Memorandum submitted by the Department
for International Development (continued)
IMPACT ON
POLITICAL AND
SOCIAL STABILITY
There is a complex reciprocal relationship between
the spread of HIV/AIDS and political and social instability. The
epidemic both fuels and is fuelled by poverty, conflict, social
dislocation, food insecurity and disasters. For a region such
as sub-Saharan Africa, parts of which are at present suffering
disproportionately from civil and political unrest, the link with
HIV/AIDS is an important human security issue. The UN Security
Council recognised it as such when they discussed HIV/AIDS in
January 2000.
HIV/AIDS as a cause and effect of political and
social instability
This memorandum has described the impacts on
households and the workforce, and the emergence of many millions
of additional orphans. The continuing growth in orphan numbers
will result in increasing numbers of impoverished and disaffected
adults. This is likely to aggravate existing social and political
tensions, especially in areas where social cohesion is already
fragile.
This memorandum has described, above the way
that the education sector is being undermined by the loss of teachers.
In addition, in situations where children are taken out of education
(to care for ill relatives or provide labour, or because of loss
of household income), their access to an important set of socialising
influences is reduced.
Yet the education sector has a vital role to
play in reducing these potential threats to social cohesion. Schools
are places for learning about HIV/AIDS prevention, not only in
providing access to the right information about the disease, but
also in empowering young people, particularly girls. Literacy
skills, increased awareness about human rights especially with
respect to HIV/AIDS, may enable individuals to feel more confident
in negotiating safer sex, or in seeking treatment and entitlements
owed to them. Access to an effective education system is an important
component in maintaining the social fabric of communities at any
time—the role is reinforced in the face of HIV/AIDS.
Impact of HIV/AIDS on the Armed Forces, and vice
versa
Armed forces (militia, military and police)
constitute a major population block—highly mobile, and frequently
called upon to serve away from home, within their countries or
abroad. Armed forces personnel operate in a risky environment—they
are young people, often away from home for long periods they have
multiple opportunities for engaging in risk behaviours such as
casual sex or drug use to relieve stress and boredom. Sexually
transmitted disease has always been a problem for armed forces
and for civilians with whom they come in contact, and HIV is no
exception. The statistics on HIV prevalence in some uniformed
populations are alarming their governments—up to 40 per
cent or more amongst soldiers in some countries.
The impact of HIV/AIDS on the armed forces can
pose a serious threat to security. Police and military capability
is compromised through illness, loss of training input, loss of
experience and skills, demoralisation, with the associate costs
of additional recruitment and replacement training.
Conflict and disaster as a cause of the spread
of HIV/AIDS
Conditions associated with conflict and forced
population displacement—poverty, social instability and
powerlessness—can exacerbate HIV transmission. Military
populations, refugees and internally displaced people may find
themselves in high risk environments, particularly since they
often live in, or interact with refugee camps. Evidence suggests
that the level of risk in refugee population varies from situation
to situation, and depends on factors such as level of physical
well-being, the need for sex work as a survival strategy, the
presence or absence of male household members, and the involvement
of the armed forces. Women and children can be especially vulnerable
due to the fact that they comprise up to 75 per cent of the world's
refugee and IDP population.
Key factors which exacerbate spread of the disease
in situations of conflict and disaster include the following:
— sexual violence and abuse is a significant
problem in many of these situations. The geographical location
of refugee camps, the social structure in the camps, services
and facilities and lack of police protection can all contribute
to incidences of sexual violence.
— where conflict leads to breakdown
in cultural and social structures, for example through loss of
family or separation from family members, this puts severe stress
on traditional coping mechanisms. People may engage in commercial
or casual sex where, in more stable situations, they would not.
— lack of educational opportunities
in refugee camps can mean that young people may engage in more
risky behaviour such as drug and alcohol abuse and increased sexual
activity. Orphans and unaccompanied children are an especially
vulnerable group as they do not have the support and guidance
of their parents.
— a lack of income and basic needs
in conflict and disaster situations can contribute to increased
sexual coercion and sexual bartering in exchange for goods and
services.
— increased ill-health arising from
conflict and disaster, combined in some situations with disruption
in access to quality health care services, can contribute to the
risk of HIV transmission. In particular, a breakdown in the ability
to provide safe blood and a lack of sterile equipment to safely
handle blood products increases the risk of transmission.
HUMAN RIGHTS
ASPECTS OF
HIV/AIDS
Significantly, the success of various HIV/AIDS
interventions has been shown to be directly proportional to the
degree to which human rights are promoted and protected in the
context of these interventions. These realities, demonstrated
time and again over the course of the HIV/AIDS epidemic, make
clear that the protection and promotion of human rights must be
an integral component of all responses to the epidemic.31
HIV/AIDS is one of many health problems and
disabilities that attract discrimination, stigma, and the abuse
of human rights. The people most at risk of HIV infection often
belong to population groups whose rights may already not be respected.
Several human rights agreements, while not specific to HIV/AIDS,
nevertheless have much potential for offering protection. The
quotation, above, comes from a UNAIDS guide written especially
for nongovernmental organisations. It empowers them to use the
United Nations human rights machinery to protect people with HIV/AIDS
from discrimination and human rights abuses, in part by holding
governments to account for their own actions or for the abuses
that occur in their countries. This section draws mainly on that
guide and on DFID's consultation document, "Human Rights
for Poor People", published in February 2000.
The IDC's call for memoranda did not explicitly
mention the gender aspects of HIV/AIDS. Discrimination against
women is reflected, however, in the fact that women may be more
severely affected than men in mature epidemics in the worst affected
countries. In addition to the severe personal consequences on
women, this can have a developmental impact—for example
if a woman is removed from a household or productive role because
of her infection, her children receive a less sound or less well-resourced
upbringing, or, in a more abstract way, if the ostracisation of
a proportion of the population contributes to a loss in social
cohesion. The human rights agreements and committees that are
relevant to HIV/AIDS do include discrimination against women,
and so it is a topic that is covered in this section. For more
information on DFID's views on gender and HIV/AIDS, please see
Annex 2.
Types of discrimination
Stories of stigmatising treatment have abounded
since AIDS first became recognised. People who have been known
or suspected to be HIV-infected have been publicly humiliated
and vilified, driven out of their homes and communities, sacked
from their jobs, socially isolated, imprisoned, deported, beaten
up, murdered, prevented from having normal burials. Some employers
have tested prospective employees, hospitals and health workers
have refused treatment to HIV-infected patients or given them
particularly low standard of care, some insurance firms have refused
cover, children have been banned from schools. Groups such as
commercial sex workers, males who have sex with males, and injecting
drug users have experienced discrimination as a result of their
lifestyles, and this has been reinforced by fears about HIV/AIDS.
As mentioned, discrimination against women contributes to the
disproportionate ways in which HIV/AIDS affects them.
There have also, of course, been examples of
good practice, sometimes in the face of widespread discriminatory
attitudes—many individuals and organisations and some large
companies took a progressive approach in the early years of the
epidemic, particularly in North America and Europe.
Participation, inclusion and obligation
These are three principles that underlie DFID's
and other organisations' emerging approach to human rights and
development.
A series of consultations with poor people in
the late 1990s found, to no great surprise, that many considered
themselves to lack influence over the decisions that affected
their lives, including in countries with democratically elected
governments. Participation is linked to access to information.
In relation to HIV/AIDS, people infected or affected by the disease
need to be able to influence the way that governments and organisations
respond to it, and they need access to accurate, explicit information
about it.
A definition of social inclusion was agreed
at the Social Development Summit in 1995, and has its basis in
the Universal Declaration of Human Rights. A socially inclusive
society is one in which all people are able to claim their rights.
Groups that are particularly vulnerable to HIV infection and to
the impact of AIDS are often excluded from society to a lesser
or greater degree, including access to health care, work, shelter
and employment. When infected or ill with AIDS, the exclusion
increases.
States have obligations under national legislation
and international human rights law. Many of the human rights instruments
(see below) contain provisions that are relevant to the protection
of people from HIV/AIDS-related discrimination.
DFID's review of the links between human rights
and development identified the following lessons, all of which
are relevant to HIV/AIDS as a development issue:
— there is a large gap between the
aspirations contained in the principles of the Universal Declaration
of Human Rights and the reality of the lives of many people in
poorer countries;
— the progressive realisation of human
rights requires resources and strategic planning for medium and
long-term action;
— there are problems with relying solely
on legal measures for the protection of human rights;
— there is no single prescription for
effective citizens' participation;
— clear standard setting and the concrete
definition of entitlements enables poor people to claim rights;
— claiming and respecting human rights
is a political process;
— the voices of the excluded can be
translated into concrete responses from government;
— there is increasing scope to translate
human rights into national legislation and policy implementation;
— the promotion of human rights requires
an understanding of the challenges facing governments in the South;
— non-state parties have responsibilities
to protect human rights.
This clearly places HIV/AIDS-related rights
and obligations within the broader human rights and development
agenda. Subject to the outcome of consultation on DFID's current
document, we will be using these lessons as the basis for a rights-based
approach to the elimination of poverty—including its HIV/AIDS-related
aspects. This will, of necessity, require partnerships with NGOs
and other organisations. An outline of the relevant human rights
institutions and documents is set out below.
The relevant human rights instruments and machinery
"Instruments" are the declarations,
covenants, conventions and charters that constitute human rights
law. The "machinery" is the array of commissions and
committees that exist to promote them and to monitor states' obligations
to apply them.
The international instruments most useful in
the protection of people infected or affected by HIV/AIDS include
the following:
— Universal Declaration of Human Rights.
— International Covenant on Civil and
Political Rights.
— International Covenant on Economic,
Social and Cultural Rights.
— Convention on the Elimination of
all Forms of Discrimination.
— Convention on the Elimination of
all Forms of Discrimination against Women.
— Convention against Torture and other
Cruel, Inhuman or Degrading Treatment.
— Convention on the Rights of the Child.
Relevant regional charters include the following:
— African Charter on Human and People's
Rights.
— American Convention on Human Rights.
— European Convention on Human Rights.
Each of these instruments is overseen by a commission
or committee. For example, the main body for discussion on progress
related to human rights is the Commission on Human Rights, which
meets annually. Its subsidiary body is the Sub-Commission on the
Protection and Promotion of Minorities. Separate commissions and
committees meet on women's rights, child rights, civil and political
rights, economic, and social and cultural rights. The African
Commission on Human and People's Rights supervises the implementation
of the African Charter, and so on.
A simple illustration of their use by individuals
is when Mary Robinson, previously President of Ireland, now UN
Commissioner for Human Rights, brought AIDS-related cases under
the European Convention in the 1980s when she was a practising
lawyer. Organisations with an interest in AIDS-related human rights
abuses can influence the work of the various bodies by submitting
reports, attending their meetings and by working closely with
UN bodies that have mechanisms for monitoring compliance with
human rights norms. While expertise on the pursuit of rights is
growing among organisations, not only related to HIV/AIDS, there
is still much potential for pressure to be brought to bear through
the formal mechanisms.
UNICEF, UNIFEM, UNDP have been active in promoting
rights relevant to their fields of work. WHO's member states are
bound by a World Health Assembly resolution on the avoidance of
discrimination against people with HIV or AIDS. As with other
organisations, the UN agencies could be more active in promoting
the protection of AIDS-related and other rights, in the pursuit
of effective social and economic development. DFID has realised
that its own expertise in rights-based development needs to be
strengthened—and hence the production of the consultation
document, "Human Rights for Poor People". When finalised,
this should underlie DFID's approach to development through the
promotion and protection of rights in the field as well as through
the formal mechanisms at global and regional levels.
IMPACT ON
THE ACHIEVEMENT
OF THE
INTERNATIONAL DEVELOPMENT
TARGETS
There has been a lot of good epidemiological
work done by UNAIDS and others to establish trends in transmission
rates, effects on different sections of the population and overall
impacts on life expectancy. However, there has been little work
so far to link this directly to impact on the international development
targets. But even without explicit data, it is generally accepted
that in countries with the highest infection rates, it is unlikely
that the international development targets will be met. This is
likely to include Zimbabwe, Zambia, Botswana and Namibia, where
20-26 per cent of people aged 15-49 are HIV positive, and Ethiopia,
Kenya, Mozambique, South Africa and Tanzania, where 9-20 per cent
of adults are infected. In countries outside of Africa, the impacts
of HIV/AIDS may be very severe for certain sectors of the population
such as commercial sex workers, men who have sex with men and
injecting drug users.
The most disturbing feature of the HIV/AIDS
epidemic is its impact on life expectancy. In the 13 or so African
countries with adult prevalence of 10 per cent or more, HIV/AIDS
will erase 17 years of potential gains in life expectancy, meaning
that instead of reaching 64 years, by 2010-2015 life expectancy
in these countries will regress to an average of just 47 years;
this represents a reversal of most development gains of the past
30 years. In contrast, South Asians, who in 1950 could barely
expect to reach their 40th birthday, can expect to be living,
by 2005, 22 years longer than their counterparts in southern Africa.
In the most severely affected countries, child
mortality is rising. In 1998, about 530,000 HIV-infected children
were born in sub-Saharan Africa, about 90 per cent of the world
total. By 2005-2010, infant mortality in South Africa will be
60 per cent higher than it would have been without HIV/AIDS. In
Zambia and Zimbabwe, 25 per cent more infants are already dying
than would be the case without HIV. By 2010, infant and child
mortality rates in these countries will have doubled.
The tendency for more women than men to be infected
in mature epidemics has profound implications for the international
development target on gender disparity in those countries. In
addition, girls are more likely to be pulled out of education
to care for sick relatives, further intensifying the disparity.
The fact that the disease strikes people in
their prime years has considerable implications for the economic
well-being target. AIDS profoundly disrupts the economic and social
bases of families. When a household loses its primary income earner
or producer, its very survival may be threatened. It sells assets
and uses savings to pay for health care and funerals. In sub-Saharan
Africa, there has been a huge loss of skilled workers to HIV/AIDS.
One large bank in Zambia lost most of its senior management to
the disease. The World Bank now estimates that GDP in the most
severely affected countries will be reduced by 1 percentage point
per annum as a result of HIV/AIDS.
There are around 7.8 million AIDS orphans in
sub-Saharan Africa alone. As a proxy for the death of mothers,
this is a clear indicator that the target for maternal mortality
will not be met in many African countries. It is likely that the
rate, in fact, will continue to get worse.
The impact of the disease on the health sector
in the most affected countries has grave consequences for the
target on universal access to sexual and reproductive health services.
Health systems in the most affected countries are being stretched
beyond their limits as they not only deal with a growing number
of AIDS patients and the loss of health personnel due to death
and illness, but also cope with rising cases of tuberculosis,
the most common opportunistic infection associated with HIV/AIDS.
With the consequent competition for scarce resources, demands
for spending on acute care is likely to take precedence unless
health-service planning improves significantly and is able to
allocate resources against well-defined priorities.
PRIORITIES IN
HIV/AIDS PREVENTION AND
CONTROL—DFID'S
AND OTHER
AGENCIES' RESPONSES
Summary
The main priorities in HIV/AIDS are prevention
of future cases and the care and support of the roughly 35 million
people now estimated to be living with HIV infection. Further,
many of the roughly 11 million AIDS orphans have special needs
that are not being met through existing coping mechanisms, for
example in education and socialisation. The impact on households
needs special attention, for example where subsistence livelihoods
are undermined to the point of pushing people into absolute poverty.
This brings government departments and organisations firmly into
the arenas of agricultural policy, micro-enterprise support including
credit, and human resource protection and development in both
the public and private sectors. The most urgent geographical area
for action is sub-Saharan Africa, but South and South-east Asia
and parts of Latin America and the Caribbean need attention too.
A rights-based approach is essential.
DFID is in the process of refining a cross-sectoral
strategy that will help it to take HIV/AIDS into account in all
its work. The strategy will provide guidance to DFID's managers
on priority interventions and locations. It will help DFID to
decide how best to allocate additional resources, not least to
the problems arising from significantly increased illness and
death among productive adults. The strategy will take account
of the recommendations arising from the IDC's hearings on the
impact of HIV/AIDS.
Priorities for Intervention
DFID and other major supporters of HIV/AIDS
programmes give highest priority to the prevention of future cases
of HIV infection, especially among people whose risk behaviour
is likely to infect others. This means concentrating on helping
people with high risk behaviour, especially the young, to reduce
the HIV-related risks they take or that they have imposed upon
them. Only in this way will the rapidly increasing future burden
of AIDS be reduced—one case prevented now among people who
take the highest risks could reduce many-fold the number of people
needing care in the future, as well as reducing the future social
and economic impact. Of the HIV risks, the most important is unprotected
sexual intercourse, especially among people who have multiple
concurrent partners.
People taking risks need access to supportive
sexual health services, including clear, explicit information
and advice; confidential testing and counselling; and condoms
and treatment for sexually transmitted infections. For young people,
those services need to be specially designed to be youth friendly.
These services need to be targeted on the groups with the highest
risks, such as sex workers and their clients—and, where
they are growing up in high-risk environments, the young. Girls
are particularly at risk—but prevention programmes need
to be available to men as well. Where injecting drug users or
males who have sex with males have high levels of partner exchange
or share injecting equipment, they should also be priorities for
risk reduction programmes.
Future technologies hold out hope for increasingly
effective prevention in the future. DFID is contributing to efforts
to find a practical HIV vaccine, for example through the International
AIDS Vaccine Initiative (IAVI—to which the UK's £14
million was the first bilateral donation); and for a microbicide
that women can use to avoid infection.
While the epidemiological and economic arguments
might be to use scarce resources almost entirely for prevention,
humanitarian realities dictate that the swelling numbers of people
with HIV-related illnesses have a major claim on governments,
civil society and international agencies. They will continue to
do so, in vastly increasing numbers, over the coming decades and
beyond. Care also creates opportunities for promoting HIV risk
reduction. DFID will contribute to well-designed, high priority
care efforts, concentrating in the countries and communities of
greatest need. In many cases this will be linked to broader health
service development and public sector reform initiatives.
At present DFID is wary of the growing groundswell
of demand for widespread access to antiretroviral drugs. While
there are sound arguments in terms of equity, there are still
concerns about practicalities such as affordability (even if there
were to be a 95 per cent cut in prices), cost effectiveness and
opportunity costs, the capacity of health systems to handle complex
medical treatments, and the relative priority to be placed on
drugs as one part of countries' HIV/AIDS strategies.
Collaborative Working
DFID works co-operatively with governments,
international agencies, and civil society including the voluntary
and commercial sectors. The UK participates in the UNAIDS-led
International Partnership against AIDS in Africa, both financially
and through the organising sessions at international and national
level. As the Partnership becomes more operational, DFID will
continue to work towards action in countries that is collaborative
and that takes place within the framework of nationally-agreed
strategic plans. DFID will also contribute to making sure that
the national plans do concentrate on the strategic priorities
in prevention, care and multi-sectoral, impact mitigation.
In terms of geographical focus, DFID will give
greatest emphasis to sub-Saharan Africa. However, HIV/AIDS is
a public health priority throughout the world. Even in the less-affected
countries in Asia, for example, failure to act now will lead to
hundreds of thousands of avoidable deaths. DFID is therefore working
with others to identify the strategic priorities in Asia and elsewhere,
and will place its support for HIV/AIDS activities in the context
of overall need.
A list of DFID-financed HIV/AIDS-related initiatives
is at Annex 3. As DFID's multi-sectoral approach develops, we
will be increasingly able to provide details of how initiatives
in, for example, education, rural and urban livelihoods, and human
rights promotion reflect the realities of HIV/AIDS prevention,
care and impact mitigation. Most projects are at present in prevention.
They reflect the highest priority that DFID has given to focusing
on the risk-behaviour groups. As the new strategic approach is
finalised and implemented, future lists are likely to demonstrate
a greater focus on impact mitigation as part of DFID's over-arching
approach to poverty elimination.
The IDC requested information about other institutions'
responses. We enclose in the package of material sent with this
memorandum a new and comprehensive matrix of 19 UN agencies' priorities
and a programme, including that of the World Bank and the other
UNAIDS co-sponsors.
CONCLUSIONS
This memorandum has tried to capture some of
the diverse ways in which HIV/AIDS impacts on people's lives and
livelihoods. This section lists, very briefly, some of the main
points. As throughout the document, it focuses not so much on
the infection or its subsequent array of diseases, but more on
the way that rapid and significant increases in illness and death
among adults affects survivors' lives and livelihoods. Our focus
is on the worst-hit countries of sub-Saharan Africa, though, as
described earlier in the paper, the impact on individuals and
households can be as great in countries with lower levels of infection—and
the greatest short-term impact, it seems, does occur at household
level:
— at the most basic level, the impact
is upon livelihoods. If coping can be defined as avoiding destitution,
households try to do so by cutting into consumption, savings and
assets. The poorer households have less of a cushion, and face
destitution earlier. The implication for governments and development
agencies is to reorient and intensify poverty reduction programmes
targeted at the poorest—taking into account the impact of
HIV/AIDS when allocating their resources.
— linked to households is the lowest
level of economic production, including subsistence farming (or
farm households that are partly subsistence, partly cash earning).
Smallholder agriculture is the largest single sector in sub-Saharan
Africa. Because they are, essentially, households, these enterprises
face the loss of savings and assets—some adjust, some cannot
adjust enough and land and housing are lost. The implications
are for government departments to examine the needs of small farmers
in the face of large scale reductions in the labour force and
to adjust policies and practice accordingly. Impact varies across
farming systems and their related local economies. There is a
need for changes in extension advice, inputs, and marketing. Affordable
credit is an essential, both as part of the support for economic
growth and as a cushion against shock. This need is not AIDS-specific—but
the extra burden of AIDS reinforces its utility as a part of anti-poverty
programmes.
— at the level of larger enterprises,
we have seen that they have been facing an increasing level of
labour loss and the associated costs in terms of benefits payments
and lost production. The threat is not only for productivity,
but also for longer-term investment in the hardest hit countries
and communities. Some firms have been facing up to this for a
decade or so, others are late in getting engaged. The formation
of AIDS-specific business coalitions is increasing, as are co-operative
relations between the private and public sectors. Much needs to
be done in this area, and much needs to be learned about the threats
and how to reduce them.
— similarly, much is not yet understood
about the macro-economic impact. It does appear that there will
be negative impact, and that in some countries this will be very
significant over a decade or two. There will be implications for
pro-poor growth policies, which must increasingly take account
of AIDS-related illness and death at the varying levels at which
it occurs from country to country. This is beginning to be reflected
in Poverty Reduction Strategy Papers, the HIPC process, and related
plans.
— education, perhaps more directly
than other sectors, is an investment in the future. In some countries
more teachers are dying than entering the cadre. Ways to maintain
the teacher presence in schools, and to keep pupils in education
when their labour is needed in the home, need to be found. Schools
and universities, as well as being sexual risk locations, are
also useful places for sexual health promotion. They need to be
protected.
— similarly, the health sector is being
particularly badly hit in the worst-affected countries. Health
worker attrition is eating into the workforce. Ways to replace
lost workers and to maintain worker morale need to be found. A
continued emphasis on health sector development and reform, aiming
at improved quality both of care and work environment, is essential.
As with education, the private productive sectors, and other institutions,
the issue is fundamentally one of human resource development at
a time that human resources are being reduced.
There are clearly many implications for the
way that DFID and the rest of the development community respond.
From the health angle, prevention is clearly the top priority
as infections prevented in an epidemic mean that many more cases
of illness are avoided in the future—it is a pre-emptive
form of impact reduction. There is also a growing population of
people for whom care, even at a basic level, is essential. National
governments and the donor community need to make sure there are
enough resources to provide care as well as to prevent infections.
Increasingly, however, agencies are becoming
involved in impact mitigation work. This raises new challenges
in understanding impact across all spheres of social and economic
life. Within DFID we are examining the implications in education
and in rural and urban livelihoods, including for example the
transport industry, as well as in the health sector. We will expand
this approach—we need to look more, for example, at how
DFID's efforts in micro-enterprise development and micro-credit
should adjust themselves to new needs. We need to find ways to
engage with governments, especially in the worst affected countries,
about how they can adjust their rural development policies including
agricultural extension, and how they deal with their increasing
human-resource development crises.
Wherever feasible, DFID's work in these areas
will be part of partnership responses. At the international level,
UNAIDS is increasingly getting engaged in a multi-sectoral approach,
and DFID is engaged with the secretariat, with UNAIDS co-sponsors,
and with other agencies on these issues. The International Partnership
against AIDS in Africa is, at present, a particular focus for
bringing a multi-sectoral effort to bear in the most affected
countries, involving governments and organisations at the international,
regional and national levels.
Department for International Development
May 2000
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