Memorandum submitted by UNAIDS
1. INTRODUCTION
1.1 The International Development Committee
of the United Kingdom House of Commons has asked UNAIDS to contribute
written evidence on the impact of HIV/AIDS on developing countries'
social and economic development. This paper has been prepared
as complementary to the memorandum already submitted by DFID.
1.2 This document provides a statistical
overview and a narrative epidemiological summary. Part 4 then
traces the impact on developing countries with regard to the effects
on the workforce, on the national economy, on individual households,
on governments' budgets, on the achievement of international development
targets and on political and social stability. Part 5 traces the
response to HIV/AIDS by the private sector and the international
community. Finally, part 6 identifies some keys to success in
responding to the epidemic. Much of the information is taken from
UNAIDS' recently published Durban Report, which is submitted to
the Committee as part of UNAIDS' written evidence.
1.3 In discussing these issues, this document
conveys the seriousness of the epidemic, but also stresses the
need to keep hope alive. The evidence demonstrates that we are
not powerless against the epidemic, but that our response needs
to be scaled up by a significant order of magnitude.
2. STATISTICAL OVERVIEW
2.1 Global estimates of the HIV/AIDS epidemic
as of the end of 1999
People newly infected with HIV in 1999: 5.4
million
Adults 4.7 million
Women 2.3 million
Children <15 years 620,000
Number of people living with HIV/AIDS: 34.3
million
Adults 33.0 million
Women 15.7 million
Children <15 years 1.3 million
AIDS deaths in 1999: 2.8 million
Adults 2.3 million
Women 1.2 million
Children <15 years 500,000
Total number of AIDS deaths since the beginning
of the epidemic: 18.8 million
Adults 15.0 million
Women 7.7 million
Children <15 years 3.8 million
Total number of AIDS orphans since the beginning
of the epidemic: 13.2 million
2.2 Adults and children living with HIV/AIDS
according to regions
— Latin America 1.3 million
— North Africa and Middle East 220,000
— sub-Saharan Africa 24.5 million
— South and South-East Asia 5.6 million
— East Asia and Pacific 530,000
— Eastern Europe and Central Asia 420,000
— Australia and New Zealand 15,000
3. EPIDEMIOLOGICAL
SUMMARY
3.1 Already 18.8 million people around the
world have died of AIDS, 3.8 million of them children. Nearly
twice that many—34.3 million—are now living with HIV,
the virus that causes AIDS. Barring a miracle, most of these will
die over the next decade or so. The most recent UNAIDS/WHO estimates
show that, in 1999 alone, 5.3 million people were newly infected
with HIV.
3.2 The impact of AIDS continues to be felt
mostly in the developing world, with about 95 per cent of the
global total of people living with HIV. That proportion is set
to grow even further as infection rates continue to rise in countries
where poverty, poor health systems and limited resources for prevention
and care fuel the spread of the virus. Hence, the huge gap in
HIV infection rates and AIDS deaths between rich and poor countries
is likely to grow even larger in the next century.
Africa
3.3 Sub-Saharan Africa is the area of the
world worst affected, with some 23.3 million estimated by UNAIDS/WHO
to have HIV infection or AIDS. Not only are infection levels highest,
but access to care is also lowest, and social and economic safety
nets that might help families cope with the impact of the epidemic
are badly frayed, in part because of the epidemic itself. Many
African nations were evaluated downwards in this year's Human
Development Index, a ranking published by the United Nations Development
Programme (UNDP) to reflect health, wealth and education. Almost
all of the major downward changes in rank could be ascribed to
declining life expectancy—the direct result of AIDS. AIDS
is now the leading killer in sub-Saharan Africa. In 1998 in Africa,
where 200,000 people died as a result of conflict of war, AIDS
killed 2.2 million people. Life expectancy at birth in southern
Africa, which rose from 44 years in the early 1950s to 59 in the
early 1990s, is set to drop to just 45 between 2005 and 2010 because
of AIDS.
Latin America and the Caribbean
3.4 Some Latin American countries, most
notably Brazil, have expanded efforts to provide treatment to
those infected. However, there is evidence that infections are
on the rise in Central America and in the Caribbean basin, which
has some of the highest infection rates outside Africa. The epidemic
is driven by the combination of early sexual activity and high
levels of partner exchange between young people. In Guatemala
in 1999, some 2-4 per cent of pregnant women tested at antenatal
clinics in major urban areas were found to have HIV. In Guyana,
HIV prevalence was recorded at 3.2 per cent among blood donors—who
are generally thought to represent a population at low risk of
infection—while surveillance among urban sex workers in
1997 showed 46 per cent were infected. The last time Haiti carried
out HIV surveillance among pregnant women, in 1996, close to 6
per cent tested positive for the virus. Altogether, UNAIDS/WHO
estimate that some 1.7 million people in Latin America and the
Caribbean will enter the 21st century with HIV infection—almost
30,000 of them children.
Asia
3.5 In Asia, the pattern of HIV infection
is lower relative to Africa. However, because of the large population
sizes that exist for example in China and India, prevalence rates
translate into large absolute numbers. Across the continent as
a whole, UNAIDS/WHO estimate that 6.5 million people were living
with HIV by the end of 1999, over five times as many as have already
died of AIDS in the region. In some countries such as Thailand
and the Philippines, strong prevention programmes have reduced
HIV risk and lowered or stabilized HIV rates. Other countries
have raised warning flags after collecting new information showing
that injecting drug use is spreading and that condom use is uncommon,
including among clients of sex workers and men who have sex with
men. India has recently made a major effort to improve its understanding
of the HIV epidemic and new results of surveillance reveal a very
varied picture. In some states, principally in the south and west
of the country, HIV has a significant grip on the urban population,
with more than 2 per cent of pregnant women testing positive for
HIV. In the north-east, HIV infection has moved rapidly through
networks of men who inject drugs and has spread to their wives.
Other states of India detected their very first HIV infections
only in the last year or two.
Central and Eastern Europe
3.6 HIV infections in the former Soviet
Union have doubled in just two years. In the larger region comprising
the former USSR as well as the remainder of Central and Eastern
Europe, UNAIDS/WHO estimate that the number of infected people
rose by a third over the course of 1999, reaching a total of 360,000.
The world's steepest HIV incidence curve in 1999 was recorded
in the newly independent states of the former Soviet Union, where
the proportion of the population living with HIV doubled between
end-1997 and end-1999. The bulk of new HIV infections were caused
by unsafe injection of drugs and occurred in two countries, the
Russian Federation and Ukraine. As the head of the Russian Federal
AIDS Prevention Center announced recently, the true number of
HIV cases in Russia may reach 300,000 or 400,000 in 2000 and about
1 million cases by 2005.
4. THE IMPACT
OF HIV/AIDS
4.1. THE IMPACT
OF HIV/AIDS ON
THE WORKFORCE
Size
4.1.1 The size of the labour force in high
prevalence countries in the year 2020 is estimated to be about
10 to 22 per cent smaller than it would have been if there had
been no HIV/AIDS. The labour force is still expected to continue
growing. But because of the increased mortality, there will be
about 11.5 million fewer persons in the labour force, without
even considering the impact on economic growth of absenteeism,
productivity decline and morbidity. In the case of the lower prevalence
countries, the impact is significant but smaller. The labour force
is expected to be between 3 and 9 per cent smaller (except for
Thailand, where the difference is just over 1 per cent) than it
would have been without HIV/AIDS, and the total labour force will
grow by about 12.5 million fewer persons over the 35 year period.
Age
4.1.2 Labour force projections also provide
some indication of the lowering of the average age of the labour
force due to the impact of HIV/AIDS. Even assuming the same labour
force participation rates, the median age of the labour force
in high prevalence countries would be reduced by as much as two
years by the year 2020, implying an increasing proportion of younger
age groups in the labour force. The age and sex distribution of
the labour force will change due to the rising number of widows
and orphans seeking a livelihood and the large proportion of people
with AIDS in the age group 20-49 years, resulting in the early
entry of children into the active labour force, the early withdrawal
of people with AIDS and the retention of older persons in the
labour force due to economic need.
Quality
4.1.3 Little is known of the impact of HIV/AIDS
on the quality of the labour force in terms of education, training
and experience. However, it is probable that HIV/AIDS will have
a severe impact on these factors, particularly in view of the
effect of HIV/AIDS on the education sector, in some countries,
where it is reducing the number of qualified teachers and leading
to a rise in early school drop-out rates for students whose parents
die of AIDS. HIV/AIDS is therefore likely to have profound effects,
not only on the size, but also on the composition and quality
of the labour force in high prevalence countries.
Human resources and labour requirements
4.1.4 In view of the expected impact of
HIV/AIDS on the composition of the available workforce, there
is likely to be a mismatch of human resources and labour requirements
in terms of qualifications, training and experience. This means
that those employees who have to leave the labour force can often
not be replaced without loss of productivity.
4.2. THE EFFECT
OF WORKFORCE
ILLNESS AND
MORTALITY ON
DEVELOPMENT
Macroeconomic impact
4.2.1 There are several mechanisms by which
HIV/AIDS affects macroeconomic performance:
AIDS deaths lead directly to a reduction in the
number of workers available, and particularly workers in their
most productive years. As experienced workers are replaced by
younger, less experienced persons, productivity is reduced.
— A shortage of skilled workers leads
to higher production costs and a loss of international competitiveness.
— Lower government revenues and reduced
private savings (because of greater health care costs and a loss
of income for workers) can lead to slower employment creation
in the formal sector, which is particularly capital intensive.
As a result, some workers will be pushed into lower paying jobs
in the informal sector.
— Lower savings rates and less disposable
income reduce the market size for business, particularly in markets
outside of the basic necessities of food, housing, and energy,
and reduce total resources available for production and investment,
thus declining economic growth.
— Expenditure increases on the monitoring
of high-risk groups, the establishment of prevention strategies,
the provision of health care and welfare.
— Pressure increases on the social
security system, including life insurance and pension funds, which
are important sources of capital for both the Government and the
private sector.
4.2.2 The macroeconomic impacts of HIV/AIDS
are sensitive to assumptions about how AIDS affects savings and
investment rates, and whether AIDS affects the best-educated employees
more than others. Studies in Tanzania, Cameroon, Zambia, Swaziland,
Kenya and other sub-Saharan African countries have found that
the rate of economic growth may be reduced by as much as 25 per
cent over a 20-year period as a result of the HIV/AIDS pandemic.
Early results of ongoing estimates by the World Bank suggest that
the macroeconomic impact of HIV/AIDS may be significant enough
to reduce the growth of national income by up to a third in countries
with adult prevalence over 10 per cent.
Vulnerable economic sectors
4.2.3 A number of economic sectors are particularly
vulnerable to the impact of HIV/AIDS. These sectors are characterized
by the requirement for workers to stay away from their homes for
long periods, and include the transport, mining and fishing sectors.
Sectors which rely on seasonal and short-term workers, such as
agriculture, construction and tourism, are also particularly vulnerable
to the impact of HIV/AIDS. Moreover, sectors which rely on highly
trained personnel are also in danger of being adversely affected
by HIV/AIDS because the loss of even a small number of specialists
can place entire systems and significant investments at risk.
Costs and revenues
4.2.4 AIDS-related illnesses and deaths
of workers affect the economy both by increasing costs and reducing
revenues. Employers have to spend more in areas such as health
care, burial, training and recruitment of replacement employees.
Revenues may be decreased because of absenteeism due to illness
or attendance at funerals, as well as time spent on training.
Labour turnover can lead to a less experienced and therefore less
productive workforce. However, the relationship between HIV/AIDS
and the costs and revenue of employers has rarely been examined
systematically up to now. Moreover, little data is available on
how HIV/AIDS affects micro and small formal and informal enterprises.
Overall there is bound to be a reduction in profits if companies
do not take early measures to prevent the impact of HIV/AIDS.
Rural sector
4.2.5 In the rural sector, losses due to
HIV/AIDS have led to reduced food production and declining food
security, as well as a reallocation of labour and time from agricultural
work to non-agricultural care activities. For example, according
to a study by the Zimbabwe Farmers Union, the AIDS-related reduction
in the production of maize has reached 61 per cent, cotton 47
per cent, vegetables 49 per cent and groundnuts 37 per cent. Agriculture
is the largest sector in most African economies, accounting for
a large proportion of production and a majority of employment.
Studies carried out in Tanzania and other countries have shown
that AIDS will have adverse effects on agriculture, including
loss of labour supply and remittance income. The loss of a few
workers at crucial periods of planting and harvesting can significantly
reduce the size of the harvest. In countries where food security
is an important issue because of drought, the decline in household
production can have serious consequences. A loss of agricultural
labour also causes farmers to switch to less labour-intensive
crops. In many cases, this means switching from export crops to
food crops, thereby affecting rural economies.
4.3. THE EFFECT
OF WORKFORCE
ILLNESS AND
MORTALITY ON
THE LIVELIHOODS
AND ECONOMIC
ACTIVITY OF
DEPENDENT HOUSEHOLDS
Effect on households
4.3.1 The few surveys of the impact of having
a family member with AIDS show that households suffer a dramatic
decrease in income. Decreased income inevitably means fewer purchases
and diminishing savings. In a study in Thailand, one-third of
rural families affected by AIDS experienced a halving of their
agriculture output, which threatened their food security. Another
15 per cent had to take their children out of school, and over
half of the elderly people were left to take care of themselves.
In urban areas in Côte d'Ivoire, the outlay on school education
was halved, food consumption went down 41 per cent per capita,
and expenditure on health care more than quadrupled. When family
members in urban areas fall ill, they often return to their villages
to be cared for by their families, thus adding to the call on
scarce resources and increasing the probability that a spouse
or others in the rural community will be infected.
4.3.2 Families make great sacrifices to
provide treatment, relief and comfort for a sick breadwinner.
In the Thai study, the families spent on average US$1000 during
the last year of an AIDS patient's life—the equivalent of
an average annual income.
4.3.3 A common strategy in AIDS-affected
households is to send one or more children away to extended family
members to ensure that they are fed and cared for. Such extended
family structures have been able to absorb some of the stress
of increasing numbers of orphans, particularly in Africa. However,
urbanization and migration for labour, often across borders, are
destroying those structures.
Orphans
4.3.4 So far, the AIDS epidemic has left
behind 13.2 million orphans—children who, before the age
of 15, lost either their mother or both parents to AIDS. Many
of these children have died, but many more survive, not only in
Africa (where 95 per cent currently live) but in developing countries
throughout Asia and the Americas.Before AIDS, about 2 per cent
of all children in developing countries were orphans. By 1997,
the proportion of children with one or both parents dead had skyrocketed
to 7 per cent in many African countries and in some cases reached
an astounding 11 per cent.
4.3.5 In African countries that have had
long, severe epidemics, AIDS is generating orphans so quickly
that family structures can no longer cope. Traditional safety
nets are unravelling as more young adults die of this disease.
Families and communities can barely fend for themselves, let alone
take care of orphans. Typically, half of all people with HIV become
infected before they turn 25, acquiring AIDS and dying by the
time they turn 35, leaving behind a generation of children to
be raised by their grandparents or left on their own in child-headed
households.
4.3.6 Wherever they turn, children who have
lost a mother or both parents to AIDS face a future even more
difficult than that of other orphans. According to a report published
jointly in 1999 by UNICEF and the UNAIDS Secretariat, AIDS orphans
are at greater risk of malnutrition, illness, abuse and sexual
exploitation than children orphaned by other causes. They must
also grapple with the stigma and discrimination so often associated
with AIDS, which can even deprive them of basic social services
and education.
4.4 THE
IMPACT OF
HIV/AIDS ON THE
BUDGETS OF
DEVELOPING COUNTRIES
Budgets under pressure
4.4.1 Pressure is put on the governments'
budgetary situation from two sides. On the one hand, expenditures
for health care costs, pensions, sickness benefits, and social
assistance are increasing due to HIV/AIDS. On the other hand,
income is reduced through a lower size of the working age population,
lower employment levels, reduced productivity and a loss of economic
growth. As a consequence, there is a contraction of the contributory
base, which leads to lower contributions and taxes.
Health Sector
4.4.2 As a consequence of the growing number
of infections, the epidemic's impact on the health sector over
the coming decade will be predictably greater than in the past
two decades combined. Already, however, the increased demand for
health care from people with HIV-related illnesses is heavily
taxing the overstretched public health services of many developing
countries. In the mid-1990s, it was estimated that treatment for
people with HIV consumed 66 per cent of public health spending
in Rwanda and over a quarter of health expenditures in Zimbabwe.
A recent study estimates that in 1997, public health spending
for AIDS alone already exceeded 2 per cent of gross domestic product
(GDP) in 7 of 16 African countries sampled—a staggering
figure in countries where total health spending accounts for 3-5
per cent of GDP. In recent years, HIV-positive patients have occupied
half of the beds in the Provincial Hospital in Chiang Mai, Thailand,
39 per cent of the beds in Kenyatta National in Nairobi, Kenya,
and 70 per cent of the beds in the Prince Regent Hospital in Bujumbura,
Burundi. A related impact of the epidemic is that patients suffering
from other conditions are being crowded out. The hospital sector
in Kenya has seen increased mortality among HIV-negative patients,
who are being admitted at later stages of illness.
4.4.3 The shifting and growing demand on
health care systems is underscored by the exploding tuberculosis
epidemic in the countries most heavily affected by HIV. As HIV
weakens people's immune systems it makes them far more vulnerable
to developing active tuberculosis. Tuberculosis has become the
leading cause of death among people with HIV infection, accounting
for about a third of AIDS deaths worldwide. Hospital data from
Africa show that up to 40 per cent of HIV-infected patients have
active tuberculosis. With a greater number of HIV-positive people
developing active tuberculosis, there is also a greater risk that
the TB bacillus will pass to others in the community. The World
Bank has estimated that 25 per cent of HIV-negative persons dying
of tuberculosis in the coming years would not have been infected
with the bacillus in the absence of the HIV epidemic. Each of
these new tuberculosis infections represents a further cost to
the health sector.
4.4.4 The development of new therapies for
HIV-infected persons and of vaccines will further raise health
sector costs in infrastructure, drugs, training, and personnel
expenditures. As in other sectors of the economy, rising rates
of HIV infection in health care workers will increase rates of
absenteeism, reduce productivity, and lead to higher levels of
spending for treatment, death benefits, additional staff recruitment
and training of new health personnel.
4.5 THE
IMPACT OF
HIV/AIDS ON THE
ACHIEVEMENT OF
THE INTERNATIONAL
DEVELOPMENT TARGETS
4.5.1 As the DFID memorandum points out,
there has been little work so far to link epidemiological data
directly to the impact of HIV/AIDS on the achievement of international
development targets. Nevertheless, it is clear that the epidemic
has an effect on all these targets, as it impacts on all areas
of social and economic development in affected countries.
Poverty reduction
4.5.2 We can assume that the goal of halving
the number of persons living in extreme poverty between 1990 and
2015 will not be met in the worst affected countries due to the
impact of HIV/AIDS. As the UN Secretary-General states in his
recent Millennium Report, "our only hope of significantly
reducing poverty is to achieve sustained and broad-based income
growth". Yet, the negative impacts of HIV/AIDS on the labour
force, on macroeconomic performance and on households (all discussed
above) severely jeopardize income growth.
Child mortality reduction
4.5.3 The goal of reducing infant and child
mortality rates by two-thirds between 1990 and 2015 is also threatened
by the epidemic. The expectation of life at birth in some of the
29 countries most affected in Africa has declined by seven years
on average, and by as much as 20 years in the most severe cases
(see Figure 1).
Figure 1:
Child mortality, especially under the age of
two, has increased by up to five fold over recent years. Studies
done in Zambia, Kenya and Cameroon revealed a decrease in under-5
child mortality achieved by all three countries between 1981 and
1986 and a subsequent upturn, which has been attributed to AIDS
(see Figure 2). Almost all AIDS deaths in young children can be
traced back to mother-to-child transmission of the virus. This
is why countries such as Zambia and Kenya, with their high adult
HIV prevalence rates, have seen a particularly steep rise in child
mortality.
Figure 2: Child Mortality in Zambia, Kenya
and Cameroon
Education
4.5.4 In the worst affected countries, the
epidemic also hinders the achievement of free and universal primary
education by 2015. In areas where HIV infection is common, HIV-related
illness is taking its toll on education in a number of ways. Firstly,
it is eroding the supply of teachers and thus increasing class
sizes, which is likely to dent the quality of education. Secondly,
it is eating into family budgets, reducing the money available
for school fees and increasing the pressure on children to drop
out of school and marry or enter the workforce. Thirdly, it is
adding to the pool of children who are growing up without the
support of their parents, which may affect their ability to stay
in school.
4.5.5 Skilled teachers are a precious commodity
in all countries, but in some parts of the world, teachers become
too sick to work or die of HIV-related illness long before retirement.
The Central African Republic, where around one in every seven
adults is estimated to be infected with HIV, already has a third
fewer primary school teachers than it needs. A recent study of
the impact of HIV on the educational sector showed that almost
as many teachers died as retired between 1996 and 1998. Of those
who died, some 85 per cent were HIV-positive, and they died an
average of 10 years before reaching the minimum retirement age
of 52. The study recorded that 107 schools had closed owing to
staff shortages, and only 66 remained open. With the teacher shortage
expected to worsen, researchers calculate that over 71,000 children
aged 6-11 will be deprived of a primary education by the year
2005. A similarly dramatic impact has been found in Côte
d'Ivoire, where teachers with HIV miss up to six months of classes
before dying (compared with 10 days missed by teachers dying of
other causes) and where confirmed cases of HIV/AIDS account for
seven out of ten deaths among teachers.
4.5.6 AIDS may also aggravate the existing
disparity in educational access between town and countryside.
In a national survey of 6-15-year-olds in Zambia in 1996, over
70 per cent of those living in cities were enrolled in school,
compared with just over half of those in rural areas. Rural postings
are already unpopular among teachers in many countries, and the
Zambian study suggested that the need to be close to a source
of health care—a town or city—acted as an extra disincentive
to teachers to go to rural areas.
4.5.7 It is commonly assumed that children
drop out of school when their parents die, whether of AIDS or
another cause. While there has been little rigorous research,
a few studies can point to AIDS in the family as a direct cause
for school drop-out. For example, in a study of commercial farms
in Zimbabwe, where most farmworker deaths are attributed to AIDS,
48 per cent of the orphans of primary-school age who were interviewed
had dropped out of school, usually at the time of their parent's
illness or death, and not one orphan of secondary-school age was
still in school. Information collected in large household surveys
representative of the general population confirms the general
assumption that children whose parents have both died are less
likely to be in school than children who are living with one or
both parents.
Gender equality
4.5.8 The fact that increasing economic
pressure tend to make poor families take their daughters out of
school rather than their sons—because in many cases the
value of girls' labour exceeds the returns that parents expect
from educating their daughters—impedes the goal of making
progress towards gender equality through education. This tendency
is exacerbated by AIDS, as girls are seen to have a high capability
of providing care to infected family members at home.
4.5.9 Moreover, while women of all ages
are more likely than men to become infected with HIV during unprotected
vaginal intercourse, this vulnerability is especially marked in
girls whose genital tract is still not fully mature. Compounding
their biological vulnerability, women and young girls often have
a lower status in society at large and in sexual relationships
in particular. It is the interplay of biological, cultural and
economic factors that makes young girls particularly vulnerable
to the sexual transmission of HIV. While both girls and boys engage
in consensual sex, girls are more likely than boys to be uninformed
about including their own biological vulnerability to infection
if they start having sex very young. Girls are also far more likely
than boys to be coerced or raped or to be enticed into sex by
someone older, stronger or richer. Sometimes the power held over
them is mainly that of greater physical strength. Sometimes it
is social pressure to acquiesce to elders. Sometimes it is a combination
of factors, as may be the case with older men who offer schoolgirls
gifts or money for school fees in return for sex. In the era of
AIDS, the consequences for young girls can be disastrous.
|
