Memorandum submitted by UNAIDS (continued)
4.6 THE EFFECT
OF HIV/AIDS ON
POLITICAL AND
SOCIAL STABILITY
Impact on the military and military/civilian interactions
4.6.1 HIV/AIDS is rapidly becoming a key
global human security issue. Apart from the macroeconomic consequences
already mentioned, its effects are felt in two other interrelated
ways: Firstly, in the impact of HIV/AIDS on the military and on
military/civilian interactions. War is an instrument for the spread
of HIV/AIDS. The armed forces (both military and police) constitute
a major population block in many societies, highly mobile and
often called upon to serve at borders or to deploy outside of
national boundaries. HIV infection poses a more serious threat
to military populations than the inherently hazardous nature of
their occupation. The impact of HIV on the military lies in the
impact on human capital—compromising armed forces' readiness.
The impact of HIV on civilian populations lies in the high rates
of sexual interaction between military and civilian populations
whether through commercial sex, or in rape as a weapon of war;
and in the extreme vulnerability of displaced and refugee populations
to HIV infection. People are six times more likely to contract
HIV in a refugee camp than in the general outside population.
4.6.2 The fact that the infection rate for
the armed forces is higher than for the civilian population is
an important factor to be aware of when foreign military and police
play a role in peacekeeping. But HIV transmission is a two-way
street, and peacekeepers may be at risk of bringing HIV home with
them as well as at risk of transmission to others if they bring
the infection with them on the mission. For example, Nigeria's
President Obasanjo announced in May 2000 that about 11 per cent
of Nigerian soldiers in the West African peace-keeping force (ECOMOG)
stationed in Sierra Leone and Liberia were infected with HIV.
The Defence Minister said the increasing involvement of Nigerian
armed forces in operations abroad and the long separation of servicemen
from their spouses had been identified as risk factors in the
spread of the disease.
Impact on fragile Geo-Political systems
4.6.3 Secondly, the effect of the epidemic
is felt in its impact on already fragile and complex geo-political
systems, especially—though not exclusively—in Africa.
There were 27 conflicts in the world at the start of 2000, eleven
of them are in Africa. Fifteen sub-Saharan countries are faced
with food emergencies, while protracted drought in east Africa
threatens further food shortages. A new, unprecedented generation
of orphaned children in resource-poor environments may surely
risk producing a generation of disaffected adolescents. Against
this canvas, AIDS is a serious threat to the political stability
of many countries.
5. RESPONSES
TO HIV/AIDS
5.1 IMPLICATION
FOR TRAINING
BUDGETS AND
PROGRAMMES
5.1.1 The relationship between HIV/AIDS
and training budgets and programmes has rarely been examined systematically
up to now. Nevertheless, anecdotal evidence suggests that companies
have to increase their training budgets in order to deal with
the HIV/AIDS-related mismatch of human resources and labour requirements
in terms of qualifications, training and experience (cf 4.1.4.).
5.1.2 Some companies have already begun
to hire or train two or three employees for the same position,
if it is feared that employees in key positions may be lost due
to AIDS. Training staff in a range of important skills so that
they can be deployed to fill gaps as the need arises, requires
considerable forward planning, as it often takes a long time for
a fresh recruit to become a fully productive specialist. Employees
can also be replaced by importing labour from neighbouring countries,
at the risk of creating a bigger immigrant sub-population, which
is often more vulnerable to HIV infection.
5.2 ENGAGEMENT
OF THE
PRIVATE SECTOR
IN HIV/AIDS EDUCATION
AND PREVENTION
Identifying the need for action
5.2.1 Businesses do not work in isolation,
and so the impact of HIV/AIDS on all productive sectors, on the
business supply chains, the effective labour supply and intellectual
capital directly impacts on individual companies. These impacts
can significantly affect the ability of business to operate. The
importance of identifying the impact of HIV/AIDS on individual
companies is two-fold:
— Long-term sustainable business responses
will only be achieved if all stakeholders (leadership, managers,
personnel, shareholders) within companies are convinced of the
real business rationale for action.
— A clear understanding of the specific
impacts of HIV/AIDS on a company and of the context in which these
occur (eg modes of transmission) are critical factors in the development
of effective and appropriate policy and programme responses.
5.2.2 The actual motivation for business
responses to HIV/AIDS within the workplace is highly variable
and dependent on factors such as the HIV prevalence rate within
their area of operation, the level of benefits available to the
workforce and the level of knowledge and awareness by the business
leadership of the real and potential impacts.
Workplace prevention programmes
5.2.3 Some employers have started prevention
programmes in the workplace at their own initiative with a view
to protecting their investment in human capital. The programmes
vary according to company size, resources, structure and employee
culture, as well as public policy. In some cases, employers' initiatives
have preceded the action taken by governments in the area of public
policy. No one programme can therefore serve as a model for all
to follow. However, the experience so far indicates that components
of an effective HIV/AIDS programme tend to include the following:
— ongoing formal and informal discussion
and education on HIV/AIDS for all staff;
— an equitable set of policies that
are communicated to all staff and properly implemented, including
protection of rights at work and protection against any discrimination
at work;
— the availability of condoms;
— prevention and rehabilitation programmes
on drugs and alcohol;
— diagnosis, treatment and management
of sexually transmitted diseases, for employees and their sex
partners;
— voluntary HIV/AIDS testing, counselling,
care and support services for employees and their families.
5.2.4 For example, at Volkswagen in Brazil,
which employs 30,000 people, the potential impact of HIV was assessed
early on. By 1996, the company considered that AIDS was accounting
for high treatment costs and employees were experiencing frequent
interruptions, precocious illness and shortened life expectancy.
It quickly established an AIDS Care Programme that included medical
care, clinical support, information and installation of condom
machines. Volkswagen also adopted a technical protocol detailing
the standard of assistance and care it should provide. Three years
later, hospitalizations were down by 90 per cent and HIV/AIDS
costs by 40 per cent.
5.2.5 Increasingly, companies are recognising
that their ability to protect their employees is limited if education
and oureach efforts are not extended to the local communities.
The disease is easily passed from the wider community to employees
and their families. Moreover, HIV/AIDS is not just a biomedical
problem; its spread is influenced by behaviours and socio-economic
pressures, which are present within the communities in which the
workforces live.
5.2.6 Therefore, in localities of importance
to companies where the risk of infection is high, companies have
engaged in social investment programmes to confront the disease.
Anglo Coal and Eskom of South Africa have both recognised the
importance of community involvement in order to prevent workforce
initiatives being undermined. The various activities they have
undertaken include focusing on wider causes of the spread of the
epidemic, particularly in terms of sexual behaviour with regard
to commercial sex workers. Another example is Chevron, Nigeria,
whose community outreach programmes have also extended to the
local youth, in recognition of the importance of early education
and prevention.
5.2.7 In India, the Tata Iron and Steel
Company has evolved its own AIDS policy in recognition that the
fight against the epidemic cannot be the responsibility of governments
alone. In its own words, "Tata Steel will take measures to
prevent the incidence and spread of HIV/AIDS in our society. In
case of need, the company will arrange to provide counselling
and medical guidance to HIV/AIDS patients and their families."
To do this, it set up a core group of professionals in medicine,
community services and education. It also targeted information
and education programmes to young people, migrant labourers, truckers,
and army and police personnel. "As a result, our employees
also benefit." Tata's work also includes media promotion,
installation of condom vending machines, work with non-governmental
organizations, training and awareness programmes at Tata Main
Hospital, counselling and help-lines.
Business coalitions
5.2.8 In a growing number of countries,
employers have formed business coalitions on HIV/AIDS to pool
resources and improve their response to the crisis in their workplaces
and communities. For example, American International Insurance,
Thailand's largest life insurance company, began its efforts close
to home by providing training on HIV and AIDS in its own offices.
In 1995, it began a nationwide fundraising "AIDSathon",
which in turn led to the development, with the Thailand Business
Coalition on AIDS, of group insurance benefits to policyholders
that demonstrated they had effective policies for combating HIV
and AIDS.
5.2.9 In Botswana's relatively recent HIV
epidemic, the tidal wave of deaths has yet to break. Recognizing
that a massive increase in sickness and death is on its way, several
companies joined forces to fund the Botswana Business Coalition
on AIDS in order to share information about prevention and care
in the workplace and keep up to date on legal and ethical issues
raised by the epidemic. The Coalition also works in close collaboration
with the Government and trade unions to coordinate approaches
to policy and HIV prevention programmes in the workplace. The
Government's occupational health service provides training to
companies that wish to initiate HIV prevention in the workplace.
Provision of health insurance
5.2.10 Certain health insurance providers
have also established facilities specifically designed for persons
with HIV infections, which guarantee and at the same time cap
payments for HIV-related treatment. These schemes currently provide
enough benefits to cover a significant share of the cost of treatment,
but employers are already worried that, as the proportion of HIV-infected
workers rises, they will not be able to maintain benefits at these
levels. Other responses include radical changes in the way that
insurance schemes work. For example, death benefits were traditionally
paid to the family by many such schemes only when the employee
died in service. Some schemes are now agreeing to pay benefits
to employees who are certified as terminally ill, so that they
can retire and spend their final days in peace at home, without
forfeiting the benefit due.
5.2.11 While the measures taken by health
and social security insurance schemes to take into account the
specific needs of people living with HIV/AIDS are encouraging,
it has to be emphasized that only a tiny fraction of the population
in the countries most affected by HIV/AIDS is covered by formal
health insurance and benefits schemes. Even those who are covered
will inevitably see their health and death benefits fall significantly
over the next few years, as insurance companies and employers
pass on at least part of the rising costs to beneficiaries and
employees, including those who are not HIV-infected.
5.2.12 Premiums on some group life insurance
policies in certain countries have already doubled, even though
they are still at a relatively early stage of the pandemic, with
the vast majority of young adult deaths still to come. Employers
will not be able to absorb all of these costs. While the practice
is certainly followed of recruiting staff on casual or short-term
contracts to avoid paying disability, death or other benefits,
a number of employers have begun to work together with the insurance
industry to develop policies and benefit packages which meet the
needs of people with HIV/AIDS and their families without bankrupting
the companies themselves.
Disadvantages of HIV screening
5.2.13 With a view to anticipating the loss
of workers due to HIV/AIDS, many companies would like to know
the proportion of the workforce they are likely to lose through
AIDS. However, increasingly, employers are beginning to recognize
the tremendous negative impact of pre-employment and on-the-job
HIV screening. Testing the existing workforce is not only unethical,
but leads to great hostility and is incompatible with effective
HIV/AIDS prevention and care programmes at the workplace. Companies
are beginning to find that, by abandoning testing requirements,
a conducive climate can be created for workplace prevention programmes.
A steadily increasing number of employers in the worst affected
countries are reaching the conclusion that prevention is much
more cost-effective than HIV-screening in the long term, and that
respect for the rights of workers is a powerful prevention tool
in its own right.
5.3 THE HUMAN
AND LEGAL
RIGHTS OF
PEOPLE LIVING
WITH HIV/AIDS
5.3.1 Many factors in vulnerability - the
root causes of the epidemic—can best be understood within
the universal principles of human rights. Vulnerability to AIDS
is often engendered by a lack of respect for the rights of women
and children, the right to information and education, freedom
of expression and association, the rights to liberty and security,
freedom from inhuman or degrading treatment, and the right to
privacy and confidentiality. Where human rights such as these
are compromised, individuals at risk of HIV infection may be prevented
or discouraged from obtaining the necessary information, goods
and services for self-protection. Where people with AIDS risk
rejection and discrimination, those who suspect they have HIV
may avoid getting tested and taking precautionary measures with
their partners, for fear of revealing their infection; they may
even avoid seeking health care. Promoting human rights and tolerance
is thus important in fighting AIDS as well as in its own right.
5.3.2 Experience has also shown that the
incidence and spread of HIV/AIDS is significantly higher among
groups which already suffer from a lack of respect of their human
rights and from discrimination, or which are marginalized because
of their legal status. These include women, children, people living
in poverty, minorities, indigenous peoples, migrants, people with
disabilities, sex workers, homosexuals, injecting drug users and
prisoners. These populations often have less access to education,
information and health care because of the discrimination they
face in relation to their economic opportunities, political and
social influence, or gender and sexual relations.
5.3.3 Without a rights-based response, the
impact of HIV/AIDS and vulnerability to the disease will inevitably
increase. As often highlighted by the late Jonathan Mann, the
protection of the uninfected majority is inextricably bound up
with upholding the rights of people living with HIV/AIDS.
5.4 THE RESPONSE
OF THE
INTERNATIONAL COMMUNITY
(A) Bilateral Funding
Difficulties in reporting funding
5.4.1 Although the UNAIDS Secretariat has
made significant progress in establishing sustainable processes
for the monitoring of donor country resource flows to HIV/AIDS
on a long-term and sustainable basis, some key issues remain.
For example, several major DAC members including France and the
European Commission continue to have major difficulties in the
reporting of their official development assistance allocated to
HIV/AIDS.
5.4.2 Moreover, there continue to be differences
in the ways that different donors define HIV/AIDS activities.
Particularly problematic is the monitoring of HIV/AIDS components
within integrated development projects or HIV/AIDS allocations
within sector wide approaches and common basket funding schemes.
5.4.3 Because of administrative differences
among the DAC member countries, including differences in fiscal
years, there is a significant delay in reporting donor country
HIV/AIDS expenditures.
Recent indications
5.4.4 Recent indications from donors are
encouraging. For example, funding by the United States for global
HIV/AIDS activities increased by US$ 65 million in 2000 and is
set to increase by as much as an additional US$100 million in
2001. The donor response to the International Partnership Against
AIDS in Africa has also been positive. This important new initiative
(see below) includes donors as one of its five key constituencies.
Representatives of donor countries are participating in all phases
of its development, and their greater understanding of, and involvement
in, national planning processes are paying off in increased support.
5.4.5 In addition, the increasing recognition
that HIV/AIDS is not only a major threat to development, but also
a threat to peace-building and human security has resulted in
higher levels of political awareness and more substantial financial
commitments. An additional US$180 million in donor funding for
activities in Africa was announced at the historic Security Council
meeting in January 2000.
Analysis of donor funding
5.4.6 There is no doubt that wealthy countries
provide substantial support to the international fight against
AIDS. Reliable data suggests that in 1998, 14 of the largest donors
in the OECD Development Assistance Committee provided US$300 million
for HIV/AIDS activities. This donor assistance to HIV/AIDS has
increased substantially over time. In 1987—soon after it
was first recognized that HIV had spread massively in many developing
countries—levels of official development assistance (ODA)
funding to AIDS were only at 20 per cent of the levels seen a
decade later. This increase has occurred at the same time that
overall ODA contributions to developing countries have steadily
declined.
5.4.7 Unfortunately, as spectacular as this
increase appears, it has not kept pace with the spread of the
epidemic—or even the most basic requirements for HIV programmes
of the most affected countries. During the same period, the number
of infections has risen from 4 million to 34 million, a figure
that continues to grow given the more than 5 million new infections
annually. Furthermore, increases in donor support had begun to
level off between 1996 and 1998, and it remains less than just
1 per cent of donor countries' total annual ODA budgets. Against
the backdrop of soaring infection rates, this trend is of critical
concern.
Table 1
HIV/AIDS ODA DISBURSEMENTS FOR SELECTED DONOR
COUNTRIES AT CURRENT PRICES AND EXCHANGE RATES, 1998
|
| Donor country | 1998 HIV/AIDS ODA
(US$ million)
| Percent of total 1998 HIV/
AIDS ODA
|
|
| Australia | 12.2
| 4% |
| Belgium | 5.2
| 2% |
| Canada | 14.8
| 5% |
| Denmark | 7.8
| 3% |
| Finland | 1.5
| <1% |
| Germany | 15.0
| 5% |
| Japan | 14.0
| 5% |
| Luxembourg | 2.0
| 1% |
| Netherlands | 21.5
| 7% |
| Norway | 14.9
| 5% |
| Sweden | 15.2
| 5% |
| Switzerland | 2.1
| 1% |
| UK | 26.3 |
9% |
| USA | 147.3
| 49% |
|
| Total | 300.0
| 100% |
|
5.4.8 The United States was by far the largest donor
of HIV/AIDS ODA, disbursing US$147.3 million (49 per cent). The
United Kingdom and the Netherlands were the next largest donors
disbursing US$26.3 million (9 per cent) and US$ 21.5 million (7
per cent) respectively. But when allocations are broken down as
a proportion of gross national product (GNP) for each country,
the picture is quite different.[1]
Luxembourg and Norway disbursed the largest proportion of their
country's GNP to HIV/AIDS activities in developing countries with
US$117 and US$103 per US$ million GNP respectively (Figure 1).
The United States and the United Kingdom disbursed US$17 and US$19
per US$million GNP respectively.
Figure 1
HIV/AIDS ODA as reported by 14 donor countries:
Total amount obligated, 1998, in US$million and obligations
reported by donor countries per US$ million 1998 GNP
5.4.9 Another way to assess the level of HIV/AIDS ODA
by individual donors is to consider HIV/AIDS ODA as a percentage
of total ODA. In this case, Luxembourg, the United States and
Australia disbursed the highest percentage of total ODA to HIV/AIDS
activities with 1.8 per cent, 1.7 per cent and 1.3 per cent respectively.
On the other end of the scale, Japan, Switzerland and Germany
disbursed 0.1 per cent, 0.2 per cent and 0.3 per cent of total
ODA to HIV/AIDS activities respectively. Overall, the US$300 million
allocated to HIV/AIDS by the fourteen DAC member countries in
1998 represent 0.7 per cent of the US$41 450 million that they
disbursed in total ODA for that year.
FLOW OF
1998 OFFICIAL DEVELOPMENT
ASSISTANCE TO
HIV/AIDS
5.4.10 Of the US$ 300 million in ODA that were allocated
to HIV/AIDS in 1998, 20 per cent was channelled through multilateral
agencies. Of the funds channelled through the Untied Nations and
its specialized agencies, almost all (95 per cent) were core budget
contributions or supplemental funding for general agency HIV/AIDS
activities. Only 5 per cent of the funds channelled through multilateral
agencies were multi-bilateral—or channelled through multilateral
agencies for projects in specific countries. The large majority
of the 1998 HIV/AIDS ODA reported (80 per cent) was transferred
directly to recipient governments or channelled through non-governmental
organizations and other private institutions.
5.4.11 An additional way to assess the flow of HIV/AIDS
ODA is to review the regional distribution of these funds. Over
one third (35 per cent) of the US$300 million reported was earmarked
for "global or inter-regional activities." It is not
possible to disagregate these funds though a substantial proportion—including
core contributions to the UNAIDS Secretariat—are eventually
allocated to regions. Of the remaining 65 per cent (US$195 million),
56.8 per cent was earmarked for activities in sub-Saharan Africa
(Figure 2), 26.5 per cent was allocated to activities in Asia/Pacific;
13.8 per cent to activities in Latin America/Caribbean; 2.3 per
cent to activities in Eastern Europe; and 0.5 per cent to activities
in the Middle East/North Africa region.
Figure 2
Distribution of regionally allocated HIV/AIDS ODA disbursements
for selected donor countries, 1998
Trends in official development assistance to HIV/AIDS, 1987-98
5.4.12 The 1998 data for the 10 donor countries for which
data are available over time—Australia, Canada, Denmark,
Germany, Japan, the Netherlands, Norway, Sweden, the United Kingdom
and the United States—confirm most of the trends highlighted
in the "Level and flow of national and international resources
for the response to HIV/AIDS, 1996-97."[2]
When inflation and changes in purchasing power parity are taken
into account, the flow of HIV/AIDS ODA from these 10 countries
increased each year from 1987 to 1996, remained stable between
1996 and 1997and continued to increase between 1997 and 1998 (Figure
3).
Figure 3
Total HIV/AIDS ODA Disbursements by Selected Donor Countries
at 1997 Prices and Exchange Rates, 1987-98
Similarly, when trends in the flow of HIV/AIDS ODA are compared
to the trends in overall ODA for these countries, the proportion
of HIV/AIDS ODA within the total pot of ODA does increase slightly
between 1987 and 1988 from 0.2 per cent to 0.7 per cent.
Finally, the trend in the decreasing flow of HIV/AIDS ODA
through United Nations agencies is also confirmed with the 1998
data. This trend has been longstanding (since 1987), but reviewing
only the last three years; donor countries decreased the HIV/AIDS
ODA that they channelled through multilateral and multi-bilateral
channels from 26 per cent of all HIV/AIDS ODA in 1996 to 22 per
cent in 1997 to 20 per cent in 1998.
1
Information on donor country GNP was taken from "Development
Assistance Committee International Development Statistics."
OECD website: http://www.oecd.org/dac/htm/dcdrsd-e.htm,22May2000. Back
2
Trend information also based on Mann J & Tarantola D, ed.,
AIDS in the World II (New York, Oxford: Oxford University Press,
1996) and Mann J, Tarantola T, eds., AIDS in the World (Cambridge,
London: Harvard University Press, 1992). Back
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