Human immuno-deficiency virus (HIV) was first identified as the cause of acquired immuno-deficiency syndrome (AIDS) in 1981. The HIV virus compromises the body’s natural capacity to fight infection. AIDS is the final stage, when the body’s defences are so depleted as to expose the body to opportunistic infection such as tuberculosis, pneumonia and other diseases which kill the sufferer. But the transition from HIV to AIDS involves a number of stages that are not discrete but gradual. The virus is contracted through sexual intercourse, blood and blood product transfusions, use of contaminated needles, from mother to child through pregnancy, birth, and breast-feeding.
The pandemic of HIV/AIDS is a disease that has ramifications for the globe. It is estimated that the global HIV/AIDS figure at the end of 2003 was 40 million, 2.5 million of whom were children under 15. It is impossible to accurately determine the number of people who are at the end stage of the disease with AIDS because a blood test is required to determine white blood cell count, although there are certain diseases that are indicative of AIDS in different parts of the world, such as pneumonia in the developed world and tuberculosis in the developing world. Indeed, the disease takes the lives of 8,000 people every day.
But levels of infection are grossly uneven across the world, with developing countries suffering much higher rates. Moreover, developing countries are unable to afford the costly, life-saving anti-retroviral drugs to treat the virus and prevent the onset of full blown AIDS. Thus, they also incur much higher mortality rates than developed countries. Indeed, HIV/AIDS is ravaging many developing countries, particularly in sub-Saharan Africa (all countries in Africa except the five that border the Mediterranean Sea), where life-expectancy has been severely cut, and economic productivity slashed through the suffering wrought by the disease. At the start of this millennium over 23 million Africans, mostly from sub-Sahara, were estimated to have HIV/AIDS. This figure accounts for almost 70% of the world's total cases. However, Africa is home to only 10% of the world's population.
In the next four articles, we seek to look at the underlying questions that spring from this bleak picture, and in exploring them, draw on the experience of one developing country, Uganda, that has led the way in both fighting the disease and mitigating its impact. Uganda has one of the oldest HIV/AIDS epidemics in Africa, but has started to see declines in rates of new infections across most sectors of its population.
We'll look at the issues under the following themes, which you can either read about individually, or in one longer piece on this page.
- Why are rates of infection so high in the developing world?
- What is the impact of HIV AIDS on people, their communities and their nation?
- Faced with the scale of the challenges, how can development agencies help?
- What are the global responsibilities created by this crisis?
Poverty and underdevelopment are the key to understanding why developing countries have higher rates of infection and mortality from HIV/AIDS than developed countries.
Let’s look at poverty first. One way of viewing poverty is as a lack of income and consumption. This most obviously manifests itself as an inadequate diet and poor health, but it also means having insufficient income to buy condoms to protect oneself from infection. But poverty is much more than a lack of income. It takes the form of a multitude of other deprivations which prevent the poor exercising control over their bodies and lives. A lack of education means that HIV mothers are often unaware of the risk of passing on the infection to their babies through breast-milk, and even when they have this knowledge, the inability to read means they are unable to follow written instructions on how to reconstitute formula milk. This, of course, is compounded by having inadequate access to clean water.
The poor may also not be able to protect themselves because they lack the power to avoid exposing themselves. This is particularly manifest for women in choosing sexual partners. Poverty forces people to take risks and gender inequality means that women face these life challenges more frequently than men. There is evidence that domestic violence is increasing in Uganda because women are fearful of catching HIV from their partners and are refusing sex, or insisting on the use of condoms.
Underdevelopment is another reason for the higher rates of HIV/AIDS in developing countries. Developing country governments are struggling to provide some of the public goods we in the developed world take for granted such as free and accessible health care, universal primary education, electrification, clean water and sanitation. Prioritising HIV/AIDS over these pressing issues, or even within the slim health care budget, is a politically loaded decision that few developing country governments have been willing or able to take.
When the above is set against the background of the debt crisis of the 1980s, and the forced pace of economic liberalisation that has taken place in developing countries since, the full extent of the unfolding tragedy and global insensitivity comes into sharp relief.
The debt crisis of the 1980s came about because for much of the 1970s interest rates on borrowing money were low. This was because the oil exporting states like Saudi Arabia had plenty of surplus money following the oil price hike in 1973/4. They invested this money in international banks that then encouraged developing countries to borrow it at low interest rates to fuel their development spending. However, in the early 1980s, interest rates began to climb, and repayments began to spiral upwards for the borrowers in the developing world. A crisis was reached when a couple of big borrowers, Mexico and Brazil, threatened to cease repaying, or default, on their loans unless repayments were rescheduled on more concessionary terms. Rescheduling did take place, but to this day, debt repayments continue to drain the financial resources of many developing countries. For the last two decades many have been paying large chunks of their annual budgets in debt repayments to foreign banks and the International Monetary Fund and World Bank. This has starved their already weak health systems of vital resources. Thus, they were ill prepared for the added shock of HIV/AIDS. Some developing country health systems are on the verge of collapse. The economic stress has sometimes led to multiple use of needles and the failure to screen blood for the virus. Both have increased infection rates.
The prescription of the international financial community, spearheaded by the International Monetary Fund and World Bank, has been to force the pace of economic liberalisation in these countries. This has meant charging for services that were previously free, such as education and health care, putting them further out of the reach of the poor and compounding the problem of tackling HIV/AIDS. Indeed, it is no coincidence that 34 of the 42 World Bank designated Heavily Indebted Poor Countries are in Africa, all of whom, with the exception of Somalia, feature in the top 50 countries worst affected by the disease. Thus, as poverty and underdevelopment facilitate the spread of the virus, so HIV/AIDS exacerbates poverty and underdevelopment.
HIV/AIDS has profound socio-economic impacts. Let’s look at Uganda. It is estimated that there are currently over a million people infected with the virus in Uganda, with nearly one million deaths to date. Indeed, HIV/AIDS is the leading cause of death among the population aged 15-45, and 80% of infections in Uganda are amongst this group. This is the most economically active section in any country’s population. It has had dire consequences for business and wealth creating opportunities in the country through reduced work rates, reduced income and livelihood uncertainty.
But the disease has not only impacted on the economic face of the country, it has also transformed the social and human fabric of Uganda. Life expectancy has fallen from 48 years in 1990, to 38 years in 1997, and an enormous burden has been placed on the very young and old. There are over a million orphans and an enormous rise in the number of grandparent and child headed households.
At the human level, sufferers have to contend with the devastating news of infection and the inevitable foreshortening of their lives. Many have the additional worry as to the HIV status of their partner and children. Families have to care for the sick person, and when death occurs, widows, widowers and orphans are left to pick-up the pieces of their shattered lives.
The impact upon children is particularly devastating. Many children are forced to quit school to care for younger siblings and work to supplement the family income. Traditionally, the extended family would have assumed the care of orphaned children, together with the assistance of the community. But the high mortality rate through AIDS has outstripped this traditional coping mechanism resulting in large numbers of children being institutionalised in orphanages. Teenage girls have no choice but to marry early for economic security. So what can be done to address this problem in developing countries?
Development agencies are international and local non-governmental organisations like OXFAM and Save the Children’s Fund, as well as foreign state development bodies like Britain’s Department for International Development, and international organisations like the World Bank. Many are involved in efforts to promote positive change in HIV/AIDS affected countries. They can do this in three ways: firstly, through funding, secondly, by building capacity within the affected country to fight poverty and tackle the disease, and thirdly, through advocacy to seek to raise global awareness of the suffering of developing countries through HIV/AIDS and to provide anti-retroviral drugs to sufferers.
Firstly, development agency funding is vital to many of the developing countries worst affected by HIV/AIDS. Aid donors can fund efforts to help raise public awareness of the threat of the disease through poster, film, drama, dance, music and workshops. This needs to be done in a culturally sensitive way and to engage the public. They have sought to put information about the nature of the disease and its prevention into the public domain, and to fight the stigma and discrimination experienced by sufferers.
Secondly, donors can help build the capacity of the affected country by putting in place measures that attack the underlying menace of poverty which provides a fertile ground for HIV/AIDS. While this is a broad based approach, it includes measures that directly impact on the disease, namely the training of medical and support staff to go out to the community to help mitigate the affects of HIV/AIDS.
Thirdly, development agencies are pivotal in showcasing the devastation wrought by the disease to the rest of the world. Through such advocacy work, they seek to raise global awareness and to motivate citizens of developed countries to put pressure on their governments and the big pharmaceutical companies to act to alleviate the human tragedy that is unfolding in Africa.
The work of Sport Relief has been important in the first and third respect. The initiative has funded an international non-governmental organisation, Healthlink Worldwide, to support HIV/AIDS affected children in 20 villages in Nigeria They are seeking to replicate the successful Ugandan model of ‘memory books’ as a store of emotional support for the children. Moreover, the publicity around the initiative has raised awareness among the British public of the HIV/AIDS situation in Africa.
But such efforts are at best piecemeal, and at worst hopeless if the political will to confront the disease is not present in the affected country. The Ugandan Government has demonstrated such political will and has formulated an integrated response to HIV/AIDS involving both the public and private sectors. Such an approach was both transparent and bold. It involved a massive public awareness campaign and high level government commitment to combating the disease. This strong political will was underpinned by donor readiness to help financially, and international and local NGOs commitment to deliver a wide range of innovative interventions.
One such innovation was the creation of Post Test Clubs (PTCs). Growing out of the Ugandan Government’s establishment of voluntary counselling and testing services, PTCs have sprung up to meet the lack of formal provision of after care services because of the non-availability of life-saving anti-retroviral drug treatments. Created at the community level, PTCs seek to build on and extend the capacity of the extended family and community to mitigate the effect of HIV/AIDS, which has been under extreme stress. PTCs are thus integrated at the local level and sustainable. They are small, organised groups of families, typically around 100 members, who following HIV testing come together to offer each other support. Their shared HIV status provides a powerful bond between them in a society that is only slowly learning to de-stigmatise HIV sufferers.
PTCs encourage members to share the trauma, sadness and burden of HIV/AIDS. They provide emotional support to cope with the news of infection and what it means for the individual and their family, as well as practical support in the form of childcare, succession planning, and micro-credit opportunities to pay for food supplements and medical care.
Succession planning is particularly important in supporting the AIDS sufferer, preparing the survivors and protecting their inheritance. Thus, infected parents are encouraged to produce ‘memory books’ in which they put down their cherished memories of their time with their children and communicate their hopes for them. They are helped in planning for their children’s education, and preparing a will so that there is legal transparency regarding property inheritance. The children are helped to take over the responsibilities of the dying relative and given guidance in life skills and vocational training to strengthen their earning capacity. Guardians are provided with micro-finance opportunities to help them assume the responsibility of the orphans’ welfare, as familial responsibilities are so frayed that there have been cases of relatives seizing property and abandoning orphaned children.
PTCs provide a positive bond among members. Their success has encouraged others to come forward for testing and has enabled many to escape the fear and isolation that can accompany a positive result. But such efforts in mitigating the impact of the disease are only a holding measure. What is really needed is for HIV sufferers to be given anti-retroviral drugs.
HIV/AIDS has been referred to as a holocaust of the poor. But it is a holocaust that can be prevented if the millions of sufferers in the developing world are given access to life-saving, anti-retroviral drugs. The World Health Organisation (WHO) has called this a global health emergency. It is spear-heading it’s ‘3 for 5’ campaign, where the goal is to give at least 3 million HIV sufferers in the developing world access to anti-retroviral treatment by the year 2005.
There is encouraging evidence to suggest that once a treatment programme is instituted, the positive spin-offs multiply. Firstly, people who would have died of AIDS now have the chance of living a normal life. Secondly, it encourages people to be tested who before believed there was little benefit in knowing their HIV status and indeed, many down sides. This has helped to prevent further infection. Thirdly, it has reduced the stigma attaching to HIV/AIDS and encouraged greater openness and discussion of the disease.
The slowness in giving the poor anti-retroviral drugs pivots around the price the big pharmaceutical companies want to charge for the drugs, and the price developing countries can pay. The big pharmaceutical companies argue that the high price is necessary to recoup the huge financial outlay in developing the drugs. But developing country governments are unable to pay this price. The WHO Director-General, Dr LEE Jong-wook has said, "Business as usual will not work. Business as usual means watching thousands of people die every single day.”
In South Africa, where a fifth of the economically active population are infected, the government took matters into its own hands. It threatened to allow cheap, generic versions of the patented drugs to be sold in its country. The big pharmaceutical companies took the government to court and for 3 years legal argument ensued. Finally, in 2001 the pharmaceutical companies backed down, and agreed to market their drugs at a more affordable price in South Africa. But while this can be seen as a victory for the human rights of poor people over the profits of commercial companies, the political will and capacity to distribute and monitor drug therapy has yet to be demonstrated in South Africa. The government has been equivocal in its response to HIV/AIDS, with the country’s president, Thabo Mbeki, publicly questioning the link between HIV and AIDS. This has sown confusion in a country with one of the world’s highest infection rates and in which the health system is in disarray.
On balance, while progress has been made in winning the right of the poor to drug therapy, and the amount spent on fighting HIV/AIDS has risen from $2.8 billion in 2002 to an estimated $4.7 billion in 2004, it is not a one tablet solution. It involves a life time programme of care. To this end, the WHO, in partnership with other development agencies, are putting in place programmes to effectively administer and monitor drug treatments in developing countries. This involves a long term commitment of resources, building the health systems of developing countries and a dedicated team of health professionals. But it also requires the political will of the government of the affected country to fully commit to fighting the disease. Vigorous action by the publics of affected countries is necessary to ensure this. Such political will needs to be found and the WHO’s ‘3 for 5’ target achieved, for the consequences of failing are too bleak to contemplate.