By Osborne Wanyama, Young Professional at the World Alliance of
YMCAs in 2000
1. Asia (India)
1.1. HIV/Aids current status -
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
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
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
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
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
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
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
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
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
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.
1.1 HIV/AIDs CURRENT STATUS
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,
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.
1.2 INDIA - A SNAP VIEW
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
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
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
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
'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.
1.3 SOCIO-ECONOMIC IMPACT (INDIA)
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
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
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
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
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
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
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
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
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.
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
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.
1.4 THE ROLE OF THE COMMUNITY (CBOS,
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
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
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.
2.0 LATIN AMERICA AND THE CARIBBEAN
2.1 HIV/AIDS CURRENT STATUS
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
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
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
2.2 SOCIO-ECONOMIC IMPACTS
(TRINIDAD AND TOBAGO AND JAMAICA)
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
HIV/AIDS is a particular threat to the health of adults and
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.
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
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.
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
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
Investments will go down by -15.6% in T&T and -17.4% in
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.
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
- 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
· Political sensitivity and denial of problem
· Religious opposition to sex-education and promotion of
· Traditional and emerging patterns of sexual union
· Discrimination/Social exclusion
· Human Rights Violations
· Lack of education and opportunities for young people
2.3 COMPARING EFFORTS - (THE
CARIBBEAN ,UGANDA AND THAILAND)
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
· 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
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
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.
3.0 SUB-SAHARAN AFRICA - - A
3.1 HIV/AIDS CURRENT STATUS
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
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
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
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.
3.2 SOCIO-ECONOMIC IMPACTS
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.
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
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
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.
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
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
Effects on Productivity-
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
Effects on Productivity-
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