House of Commons - International Development

Select Committee on International Development Third Report

Section 1 — The Nature of the Epidemic

OTHER ASPECTS OF POVERTY WHICH AFFECT THE SPREAD OF HIV/AIDS

21. It is not only poor health provision which exacerbates the HIV/AIDS epidemic. Alan Whiteside gave the example of migration for work. Referring to the fact that there was a higher prevalence of HIV/AIDS in the province of KwaZulu Natal than in other provinces of South Africa he pointed out that "KwaZulu Natal has something like 20 per cent of the population and 8 per cent of the land — so we have a very much more concentrated population. In terms of the movement of people, and [there are] very many more migrants, particularly men, from KwaZulu Natal, we obviously have the major transport nodes of Durban and Richards Bay. That has an awful lot to do with it".[10] The migration caused by poverty results in an increase in casual sexual contacts, with a resulting increase in HIV/AIDS.

22. Conflict similarly, with all the upheaval and displacement associated, is another catalyst to the spread of the epidemic. We were told when in Mozambique that two of the main factors in the spread of the HIV/AIDS epidemic in that country were , first, the many migrant workers who went for employment to South Africa, were infected, and then returned to their homes, spreading the disease, and secondly, the return of refugees with the conclusion of the conflict in Mozambique.

23. Poor education also increases vulnerability to HIV/AIDS. Schools for example are a fundamentally important forum for the dissemination of information about HIV/AIDS and how to prevent it. We live in a world, however, where amongst least developed countries primary age group enrolment is still only 60.4 per cent, with secondary enrolment at 31.2 per cent.[11] Furthermore such statistics do not assess absenteeism, dropout rates and the quality of the education provided, nor the often appalling differences between boy and girl enrolment. Poverty means poor education and poor education means a lost opportunity to provide information on HIV/AIDS. Furthermore, analysis from UNAIDS suggests a clear link between better education and condom use, and that in high-prevalence countries the better educated are delaying their first sexual experience — "These results suggest that the best-educated people in the countries hardest hit by the AIDS epidemic may be shifting towards less risky behaviour".[12]

HIV/AIDS IS EXACERBATED BY THE DENIAL OF HUMAN RIGHTS

24. It is not only a lack of resources which makes the poor more vulnerable to HIV/AIDS. Such vulnerability is also exacerbated by a denial of other rights. UNAIDS states that "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".[13]

25. Women are more vulnerable than men to HIV infection for biological reasons, this vulnerability being particularly marked in young girls. This biological vulnerability is, however, compounded by the lower status of women and girls, the prevalence of domestic violence and rape, and the more general inability of women to negotiate successfully the use of condoms by their male partners. UNAIDS emphasises that there is a particular vulnerability for young girls, "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".[14] A striking instance is given by UNAIDS of HIV prevalence rates among teenagers in Kisumu:

On our visit to Kenya in 1998 we visited Kisumu High School and saw AIDS education work through drama performed to a mixed audience of boys and girls. We were impressed with what we saw. The above graph, however, makes shocking reading. By the age of 19 a third of Kisumu girls are HIV-positive, a much higher rate than for boys. Prevalence amongst the boys begins later and remains much lower. The assumption is that girls are being infected by sexual relations with older HIV-positive men, who can apply pressure to agree to sex and who believe it less likely that someone so young is infected themselves. This case demonstrates how important it is to design HIV/AIDS work with a sensitivity to context and human rights. The drama we saw addressed sexual relations between boys and girls of the same age. It appears more necessary to give the girls training in how to deal with the approaches and pressures from older men.

26. We have discussed many of the issues surrounding women and development in a recent Report of that name.[15] In that Report we concluded that "Development programmes must be designed to support the elimination of the fundamental reasons for women's poverty: namely gender-based discrimination and violence".[16] We are convinced that an essential part of any effort to tackle HIV/AIDS must be the ending of gender-based discrimination and violence, the promotion of women's rights and development, and the protection of the rights of widows and of children, girls in particular.

27. Not only does the denial of the rights of women have an impact on the spread of HIV/AIDS. So does the denial of the rights of those from traditionally stigmatised sections of society. The stigmatisation of commercial sex workers, of men who have sex with men, of those who are infected with HIV, results in such persons being denied, or being unwilling to request, treatment and assistance. This can mean that at an early stage of the epidemic there is ignorance in high-risk groups about the disease or difficulty in ensuring effective prevention. In such circumstances the epidemic will soon reach the general population.

TO FIGHT HIV/AIDS IT IS ESSENTIAL TO FIGHT POVERTY AND PROMOTE HUMAN RIGHTS

28. We have shown that the HIV/AIDS epidemic spreads more quickly in poor countries and amongst poor people. And it is the poverty itself which is the reason for such an exacerbated effect. Thus a basic and vital point to make at the beginning of a discussion of HIV/AIDS — though one usually ignored — is that the fight against HIV/AIDS can only be won through progress in the elimination of poverty. It is poverty which spreads HIV, with all its terrible consequences, and it is only the reduction of poverty which constitutes a sustainable basis for the control of the disease.

29. The World Bank recently provided information on trends in the provision of official development assistance (ODA) to Africa. Since 1995 ODA per capita in sub-Saharan Africa has decreased at current prices from US$ 31 per capita in 1995 to US$ 18 per capita in 1999. In the same period nominal ODA at current prices decreased from about US$ 17.8 billion in 1995 US$ 11.6 billion in 1999.[17] Development assistance is not the only element necessary for the countries of sub-Saharan Africa to escape poverty — there are important matters such as governance, corruption and trade which must all be addressed. Nor is the amount of money always a necessary indication of effective anti-poverty interventions. Nevertheless, we consider the declining amounts given in official development assistance to be a worrying indication of a failure of will by the international community to eliminate poverty. This decline must be reversed immediately. Increasing amounts spent on HIV/AIDS will be limited in their effect if poverty itself is allowed to continue and deepen.

30. We add as a caveat to this discussion that the relationship between HIV/AIDS and poverty is not a straightforward or automatic one. It was observed during the inquiry that amongst the first to be infected in developing countries were very often the professional classes — a result of their greater mobility.[18] This greater vulnerability tends, however, to decline at later stages of the epidemic when the benefits of education mean that such persons appear more likely to use condoms.[19] Similarly, UNAIDS point out that on occasion development itself can be a facilitator of the spread of the epidemic, "Paradoxically, some usually positive features can also fuel a country's HIV epidemic, such as a good road network which enables people from low- and high- prevalence areas to travel and mix more freely. It is important to anticipate such unintended impacts so as to take them fully into account in national development and AIDS prevention plans".[20] We have heard, for example, of the role lorry drivers have played along certain key transport routes in spreading the epidemic in developing countries. There is a clear need in such cases for targeted interventions to promote safe sexual behaviour.

31. We must also note that not all poor countries nor all poor people are equally vulnerable or equally infected. People behave in different ways and there are a variety of reasons why some people might engage in risky behaviour. We have outlined above both the different routes of HIV infection and the fact that in different regions of the world HIV spreads in different ways. There are poor countries outside sub-Saharan Africa with much lower prevalence rates at present. We could mention the sub-continent, China, or the countries of South-East Asia. It must be remembered, however, that the epidemic is younger in these countries. Their poverty still makes them vulnerable to an escalation of the epidemic, for all the reasons outlined above. To avoid such escalation it is vital that lessons are learned and applied from those countries which have seen some success in their efforts against HIV/AIDS.

Why consider HIV/AIDS separately?

32. We have made the point that HIV/AIDS is now primarily a disease of the poor. HIV/AIDS must be 'mainstreamed' in all development work. It is not, however, enough simply to tackle HIV/AIDS within a broad anti-poverty strategy, or even within a sexual and reproductive health strategy. By itself such mainstreaming will not be sufficient to reverse the spread and impact of the epidemic. A distinct HIV/AIDS strategy is also necessary. To understand why we must consider the peculiarities of the disease and epidemic. Some are biological. One fact of great significance is that a person infected with HIV may well be asymptomatic for ten years or so. During that time, however, he or she is capable of infecting others with the virus. Thus, by the time that large numbers are visibly ill, many others may well be infected. The fact that HIV is asymptomatic for so long means that it is easy to be unaware of one's condition. UNAIDS estimates that only 5 per cent of HIV-positive people in the world know of their condition.[21]

33. The 'invisibility' of HIV/AIDS is then exacerbated by the stigma and denial attached to it. HIV/AIDS is not only a biological phenomenon but a behavioural and cultural one. Even where testing facilities are available to learn whether or not one is HIV-positive, relatively few wish to know. HIV/AIDS carries a stigma quite unlike any other disease — because it is about sex, because there has been an association with traditionally stigmatised behaviour such as homosexuality or drug use, because there is no known cure. This affects the willingness to know of one's condition, the ability to discuss openly sexual behaviour and how best to avoid infection, the treatment of those known to be HIV-positive. This in turn has an effect on the continuing spread of the disease.

34. Denial is further assisted by the fact that "HIV does not cause a single, specific fatal disease; instead, individuals whose immune system has been weakened by the virus fall prey to infections and ailments that may look familiar in their community. In other words, people who do not want to accept the reality or gravity of AIDS can find all sorts of ways of questioning whether it is as bad as the data from surveillance suggests".[22]

35. 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. DFID officials agreed that such behavioural and rights issues demanded a distinct approach. Dr Julian Lob-Levyt said, "In the absence of a vaccine, in the absence of affordable and effective drugs, it is about social change which is going to enable people to protect themselves better".[23] Paul Ackroyd from DFID added, "[HIV/AIDS] does raise very sensitive social issues which make it very much more difficult to talk about than it is to talk about malaria or TB or those diseases which do not have that emphasis".[24]

36. In addition to the nature and sensitivity of the epidemic, it is its scale which requires particular attention and strategic thinking. Dr Julian Lob-Levyt explained that "What is qualitatively different is the size of the problem which requires that we have a particular attention and focus to it within [the poverty and development agenda] and that it does actually need substantial resources to make a difference. We are going to be looking for more resources and greater political commitment within that poverty and development agenda to address the HIV needs".[25]

37. Even with a separate HIV/AIDS strategy it may well be the case that many of the interventions and much of the funding is through mainstreamed programmes. The HIV/AIDS strategy should ensure, however, that HIV/AIDS, with its distinctive challenges, is explicitly, specifically and coherently addressed. We consider that a distinct HIV/AIDS strategy is essential for all donors of official development assistance and for all countries affected by the epidemic.

Two crises, not one

38. Our Report does not only argue that HIV/AIDS requires particular and urgent consideration. We also believe 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. As we will show in the next section of this Report, the levels of HIV infection are so high in many 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 fully grasped the scale and seriousness of this African HIV/AIDS crisis, nor that they are agreed on how to address it.

10 Q.111 Back

11 Human Development Report 2000 p.197 Back

12 UNAIDS June 2000 Report p.44 Back

13 UNAIDS June 2000 Report p.37 Back

14 UNAIDS June 2000 Report p.47 Back

15 Seventh Report from the International Development Committee, Session 1998-99, Women and Development, HC 160 Back

16 Seventh Report from the International Development Committee, Session 1998-99, Women and Development, HC 160, Executive Summary Back

17 African Development Indicators 2001 The World Bank pp.282-303 Back

18 Q.18 Back

19 UNAIDS AIDS epidemic update: December 2000 p.14 Back