THIRD REPORT
The International Development Committee has agreed
to the following Report:—
HIV/AIDS: The Impact on Social and Economic
Development
Executive Summary
Introduction
In 1999 war claimed 269,000 lives throughout the world. Homicide and violence a further 527,000. The figures are shocking and whilst easy to write almost impossible to register or imagine. Nevertheless we take them seriously. Murders are reported and worried over. Wars and conflicts fill our newspapers and television screens. However, in 1999, 2.8 million people worldwide died with AIDS. More than three times the combined deaths from war, murder and violence. The catastrophe of HIV/AIDS must be the priority for action by the international community.
HIV/AIDS — a disease of poverty
HIV/AIDS is having a disproportionate effect on the poor. Of the estimated global total of 34.3 million people who at the end of 1999 were living with HIV/AIDS, 24.5 million of them were in sub-Saharan Africa; a further 5.6 million were in South and South East Asia. The prevalence rate for sub-Saharan Africa in 1999 was 8.57 per cent, compared to a global prevalence rate of 1.07 per cent and a prevalence rate in Western Europe of 0.23 per cent.
The impact of HIV/AIDS is massively exacerbated by poverty for a number of reasons. Poor education systems, poor health systems which lack the capacity to treat sexually transmitted diseases and opportunistic infections, a denial of human rights and conflict all conspire to increase vulnerability to infection. The fight against HIV/AIDS can only be won through progress in the elimination of poverty. We deplore the recent decline in the amount of official development assistance going to sub-Saharan Africa. HIV/AIDS must be tackled as part of a coherent strategy to develop healthcare systems and combat other communicable diseases such as TB and malaria.
It is also vital, however, that every donor and every national government have a distinct HIV/AIDS strategy. Dealing with HIV/AIDS means dealing with the most intimate aspects of human behaviour, with stigma and denial, with the promotion of human rights, with the multifaceted nature of poverty. There is also the sheer scale of the epidemic which requires particular attention and strategic thinking.
Two crises, not one
The Report argues that there are, in fact, two inextricably linked but distinct crises facing us. First, there is the crisis of a global HIV/AIDS epidemic, with the tragedy of unnecessary deaths, bereavements, illness, and impoverishment that the disease brings in its train. Secondly, however, there is sub-Saharan Africa with its appalling levels of prevalence. Levels of HIV infection are so high in may sub-Saharan African countries that there is a real danger of the collapse of systems and infrastructures, the erosion of the state, and the reversal of all recent gains made in development. Such deterioration would make effective action against the epidemic almost impossible. We do not believe that the international community has as yet grasped the full scale and seriousness of this African HIV/AIDS crisis, nor that they are agreed on how to address it.
The Impact of HIV/AIDS
HIV/AIDS will further and profoundly impoverish those who are already poor. In those countries, particularly in sub-Saharan Africa, with high prevalence rates, its effect could well be to reverse past development gains and destroy state, social and household systems which have previously been extremely resilient to shocks. This means that development may well have to be done in a different way. Donors are now generally aware that HIV/AIDS is not merely a medical problem but a developmental one — and by this they mean it is having a pervasive and destructive effect on the poor, thus making its prevention one of the main developmental challenges.
What is still lacking amongst donors is a real and determined attempt to examine how HIV/AIDS affects all aspects of development activity. Support for education, the private sector, agriculture extension and rural livelihoods, developing country government departments, to give just a few examples, must not only be increased but, more importantly, redesigned. We have on a number of occasions in this Report commented on DFID publications which ignore the impact of HIV/AIDS and how the epidemic should change the way development is done. For money to be well spent, projects and programmes must be robust against the depredations of HIV/AIDS. We single out DFID because it is the donor we have a responsibility to scrutinise. But this failure is a general one, and certainly not confined to DFID.
The HIV/AIDS epidemic is threatening the realisation of the International Development Targets. For example, the target of reducing infant and under-5 child mortality by two-thirds by 2015 is affected by the increasing infection of infants through mother-to-child transmission of the HIV virus. Similarly, the two educational targets are unachievable as children are withdrawn from school to care for sick relatives or supplement a declining family income. HIV/AIDS disproportionately affects mature adults in their working years meaning that families which are already poor find their income massively reduced as 'breadwinners' fall sick. As well as experiencing a loss of income, they also require greater expenditure to care for those who have fallen sick. HIV/AIDS thus directly affects the numbers living on less than a dollar a day, the criterion of those in extreme poverty.
HIV/AIDS is also having a significant impact on the economies of developing countries; an impact which is only going to become more severe as the HIV epidemic turns into an AIDS epidemic. Standard Chartered Bank estimated that 70 per cent of staff in Africa had close relatives and/or friends, who were infected with the HIV virus. Up to 30 per cent of their workforce in Zambia could be infected. Many large, multinational companies have yet to assess the likely impact of HIV/AIDS on their activities. As a result, vital opportunities to reduce incidence of HIV/AIDS are being missed meaning that their future productivity and profitability will be seriously impaired.
HIV/AIDS, the elderly, children, education and household survival
One impact of HIV/AIDS which has been badly ignored has been the impact on the elderly. As in many other policy areas, the needs of the elderly with regard to HIV/AIDS have been ignored for far too long. The Report makes a number of recommendations including: that more research be conducted into HIV/AIDS amongst the over 50s; that there be greater provision of HIV/AIDS information and education for older people; and that all HIV/AIDS strategies include explicit policies and action plans to meet the needs of the elderly.
The statistics on HIV/AIDS and children make terrible reading. By the end of 1999, 600,000 children had been infected with HIV/AIDS in that year alone; the cumulative death toll of children as a result of HIV/AIDS had reached 3.6 million. By the end of 1999 there were estimated to be 13 million AIDS-orphans — 95 per cent of them in sub-Saharan Africa.
The education of children is also being affected. Schools are a fundamentally important forum for the dissemination of information about HIV/AIDS and how to prevent it. However, in least developed countries, primary age group enrolment stands at only 60.4 per cent, with secondary enrolment at 31.2 per cent. Furthermore, children are increasingly being called upon either to work or to take on part of the burden of care as income-generating adults become ill. They are also increasingly being withdrawn from school simply because school fees or associated costs can no longer be afforded. HIV/AIDS has an equally disastrous impact on the supply of education. Teachers are not only being lost to the epidemic (in the most heavily affected countries some 20-30 per cent of teachers are HIV-positive) but, as mortality across the workforce increases, teachers are being recruited to other sectors which pay better than schools.
The Report also notes the impact of HIV/AIDS on the health sector. HIV levels are the same in the health sector as in the general population. Sickness and death due to AIDS are growing rapidly among health care personnel. Few countries have as yet fully understood the epidemic's impact on human resources in their health sector. 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 for new personnel.
There is also an impact on health budgets and on the health of those not infected with the virus. In the mid-1990s that 66 per cent of Rwanda's health budget and over a quarter of the health budget of Zimbabwe were spent on treatment for people with HIV. Given the small percentage of GDP dedicated to health spending in developing countries these amounts devoted to the care of those with HIV will inevitably be at the expense of other forms of health service delivery and care. HIV-positive patients are crowding out of hospital beds those uninfected with HIV but also ill.
Other Impacts
Other effects of the HIV/AIDS epidemic include those on agriculture and the public sector. A decline in the efficiency of government departments in countries severely affected by HIV/AIDS will have a whole host of implications for development in areas such as revenue collection, the management of the country's debt, the efficient regulation of industry, the preparation of necessary legislation.
HIV/AIDS is increasingly being recognised as both being affected by conflict and as a cause of conflict in itself. As HIV/AIDS increases poverty, there will be greater social insecurity and possibly conflict as a result of the HIV/AIDS epidemic. The United States has already declared the epidemic a national security threat, noting that the disease may destabilise governments in Africa and Asia.
Prevention and Care
Clearly, the most effective action to reduce the impact of HIV/AIDS on a country or region is to reduce the number of transmissions of HIV through effective prevention. There is no one simple answer to reducing transmission of HIV. Social change, changes to sexual behaviour and relationships, use of available means such as condoms, and research to try to discover new technologies are all needed. The means of preventing or reducing transmission of the HIV virus are already known; what is lacking is the will to make this happen on the necessary scale.
Uganda is frequently cited as an example of successful prevention. It was once the country with highest prevalence rate in the world. Now it is fourteenth. Since 1993, it has seen declining prevalence rates in the ante-natal screening programmes.
Uganda has become a beacon of hope for Southern Africa. The prevalence rate among pregnant women attended surveillance ante-natal clinics appears to be stabilising around 10% (from 25-30% in the early 1990s).
Whilst it is important to stress the cataclysm of the epidemic — the need for urgent and concerted action to decrease rates of infection and mitigate the impact of the disease — it is also important to emphasise that the fight against HIV/AIDS is not a hopeless one. Even in the absence of a vaccine, and with limited resources, successful prevention is possible.
Material interventions
Condoms remain the only proven effective means for preventing and reducing the transmission of HIV through sexual intercourse. The provision of condoms to all African countries which are at significant risk of HIV should be a highest priority. The ability of donor countries to influence their use is limited but where demand is outstripping supply, there is a clear role for bilateral aid and international action to make a difference.
The female condom also clearly has an important role to play. The Report congratulates DFID for its early support. Whilst the female condom has a number of drawbacks — it is not invisible or inconspicuous; women who currently find it impossible to get a male partner to wear a condom will not be spared the need to negotiate — there are situations where it will have an advantage, especially for sex workers.
The Report regrets the fact that support for the development of microbicides has been relatively limited. There is clearly potential for greater investment. The development of an effective microbicide would have the potential to reduce dramatically incidence of HIV infection.
Great hopes are being placed in the future discovery of a vaccine that will be effective at preventing the transmission of the HIV or mitigating its effects. The Report notes that the most optimistic timescale for the discovery of a safe and effective vaccine is between seven and ten years. However, this timescale has been postulated for some considerable time. Whilst donors should continue to support the search for a vaccine, such expenditure should be balanced by support for work aiming to achieve behavioural and social change and to promote the use of condoms — the only proven effective means of prevention for the foreseeable future.
Care
Too often, the debate about access to treatments for HIV/AIDS has been reduced to a debate about access to anti-retroviral drugs. No evidence to the Inquiry called for the purchase and donation of anti-retroviral drugs to be a priority for donor funds. All too often, the healthcare infrastructure to deliver and monitor these complicated drug regimes does not exist in the worst affected countries. The provision of anti-retroviral treatments to people with HIV in the poorest developing world is clearly not a practical or sustainable development intervention. Donor funds and activities should concentrate on prevention of further infections, development of basic healthcare systems, provision of palliative drugs and basic treatments of opportunistic infections.
There is room for price reduction for drugs to treat opportunistic infections. We welcome efforts, both through negotiations with pharmaceutical companies and through exploration of TRIPs provisions to secure access to cheaper drugs.
Responses and Responsibilities
Expenditure on HIV/AIDS has increased from about US$ 59 million in 1987 to US$ 293 million in 1998. 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. Donor support for HIV/AIDS remains less than just 1 per cent of donor countries' total annual ODA budgets.
The World Bank has committed US$500 million for a three-year HIV/AIDS programme for Africa. The Report expresses concern that IDA lending is being used to finance the attack on HIV/AIDS in sub-Saharan Africa. The debt management capacity of many of these countries remains weak and it would be unforgiveable for the donor response to HIV/AIDS to result in an increase in their unsustainable debt burden. The full impact of the AIDS epidemic has yet to be felt. The Report concludes that as much as possible of the US$500 million committed by the World Bank to HIV/AIDS in sub-Saharan Africa should be in grant rather than loan form.
The Report considers the response of the Department for International Development to the HIV/AIDS epidemic. It criticises DFID's lack of an explicit HIV/AIDS strategy and urges the Government to redress this omission as soon as possible. Whilst the Report welcomes the prevention work being supported by DFID in Asia, it recommends that DFID reverse the recent decline in its HIV/AIDS expenditure to sub-Saharan Africa and include in its HIV/AIDS strategy an account of how it plans to confront the epidemic in the region.
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The number of people living with HIV/AIDS is 36.1 million.
The total number of AIDS deaths since the beginning of the epidemic is 21.8 million
2.2 million of the 2.8 million AIDS-related deaths in 1999 were in sub-Saharan Africa.
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. [UNAIDS]
WHO statistics reveals that in 1999 HIV/AIDS accounted for 4.8 per cent of deaths (2.7 million people). Tuberculosis accounted for 3 per cent of deaths (1.7 million people) and malaria for 1.9 per cent (1.1 million people).
In Botswana, adult HIV/AIDS prevalence is 35.8 per cent, in Zimbabwe it is 25.1 per cent and in South Africa, 20 per cent.
It has been estimated that in South Africa the overall growth rate over the next decade is likely to be 0.3 to 0.4 percentage points lower every year than it would have been without AIDS. The cumulative effect of the epidemic will result in GDP in South Africa being 17 per cent lower in 2010 than it would have been without AIDS.
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 will regress to an average of just 47 years; this represents a reversal of most development gains of the past thirty years.
African countries where less than 5 per cent of the adult population is infected will experience a modest impact on GDP growth rate. As the HIV prevalence rate rises to 20 per cent or more (as it already has in a number of countries in southern Africa), GDP growth may decline up to 2 per cent a year. [UNAIDS]
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 keep growing. But because of the increased mortality, there will be about 11.5 million fewer persons in the labour force. [ILO].
Older people are now the primary carers and supporters of younger family members, both those dying of the disease and orphans. Older people who are already poor face the loss of economic support from their adult children, little social security and income support ... and unexpected social, psychological and economic burdens due to the caring role they assume. [HelpAge International]
By the end of 1999, the cumulative total of those orphaned by HIV/AIDS was 13.2 million, 12.1 million of them in sub-Saharan Africa.
Before HIV/AIDS, 2 per cent of all children in developing countries were orphans. By 1997 the proportion of children with one or both parents dead had increased to 7 per cent in many cases and in some countries had reached 11 per cent. This translates into a figure of 13.2 million orphans, 95 per cent in sub-Saharan Africa, created by AIDS since the beginning of the epidemic. [UNAIDS]
It must be absolutely soul-destroying to have to sit in a clinic in rural KwaZulu Natal and watch people die, and people you know. Probably the morale of the health sector is the worst affected. [Professor Alan Whiteside]
A study in Zambia showed that in one hospital, deaths of health care workers increased 13-fold over the 10-year period from 1980 to 1990, largely because of HIV. [UNAIDS]
Health service staff are at particular risk from infection, and in some countries, staff are dying faster than they can be trained. [DFID, Better Health for Poor People]
It is certain that various conflicts, which are there, are creating the conditions for future epidemics ... One can see this in a country like Rwanda or Ethiopia. We are now seeing increases in the level of AIDS. [Jacques du Guerny]
Following a concerted effort to improve preventative measures in Uganda, the age of first intercourse increased by two years, condom use increased from 15.4% in 1989 to 55.2% among men in 1995. There was also a drop of 50% in commercial sexual transactions. [Open Secret, Strategy for Hope, 2000]
I believe that all poor countries need a universal primary health care system, and for something like as little as US $12 a head a year you can get a basic primary health care system reaching all, then you have a mechanism for immunising children, giving people access to reproductive health care, proper supervision of TB treatments and malaria advice...That is our passion and our work.
[Rt Hon Clare Short MP]
How much money is necessary? UNAIDS have estimated a cost of US$ 1.5 billion for an adequate response to HIV/AIDS in sub-Saharan Africa, "which includes youth-focussed interventions, interventions focussed on sexual behaviour, public sector condom provision, condom social marketing, strengthening services to treat sexually transmitted infections, voluntary counselling and testing, workplace interventions, strengthening blood transfusion services, the prevention of mother-to-child transmission, and mass media and capacity building"
ODA funding per person living with HIV peaked in 1988 at approximately US$22. It has since steadily dropped to its 1997 rate of under US$ 9 per person living with HIV. [UNAIDS]
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The Report welcomes the growing seriousness with which DFID is taking the HIV/AIDS epidemic and recommends that it should continue to increase its expenditure on HIV/AIDS. At the same time, a review of how HIV/AIDS is affecting all DFID's development activity is urgently required, particularly in the case of sub-Saharan Africa. The Department needs to consider how development work might need to be redesigned to meet the new realities created by the epidemic.
National Political Leadership
There can be no effective response to the HIV/AIDS epidemic which is not spearheaded by the national governments of the developing countries themselves. Uganda has been cited as an example of how an early and clear position of the need to combat HIV/AIDS and use condoms has resulted in a decline in infection rates amongst young people. Until very recently such political commitment has been tragically lacking elsewhere in the sub-Saharan Africa. The response to the HIV/AIDS epidemic, particularly in sub-Saharan Africa, has been a culpable and serious failure in political leadership and governance. The Report argues donors should consider carefully, and target effectively, before providing funds to any government which has not attempted basic interventions such as information campaigns, and ensuring the widespread availability of condoms.
Conclusion
The Committee is concerned that the current and legitimate debate over drug pricing might distract from consideration of the real crisis — the crisis of poverty. It is the denial of resources, services and rights which has done so much to exacerbate the spread of HIV/AIDS and control of the epidemic will only be secured when such poverty issues are addressed. With inroads into poverty we would expect to see progress in the reduction of infection rates and standards of care.
HIV/AIDS is not only exacerbated by poverty — it also entrenches poverty still further. The Report concludes that development programmes, including those of DFID, have much work to do in assessing the impact of HIV/AIDS on the whole spectrum of development activity. There is an urgent need to redesign development programmes, policies and approaches, particularly in sub-Saharan Africa, to take account of the new realities caused by HIV/AIDS.
Are we doing enough? The answer is clearly not. More resources are in our view necessary, especially for sub-Saharan Africa. It is not, however, only a question of resources but of political determination, solidarity, and effective organisation of a response.
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In sub-Saharan Africa, where the epidemic is the most severe, there are large differences in funding for countries with similar epidemics. Nigeria has over twice as many people infected with HIV/AIDS as Uganda (although with a lower prevalence of HIV/AIDS), yet Nigeria reported spending less than US$2 million in 1996, compared to the US$37 million reported by Uganda.
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