the sample, the middle-income 51.7 percent and the low-income 26.8 percent.

Prevalence of HIV
Commercial sex workers in India are becoming infected with HIV at rates that rival the highest ever reported. Researchers evaluated 851 HIV-negative patients at sexually transmitted disease (STD) clinics every three months during the period 1993 to 1995. It is estimated that the overall incidence of new HIV infections for the CSW patients to be more than 10 percent per year, compared to the incidence rate of 8.4 percent of people who were not commercial sex workers.
The incidence of HIV infection was higher in women (14.1 percent per year) than in men (9.4 percent per year). HIV infection is also more common for commercial sex workers because a woman who already has one or more sexually transmitted diseases is also at increased risk of being infected with HIV.
Risk of HIV has an inverse relationship with economic status; that is, women who work at higher-per-transaction price level are at less risk, whereas women who earn less per transaction are at greater risk. This is because women who work with well-off men are less likely to use intravenous drugs or have other risks for infection. Not surprisingly, condom use is extremely low; as CSWs have very limited power in negotiating with their clients. These power differentials means that if a woman insists on using condoms, the client will go elsewhere and she will lose the income she relies on to survive.
One can argue that regardless of economic environment, the HIV virus will spread. However, it can be noticed that cities which received more investment, and have more commercial activity have higher rates of HIV. It has been found that Mumbai, receiving the highest proportion of investment (37 percent), has the highest rates of HIV infection among commercial sex workers. Numerous reports on the trafficking of young girls from Nepal into India, and mainly Mumbai illustrate the fear of HIV and other infections. Demand has risen for younger and younger girls, who would be less likely to have any sexually transmitted diseases. Thus the cycle continues, as more women and girls are infected, the more girls will join the sex industry and the more mortality caused by Acquired Immune Deficiency Syndrome (AIDS).
Because HIV spreads exponentially, at the current rate, mortality caused by AIDS will soon touch everyone in the country. Sex work causes mortality among others than the prostitutes and their clients. Wives and other partners of the clients are at risk, as well as children of the sex workers. There are numerous estimates of India's national HIV/AIDS prevalence. According to the World Health Organisation, by the year 2000, 1 million people
will have AIDS in India and 5 million will be HIV-positive. And, if trends hold, India could have as many as 30 million people with HIV by the year 2010 - about 1 1/2 times today's worldwide total, although new AIDS cases reported by the government dramatically underestimate reality, they are an indication of the increase.

The evidence suggests that the New Economic Policies have increased mortality caused by AIDS among commercial sex workers. More data is needed on numbers of girls and women that were in the trade before the NEP and currently. More specifically, trends on the percentage of the population who are commercial sex workers, to adjust for total population size are needed. This lack of data merely illustrates how marginalised this population is- they are difficult to access and little is known of them.
An additional concern would be what projected mortality rates will do to India's economy as a consequence. It is estimated that AIDS will cost India US$11 billion cumulatively by 2000, 5% of the country's gross domestic product. It could develop into a cycle where cuts in government subsidies causes more incidence of HIV infection which increases the need for health services in order to treat opportunistic infections, continuing to strain resources. Additionally, high levels of AIDS morbidity and mortality among individuals during their most productive years would reduce overall productive contributions of society to economic development. Countless orphans left by AIDS mortality would also strain the public welfare system, which would be expected to provide for them. So while the new economic policies may bring in hefty returns for many, a larger majority would have to pay the price.
As economic policies accelerate the incidence of HIV, a new perspective of the disease is needed. India could create new effective and innovative programs in AIDS prevention, that are sensitive to the needs of CSWs, and a softening of the effects of the new economic policies. Experience from Thailand has shown us that even in the face of increasing industrialisation, economic policy mandates from the IMF (The Economist 1997) and increasing commercial sex work, it is possible to reduce incidence of HIV infection with aggressive, condom-oriented prevention programs.
Economic policy changes could include shifting emphasis from production of commodities for export to diversified agricultural production, supporting marginal producers and subsistence farmers, supporting regional self-sufficiency, altering the IMF and World Bank to permit cancellation or restructuring of debt and a concentration on preventative health care. Gender sensitive economic and social welfare policies that protect women from slipping into poverty as globalisation continues would also slow the spread of HIV. Micro-credit programs that focus on women's economic empowerment are also worthy of investment.



Imagine a world free of poverty. A world, where quality of life guarantees human dignity. A world, where everyone exercises basic human rights. A world, where all children will live to their fullest potential socially, economically and in human development. AIDS threatens India. AIDS threatens to reduce, halt and even reverse economic growth of India. It threatens to kill the people of India at the prime of their productive years. It threatens to tear apart the very social fabric of India. Ultimately, but without exaggeration, AIDS threatens the security and stability of a nation. It is unlike any other disease. It is decidedly not just a public health matter. It is a singularly most critical socio-economic development issue.

AIDS threatens India, today. Not in generations, not in decades, not in years, but now, today. At least 33 million people are infected worldwide. About 8 million, of them are in India, and most likely more. Preventing AIDS epidemic is, therefore, not the agenda of India alone. The highest absolute number of the poor live in India still. AIDS' threat to Asia is a threat to the world. To avoid India's hard-earned economic and social achievements is a global threat. To deny the people of India the dream of the world without poverty is to deny that dream for the entire world. Preventing the epidemic in India needs a redress of global economic policies, a global development agenda.
The AIDS epidemic overwhelms health finances. But, it will not stop there - the entire public finances come under an enormous pressure. AIDS patients require a variety of medical care, as they cope with repeated bouts of infection and tuberculosis. This raises health-care costs, even in places that cannot afford expensive drug therapy.

India has been fighting the spread of HIV/AIDS for almost a decade now, but she already has the largest number of infected people of any country in the world. Suppose the infection rate rises to 5 percent of adult Indian population. The nation's public health budget could swell by at least 30 percent. Average treatment expenditure per year on each and every AIDS case costs more than educating 10 primary school students in India -without counting expensive therapies. Larger health expenditure from an AIDS epidemic will force very hard trade-offs in public finances.

AIDS threatens more valuable things than finances. It destroys families. It intrudes in the most intimate relations between people. It erodes trust in each other. It devalues our basic right to procreate. It spreads silently. It kills. It tears at the very fabric of society. It is like no other disease. In a fundamental sense, it is a threat to the security of societies and of nation states.

India can learn from the Asian experience. Thailand offers an outstanding example of how to slow down the spread of HIV by enabling people to adopt safer behaviour. The nation's vigorous response worked - program promoting 100% condom use in commercial sex, public information campaign about HIV/AIDS, and various other prevention measures. The number of STD patients is one-tenth its former level. Infection rates among army conscripts have halved. Such achievements are tribute to Thailand's government and civil-society leaderships, working together.
Thailand articulates a need to act forcefully and immediately, spite of her tremendous success, the virus has now infected nearly 1 million people.
Today, India has a golden opportunity to act early. It does not have pockets of concentrated epidemics. Nearly 600 million Asians live in countries with such pockets. The success of Thailand teaches us that concentrated epidemics can be contained, that one can slow down the spread of HIV, by enabling those with the greatest risk to protect themselves and others. India is fortunate because it has " a generalised" epidemic - where HIV has spread to more than 5 percent of the population. Three-quarters of the people in India live in states provinces where HIV/AIDS is not widespread. Much of China, Indonesia, the Philippines, Korea, Bangladesh, Bhutan, Sri Lanka. Africa and some Caribbean nations were not so fortunate. By the time scientists understood how HIV was transmitted, it was too late.

India has a small gift of time. Time to act. Time to act early. Time to prevent a generalised epidemic. Use it, before it turns against it. In the Sonagachi red-light district of Calcutta, sex workers are leading the war against HIV/AIDS. They have organised themselves into a crusading force to promote the use of condoms. With support of the government, non-government organisations, and international agencies, the Sonagachi women raised condom use from 3% in 1992 to over 90% in 1998. HIV infection is held to about 5% there, compared to more than 50% among sex workers of Bombay.
But, the impact of this program has gone well beyond HIV prevention to development -- economic, social and human development.

Like those sisters in Dhaka, they too have their own financial co-operatives. They are becoming literate, have organised to demand protection from police abuse, and are preventing child prostitution.

Confronting AIDS is not easy. Acting to fight it is even tougher. But, engagements like the Sonagachi and Dhaka ones can prevent AIDS epidemic.. Early and enlightened government actions like the foregoing in true partnerships with non-government organisations and the civil society - can shift the paradigm, the path and outcomes of nation building in India, and the rest of the world beyond.


The 1980's has been a lost decade for development in much of the Third World. The debt crisis today has brought us to the perverse situation where the developing nations, those regions which need development capital most to meet basic human needs, have become net exporters of capital to the developed (or overdeveloped) world. To service their debts, the nations of Latin America, for example, exported over $130 billion in capital from 1982-88. Meanwhile real per capita income fell, and this had dire consequences for the marginalised majority. Latin America and the Caribbean along with their brothers in Asian and Africa currently experience economic devastation that the servicing of foreign debt wrecked on debtor nations.

In Latin America and the Caribbean countries, the number of new infections has been steady at 200,000 per year for several years. This has concentrated the epidemic in more that half of the countries. These include the most populous countries in the region - Brazil and Mexico. Six countries have nascent epidemics; Guyana and Haiti have generalised epidemics. Injecting drug use and sex between men have played a major role in transmission in many countries in Latin America. Roughly one-quarter of all HIV infections in Brazil (24 percent, 1992) and a third in Argentina (39 percent, 1991) have been attributed to transmission through injecting drug use, which is an important source of transmission in Uruguay as well.

The epidemic is well established among homosexual and bisexual men in Argentina, Brazil, Colombia, Mexico, and Peru and has infected significant numbers of sex workers in Argentina, Brazil, the Dominican Republic, Guyana, Honduras, Jamaica and Trinidad and Tobago. The relatively high prevalence of HIV among injecting drug users, homosexual and bisexual men, and sex workers in Latin America suggests that in many of these countries the virus is poised to spread to the low-risk sexual partners of people who engage in high-risk behaviour. In the Caribbean and parts of Central America, HIV is spread mostly through heterosexual transmission. Male and female cases are roughly equal in Haiti; the epidemic has spread broadly to 8 percent of pregnant women, and there is significant mother-to-child transmission. More than 70 percent of AIDS cases in the Dominican Republic is attributed to heterosexual transmission; the ratio of male-to-female cases now stands at 2 to 1 and is declining. HIV prevalence among pregnant women in that country has risen to a national average of 2.8 percent, and in some areas has reached 8 percent. Following a similar path, 1 percent of pregnant women in Honduras are also infected with HIV.

In Guyana, which is in South America but faces on the Caribbean, nearly 7 percent of women attending antenatal clinics were infected, as of 1999.

HIV is ravaging the populations of several Caribbean Island states. Indeed, some have worse epidemics than any other country in the world outside of Sub-Saharan Africa. In Haiti, over 5% of adults are living with HIV, and in the Bahamas the adult prevalence rate is over 4%. In the Dominican Republic, 1 adult in 40 is HIV-infected, while in Trinidad and Tobago the rate exceeds 1 adult in 100.
At the other end of the spectrum lie Saint Lucia, the Cayman Islands and the British Virgin Islands, where fewer than 1 pregnant woman in 500 tested positive for HIV in recent surveillance studies. In most of the worst-affected countries of the Caribbean, the spread of HIV infection is driven by unprotected sex between men and women, although infections associated with injecting drug use are common in some places, such as Puerto Rico. High rates have also been recorded among small populations of men who have sex with men in a number of islands, including Haiti and Jamaica.

Haiti, where the spread of HIV may well have been fuelled by decades of poor governance and conflict, is the worst affected nation in the region. In some areas, 13% of anonymously tested pregnant women were found to be HIV-positive in 1996.
Overall, around 8% of adults in urban areas and 4% in rural areas are infected. HIV transmission in Haiti is overwhelmingly heterosexual, and both infection and death are concentrated in young adults. It is estimated that nearly 75 000 Haitian children had lost their mothers to AIDS by the end of 1999.

The Dominican Republic, which has conducted systematic HIV surveillance among pregnant women, sex workers and patients with sexually transmitted infections every year since 1991, also has a substantial heterosexual epidemic. The HIV prevalence rate among new mothers in the capital, Santo Domingo, more than doubled over the seven-year period for which surveillance results are available, reaching 1.9% in 1997, while the average rate in sex workers and patients with sexually transmitted infections was around 6.8%.

The heterosexual epidemics of HIV infection in the Caribbean are driven by the deadly combination of early sexual activity and frequent partner exchange by young people. In Saint Vincent and the Grenadines, where the prevalence of sexually transmitted infections such as syphilis is high for the region, a quarter of men and women in a recent national survey said they had started having sex before the age of 14, and half of both men and women were sexually active at the age of 16. In a large survey of men and women in their teens and early twenties in Trinidad and Tobago, fewer than a fifth of the sexually active respondents said they always used condoms, and two-thirds did not use condoms at all. A mixing of ages which has contributed to pushing the HIV rates in young African women to such high levels is common in this population too: while most young men had sex with women of their age or younger, over 28% of young girls said they had sex with older men. As a result, HIV rates are five times higher in girls than boys aged 15 to 19 years in Trinidad and Tobago, and at one surveillance centre for pregnant women in Jamaica, girls in their late teens had almost twice the prevalence rate of older women.


Life expectancy
Between 1900 and 1990 enormous progress has been made in the fight against infectious diseases. Life expectancy has increased from 40 to 64 years of age in the developing world, bridging the gap between the industrialised nations. HIV/AIDS has now halted this tendency, and in some cases has even reversed it.

In some countries the life expectancy has fallen lower than from where it was a decade ago. In many southern countries of Africa, where the life expectancy had gone up from 44 years in 1950, to 59 in 1990, it is estimated that it will fall back to 45 years of age, between 2005 and 2010. In the Caribbean given the prevalence trends, life expectancy will also surely be affected.

Adult mortality
HIV/AIDS is a particular threat to the health of adults and their dependants.
In 1990, worldwide, HIV/AIDS was the fourth highest cause of death in developing countries, after tuberculosis and other infectious diseases. In the year 2020 HIV/AIDS will be the second highest cause of adult mortality, after tuberculosis which is exacerbated by HIV.

In Latin America and the Caribbean by the year 2020, estimates of HIV may account for 73.5% of deaths. In the English-speaking Caribbean, in the 15-44 age group, HIV/AIDS is already the largest cause of death in men.

Child mortality
Similarly, HIV/AIDS has also reduced the important achievements in infant and child survival, despite such rigorous interventions like immunisation programmes.

In Botswana, HIV/AIDS will be the principle cause of death of 64% of children below the age of five. In other words: progress made in the area of health to reduce infant mortality will disappear. It is estimated that in Zimbabwe, in 2010, the child mortality rate will be three and half times higher than it would have been without HIV/AIDS.

It is difficult to tease out data from the Caribbean, but these African data suggest the impending impact when you compare mortality rates of children under five, with and without AIDS.

At the end of 1999, the HIV/AIDS epidemic has left a cumulative total of 11 million orphans, the majority of which are in sub-Saharan Africa. In Haiti, an epidemiological model has estimated that by the end of the year 2000, there will be more than 25,000 orphans under the age of 15. Caribbean data estimates 83,000 orphans at the end of 1999.

Economic impact
Today there is no question about the considerable impact HIV/AIDS has had on the economies of nations. With respect to direct and indirect costs, the epidemic has cost millions and millions of dollars to individuals and their families, to businesses and to the State.

Based on a macroeconomic model, it is estimated that in countries with high HIV prevalence, the Gross National Product will be reduced between 0.8 to 1.4% annually.
In the year 2000, the total cost of the AIDS epidemic in the Caribbean has been established to be close to 6% of the Gross Domestic Product.

A study done by CAREC and the University of the West Indies on Trinidad and Tobago and Jamaica shows the following macroeconomic impact from 1997 to the year 2005 based on a low case scenario of HIV/AIDS infection.
Some figures are notable:

Macroeconomic Impact on the Principal Variables for Trinidad and Tobago and Jamaica

Impact Variables Trinidad & Tobago Jamaica
The GNP will be lowered by -4.2% -6.4%
Savings will go down by -10.3% in T&T and -23.5% in Jamaica
Investments will go down by -15.6% in T&T and -17.4% in Jamaica
Manpower in these four categories will go down by 20%
Employment in agriculture -3.5% -5.2%
Employment in manufacturing -4.6% -4.1%
Employment in the service sector -6.7% -8.2%
Labour force -5.2% -7.3%
And the cost of HIV/AIDS will go up by +25.3% in T&T and 35.4% in Jamaica

Similar macro-economic effects are to be expected in other Caribbean countries, but
because of HIV's long latency period, the immediate economical consequences may not be felt for some time.

Household impact
The impact of HIV/AIDS on households translates into a dramatic reduction of household income.
This is due to:

- a reduction of income or even loss of employment of the HIV infected person who, in many cases, is the breadwinner of the family
- considerable cost for health care and medication
- reduction of income of other family members who may have to leave their employment to take care of their family member.
- full loss of income upon death
- funeral and burial costs


Impact on the Health Sector
An example of the high impact on the health sector is seen in many African hospitals where 50% of all beds are occupied by, and the majority of services are allocated to HIV/AIDS patients. At the end of 1998 it was estimated that 38% of the hospital admissions in Kingston General Hospital of St. Vincent and the Grenadines were due to HIV/AIDS-related conditions. It should be pointed out that the financial burden created by the epidemic could very well absorb the total health budget for the year 2000 in Jamaica.

Impact on Business
As cited macroeconomic impact projections for Trinidad and Tobago and Jamaica, the undeniable realities which are now confronting the business world are an increase of production cost and the decreases in profits due to HIV/AIDS. This can be seen in:
- high rates of absenteeism
- death of its labour force
- investments in retraining of its skilled labour force

Companies need to anticipate the loss of workers, so that they can plan extra recruitment and training. While many companies would like to know exactly what proportion of their workforce they are likely to lose to AIDS, most recognise that this is not a straightforward issue. Increasingly, employers are rejecting the idea of pre-employment screening of job candidates - an applicant who is HIV-negative when hired may in any case go on to acquire the virus later on. Testing the existing workforce would be unethical unless individuals gave their consent. Mandatory testing would lead to great hostility or industrial action. However, in some Caribbean countries, HIV testing is mandatory for insurance purposes - so those who know their HIV status do not bother to apply for jobs which leads to increasing poverty in the community of people living with HIV/AIDS. Last but certainly not least, mandatory testing is incompatible with effective AIDS prevention and care programmes at the workplace. By abandoning testing requirements, a company creates the right climate for workplace programmes and maximises their chances of success.

All this means that the Caribbean region is vulnerable and that the cost of inaction will be enormous. Societal responsibility needs to be built by addressing a range of inequalities that create a breeding ground for HIV. Identifying and weighing the various social forces that shape the HIV/AIDS epidemic is too rarely addressed. By combining social analysis with ethnographically informed Epidemiology, we can identify and weigh the most significant of these forces that play a demonstrable role in determining HIV transmission in the Caribbean:

Some of these are:
· Deepening poverty
· Gender inequality including subordination of women and domestic violence
· Political sensitivity and denial of problem
· Religious opposition to sex-education and promotion of condoms
· Traditional and emerging patterns of sexual union
· Discrimination/Social exclusion
· Human Rights Violations
· Lack of education and opportunities for young people


There exist many opportunities for slowing the HIV/AIDS epidemic in the Caribbean.
We need to focus on social mobilisation to

· Increase awareness and promote tolerance and solidarity with people living with HIV/AIDS
· Promote safety when it comes to sex, which means 100% condom use in all risky sexual behaviour
· Offer sex education and life skills training for youth both in and out of school, a strategy which has proven to delay the age of first sexual intercourse, and to reduce the number of different sexual partners
· And lastly, allocate resources to care for those affected by the epidemic.

Action will require partnerships and political commitment. Governmental leadership, together with support from civil society, the religious communities, the international community, the private sector, NGOs (YMCAs) and pharmaceutical companies will be the formula for success. There is solid evidence that, at community and national levels, considerable results can be obtained with systematically applied programmes.
A comprehensive plan for prevention must therefore include:

· information, education and peer counselling for young people
· access to confidential, voluntary testing and counselling
· safe blood supplies
· promotion of condom use and accessibility
· treatment of Sexually Transmitted Infections (STIs), particularly for CSW both male and female
· Services and programmes aimed to reduce vulnerability of Men who have Sex with Men, Intravenous Drug Users, street children and young people who are forced into the sex trade.

Among examples of successes are those of Uganda and Thailand. In Uganda, the Government, NGOs including the YMCA, civil society, and religious organisations, both Muslim and Christian, made a joint decision to deal with the HIV/AIDS epidemic in an open and transparent manner, and with a coherent prevention strategy. This has resulted in an energetic expanded response from the highest political level down to each village. A significant change could be observed in sexual behaviour, such as a reduction of sexual partners and an increase in condom use.

Sentinel surveillance data now indicate that there has also been a decrease in the prevalence in HIV among pregnant women in Uganda's rural areas, which is a reflection of an HIV incidence decrease within the overall population. The most important lesson to learn however is that a country with scarce resources and a weak infrastructure can be successful in reducing the epidemic.

In Thailand, a study conducted among 21-year-old men between 1991-1995 indicated a high frequency of unprotected sexual relationships with sex workers and Sexually Transmitted Infections.
A national campaign was launched which has resulted in a remarkable decrease in visits to sex workers and an increase in condom use. These behaviour change successes were clearly reflected in a reduction of new STIs.

It has been proven that mother-to-child-transmission of HIV can be reduced effectively and at low cost. It is therefore crucial that this initiative becomes an integral part of national programmes, and that resources are allocated for this intervention. When applied immediately and effectively, Mother-To-Child-Transmission programmes may prevent more than one million infants from being infected with HIV over the next three to four years.

Mother-to-child-transmission of HIV now accounts for 6 per cent of reported AIDS cases in the LACC countries, and it is estimated that, without medical intervention, 25-30 per cent of children born to mothers living with the virus will be infected. To date 95% of HIV in children is due to Mother-To-Child-Transmission, making it a major public health priority.

In the Caribbean there are national mother-to-child transmission programmes in Cuba, the French territories, Barbados, the Bahamas, and pilot projects in Antigua, Dominica, St. Lucia, Haiti, the Dominican Republic, Trinidad and Tobago, Jamaica and Belize.

Participation of people living with HIV/AIDS (PLWHA) in the expanded response to the epidemic is mandatory at all levels. This includes policy development, conceptualisation of plans and programs and their execution. It is the single most important element to guarantee success of interventions and a powerful tool to overcome prejudice and discrimination.

Uniting networks of institutions and NGOs working with and formed by PLWHA at the national level facilitates an important cohesive base, which unites PLWHA and helps to break their sense of isolation and exclusion. Expanding support groups to grass roots levels encourage access to health care with user friendly medical personnel and empower PLWHA to rally together for their human rights. PLWHA are not part of the problem but part of the solution.


The HIV/AIDS epidemic has not been overcome anywhere in the world. Virtually every country saw new infections in 1998. Sub-Saharan Africa remains the epicentre of the pandemic, with nearly 23 million men, women and infected children with HIV as of the end of 1998, according to UNAIDS/WHO estimates. AIDS is now the leading cause of death in Africa. In the hard-hit countries of the continent, where a tenth or even a quarter of all adults are infected, the epidemic is decimating the limited pool of skilled workers and managers and eating away at the economy. Even there, however, a conspiracy of silence surrounds HIV.

Roughly 90 percent of all HIV transmission in Sub-Saharan Africa is by heterosexual sex. HIV has spread rapidly among people with high-risk behaviour and widely among those assumed to be at lower risk. Prevalence among urban sex workers exceeds 20 percent in seventeen countries, and is 50 percent or more in nine countries.

Infection rates among women attending antenatal clinics have grown rapidly to high levels in some areas, and have stabilised at lower levels in others. In Kampala Uganda, levels appear to be declining. HIV has infected more than 5 percent of women attending urban antenatal clinics in nineteen countries, and in six countries more than 20 percent are infected. An estimated two-thirds of all new cases of mother-to-child transmission worldwide occur in Sub-Saharan Africa.

The countries with generalised epidemics include most in eastern, southern, and central Africa, plus Côte d'Ivoire, Benin, Burkina Faso, and Guinea-Bissau in West Africa. There is often considerable geographic variation in infection levels within countries. Nigeria, which has more than 100 million people and is the region's most populous country, has areas at all three stages of the epidemic. In more than half of Nigeria's states the epidemic is concentrated. HIV has spread most widely in Lagos, along the West Coast, and in Delta, Plateau, Borno, and Jigawa states, located to the east and north-east. However, in three states; Edo, Niger and Oyo, the epidemic is still nascent with low prevalence levels, even among subpopulations with high-risk behaviour. HIV was detected early in the Democratic Republic of the Congo (formerly Zaire), but in contrast to many eastern and southern African countries, prevalence has established at less than 5 percent on average in urban antenatal clinics. In Uganda, one of the hardest-hit countries in Africa, HIV prevalence among young people has declined.

While new infections are thought to be levelling off in Sub-Saharan Africa as a whole, in some countries, military conflict and civil unrest may be spreading the pandemic.

The HIV epidemic is a multifaceted national and international problem. Without treatment, over 50% of the people develop AIDS within 8 to 15 years of becoming infected with HIV1 or HIV2, and most of these infected people will die within 3 to 8 years. Another 40% or more will develop more clinical illnesses associated with HIV infection. Of the 34 million sub-Sahara Africans infected, 11.6 million of these people died and almost 3 million of them were children.
AIDS caused 2.5 million deaths in 1998 and is now killing more people in Africa than Malaria. Every minute, five youngsters between 15 and 24 years old are infected with HIV.
Over 22.5 million men and women are presently living with HIV in Africa. To our knowledge, there is no single country in sub-Sahara Africa that has escaped this grave disease, however, the number of cases among sub-Sahara African countries are significantly disparate, with some countries being far worse off than others. In South Africa, Malawi, Mozambique, Rwanda, and Zambia, infection rates are from 1:7 to 1:9. In the Central African Republic, Côte dí Ivoire, Djibouti, and Kenya, the adult ratio is over 1:10. In Botswana, Namibia, Swaziland, and Zimbabwe, the ratio is 1:5. The ages most affected are from 14 to 49, the age span when people are at the peak of productivity and human reproductive capability.

In some countries, about 25% of the pregnant women are infected yearly, a rate which is likely to increase. At least one-third of these babies is likely to be unintentionally infected via perinatal transmission or breast-feeding. Clearly, HIV/AIDS has become a major public health problem and human crisis in Africa, straining heavily on health care and social service resources far beyond the capability of these sub-Sahara African countries. For these reasons, in 1996 the Foundation for Democracy in Africa (FDA) urged healthcare policy makers to re-evaluate public health policy in Africa toward the care and management of HIV infected persons and the containment of the virus. The scope and the gravity of this disease represent a complex set of social and economic problems for the new Africa.

One of the greatest assets of Africa is her people, most of who originally hail from a conservative environment. They are aesthetic with a positive attitude toward religion, family, education, economic motivation, culture, achievement, and social relationships. As with all people, they recognise the inevitability of changes in their quality of life due to the HIV/AIDS epidemic, but remain very cautious of the ravages of this uncontrolled and uncontainable disease. This disease has become an issue of major importance to the people of Africa and the friends of Africa.

This growing problem demands urgent attention in order to mitigate the devastating social and economic impact of HIV/AIDS, such as increased infant mortality, massive expenditures for hospital care and prohibitive drug costs. These are major challenges that pose a security risk to all emerging new democracies in Africa.

Social Impact
In Africa, HIV/AIDS account for more than 50% of all adult admissions to hospitals, in addition to a significant number of paediatric admissions. The overall effect of HIV/AIDS on the social infrastructure in sub-Sahara Africa is staggering. The prevalence rates in several African countries have been very high. The high-risk groups such as commercial sex workers (prostitutes), migrant workers, and truck drivers, are regarded as the HIV reservoir or agents of HIV transmission responsible for spreading the virus from the urban areas to the rural areas. The social infrastructure needed to support the victims of this disease is fast collapsing due to a very high demand on the social services available.
This has prolonged the AIDS mystery among sub-Sahara Africans.

Africa is seriously handicapped to deal with this disease. Most of the African government policies and programs are not adequately addressing the peoples need to combat this disease. Presently, the disease has overwhelmed the public health system in Africa. The social environment in Africa offers very little support for individuals infected with HIV/AIDS. Africa is seriously disadvantaged when it comes to establishing adequate programs that will address the needs of pregnant mothers/women infected with HIV, children born with HIV, and orphans who live in Africa.

Slowly, the impact of HIV/AIDS continues to disintegrate and destabilise the traditional African extended family system that have served as the bedrock for family foundations responsible for its history and the long genealogy line.
According to UNAIDS, over 40% of children in rural East Africa have lost a parent by age 15 to AIDS. Zambia has been shown to have the highest proportion of orphaned children with 23% of the children under age 15 missing one or both parents. As a result, over ninety thousand (90,000) children are living in the streets of Lusaka as compared to thirty-five thousand (35,000) in 1991.

As their parents die of AIDS, these large numbers of African children become orphans who are abandoned, and as a result, they have been forced to seek help in the streets, begging for money. Because housing, schools and food are not provided to the children, as a consequence, they become vulnerable to abuse. The girls turn to prostitution to survive and most likely become infected just like their parents, thus perpetuating the vicious cycle. This has become a social predicament that may result in Africa's zero population growth.

Already, life expectancy has been seriously impacted, dropping drastically by half, for example from age 68 to 34. The response to social pressure among the youth is also known to be very high, resulting in a spread rate of over 10%. African women and children have been particularly hard hit by HIV/AIDS, for example, women constitute half of all the affected adults. It is believed that over 90% of all the world's orphans reside in the continent of Africa, where 80% of all AIDS deaths in the world have occurred and 70% of all new HIV infection also occur. The poor account for the largest number of people infected with HIV. HIV/AIDS is also high among the educated and highly trained people in Africa. In fact, this disease is equally distributed among the poorest segment of the population and the best-educated and wealthy segment of the population. Therefore, although this disease is not a disease of the poor, its impact creates and perpetuates poverty in sub-Sahara Africa.

Initially among the churches, there was a serious denial of the extent of the disease, and it was characterised as a foreign problem or a disease of sinners. Some religious leaders were openly hostile to all preventive efforts and measures to halt the spread of this disease. Due to lack of knowledge, some clergy members organised anti-condom rallies where condoms and AIDS information brochures were burned.
Today, because of the grave impact of this disease, a new national policy guideline was incorporated by all church denominations to help educate their members.

Economic Impact
Since many economies in African countries are in flux, it is very difficult to determine the impact of AIDS on each country's economy. However, it has been documented that this disease has multiple and complex effects on sustainable human development in sub-Sahara Africa. Due to the disease's erosion of the human resource base, the countries of Africa have suffered significantly from reduced growth in the productivity, capital, and labour industries.

Denting the prospects for economic development in Zimbabwe, several companies have reported that AIDS costs them one-fifth of their company earnings. In Tanzania and Zambia, AIDS illness and/or death cost companies more than their total profit for the year. Also, according to the United Nations Food and Agriculture Organisation (FAO), AIDS related illnesses among sugar factory workers resulted in a loss of 8,007 labour days per each of the various sugar factories between 1995 and 1997.

AIDS kills those on whom society relies to grow the crops, work in the mines and factories, run the schools, and hospitals and govern countries. It creates new pockets of poverty when parents and breadwinners die and children leave school earlier to support the remaining children. Perhaps, no other statement or words can better express the true picture that depicts the economic impact of AIDS - ravaging all the countries of Sub-Sahara Africa.

Effect on Economic Growth
Major portions of the government funds and household savings are constantly diverted to purchase health and health-related goods and services. By doing so, fewer resources are available for investment, which is the main instrument for achieving economic growth. Subsequently, with less productive investment, there is slow growth in GDP and less growth in employment. This has compounded the unemployment problem affecting sub-Sahara African countries today.

A reduced growth in the economy has also resulted in a complete system failure. The social and economic infrastructure capacities to function are rapidly collapsing due to the erosion of human capital and resources. These two institutions (economic and social) can function properly only when healthy individuals from both the private and public sectors of the economy are available to manage them. For example, in the justice department, (the court or legal system), for cases to be prepared and heard by judges in a very timely manner, healthy individuals are needed to be involved as witnesses, lawyers, court officials, etc. When these individuals are sick and unable to come to court or work, the efficiency and the capacity of the court system are seriously compromised. These effects are beginning to surface and in many African countries today.

Effects on Human Development
It has been observed that life expectancy may be directly related to standards of living and this serves as an aggregate measure for human development. Countries in sub-Sahara Africa with a matured HIV/AIDS epidemic and prevalence are known to have inadvertently stunted human development progress, and as a result, life expectancy has been cut in half. For example, in Zambia there is a 10-year loss in human development progress. In Tanzania, a lost of 8 years, in Zimbabwe, Burundi, Malawi, Kenya and Uganda, losses range from 3 to 5 years. In Rwanda the loss is estimated to be 7 years and for the Central African Republic it was 6 years. The decline in life expectancy coupled with the slow growth in average per capita income are known to have more effect on poor people ñ especially those who are already the most deprived and least able to cope with the multiple impacts of the HIV/AIDS epidemic.

Effects on Households
The social and economic impact of HIV/AIDS on individuals and families attempting to deal with illnesses and/or death is becoming very serious. These individuals and/or families experience loss of earning power as they are faced with exorbitant medical costs that rapidly depletes their savings. Ultimately they are forced to dispose of assets such as land and property in order to pay for more medical services. About one-third of their yearly salary is spent on a single funeral arrangement. Therefore, it is obvious that the sustainability of the households, either as a social unit and/or as a productive economic unit, is significantly impeded.

Effects on Productivity- Subsistence Agriculture
Agriculture remains the economic base for most of the African countries. Subsistence agriculture accounts for a portion of the GDP in some Sub-Sahara African countries. If individuals and/or families are expected to continue to produce food, even after the loss of their parents, land and other assets such as housing and farm animals must be protected. HIV/AIDS has a dramatic impact on subsistence agriculture by preventing the traditional farmers who are affected by the disease from sustaining their business/family infrastructure upon which the success of the family farm industry depends.

Effects on Productivity- Commercial Agriculture
Commercial agriculture accounts for a greater percentage of the GDP of these African countries than subsistence agriculture. This is an important contributor to national output and it serves as the major source of employment for the people of this region of the world. AIDS-related deaths have increased the cost of labour due to manpower shortages. Subsequently, an increased cost of food production results. With fewer pe