AIDS, PUBLIC HEALTH, AND INNOVATIVE POLICY INTERVENTION IN AFRICAN DEVELOPMENT

By John Kiwanuka Ssemakula (MD, MPH), 12 December 2002

(First presented at the Journal of International Affairs, Columbia University open discussion entitled "Face of the State: Population, Politics, and Stability" - "HIV Pandemic in Africa: What are the repercussions of the shift in demographics as evidenced throughout an increase in HIV related cases and the resulting economic, social and political disintegration of African countries?" in October 2002 and then at the Institute of African Studies, School of International & Public Affairs, Columbia University, New York, December 2002)

"At 21 years old, entering its third decade the HIV AIDS epidemic is no longer just a ‘health’ problem"

Conflict and security, slowed economic growth and development, famine and food security, social breakdown and orphans. None of these would be considered “health” problems, yet the HIV/AIDS epidemic has been implicated in each of these different problems.  Wherever AIDS is found it, whatever problem it interacts with, the HIV/AIDS epidemic magnifies, compounds and greatly worsens the problems.

The HIV/AIDS epidemic is now 21 years old; but the epidemic is far from over. It is still growing, and the pace of its growth has continued to confound and alarm epidemiologists, researchers and public health officials.  At the end of 2002, Africa continues to be by far the worst affected region.

• Almost 30 million African men, women and children (70%) out of a global total of 42 million were infected with HIV
• There were almost 3.5 million new HIV infections in Africa.
• There were an estimated 2.4 million deaths in Africa, almost three quarters of all deaths from AIDS worldwide (74.4%).
• The demographic group most affected is 15-45 year olds – the productive sector of populations.
• 90% of HIV/AIDS cases are transmitted heterosexually.
• By the end of this decade more than 50 million Africans will have died from AIDS.

HIV/AIDS is visible everywhere across Africa and is now considered the greatest threat to African development es pecially in Sub Saharan Africa.

The spread of HIV/AIDS in Africa has been relentless and shows no evidence of abating. With almost 30 million people infected with HIV/AID at the end of 2002, the effects on African nations are going to be felt for years to come, even if the epidemic were to be stopped in its tracks now. Life expectancy in the most severely affected countries is being markedly reduced, and the gains of child survival programmes are being wiped out, as economies continue to suffer. Less than 1% of HIV/AIDS sufferers in Africa (30,000 people) are currently receiving treatment with life saving anti-retroviral drugs

In Southern Africa 14 million people are currently under threat of starvation. HIV/AIDS has played a part in the evolution of this unfolding humanitarian disaster and is greatly exacerbating its effects. Millions of women are infected with virus. Millions of orphans are being created as the parents die of AIDS and families break up. In Africa 13 million (10 million 15-24 year olds &  3 million children under 15 years old) 44% of the total are infected. Young people continue to drive the epidemic.

The figures are mind boggling. But new studies and research suggest that there is a possibility that the AIDS pandemic will worsen rapidly in Sub Saharan Africa in the next five years and the numbers of AIDS cases could double according to analysis by US intelligence. The National Intelligence Council in USA has concluded that Nigeria and Ethiopia are set to be part of the next wave of countries wit h figures projected to be huge:

Nigeria: 10–15 million by 2010, Ethiopia: 7-10 million cases by 2010

Between them these two countries have a combined population of nearly 200 million people, almost  1/3^rd of the population of  Sub-Saharan Africa.

The socioeconomic effects of the HIV/AIDS epidemic:

Population and Demographic changes:

• Increased adult mortality by factors of 5 or 6 in worst affected countries
• Reduced fertility.
• Smaller total populations as a result of the huge increases in adult and under-five mortality
• Reductions in population growth rates and demographic changes caused by AIDS are leading to changes in the structure of populations. Overall populations will get younger. There will be deficits in the 15-49 yr age group
• This will have profound implications for the future of the labour force in Africa.

Economic effects:

• Loss of human capital is further decreasing economic stability in the already weak markets of Africa. 
• Though losses are across all sectors, they are highest amongst the skilled, professional and managerial sectors.
• The rate of economic growth in sub-Saharan Africa has fallen by as much as 4% because of AIDS. 
• Labour productivity has been cut by up to 50% in the hardest- hit countries.
• By 2020, over 25% of the workforce may be lost to AIDS in some severely affected countries.
• AIDS will also have the effect of discouraging foreign investment putting already weakened economies under even more pressure.

Food supply and food security:

• AIDS is a serious threat to food supply and security in Africa
• The FAO estimated that more than 7 million agricultural workers died between 1985 and 2000, and 16 million more could die in the next 20 years.
• South Africa, Mozambique, Zimbabwe, Namibia suffered a decline of between 1/5^th to ¼ of their agricultural labour force between 1985 – 2000.
• 14 million people are under threat of starvation in Southern Africa.

 Children affected by AIDS(orphans) and the disintegration of families

• By the end of 2000, over 12.1 million African children had lost either their mother or both parents to AIDS. This figure is set to double over the next two decades, by which time there will be an estimated 42 million orphaned children from akk causes.
• In Uganda, a recent DHS survey estimated that  every fourth family (25%) is hosting an orphan. There are between 1.4 million – 1.7 million orphans.
• In the 1980’s less than 2% of African children were orphaned , but that proportion has now reached 15-17% in some countries.

Gender:  the disproportionate effect on women (crisis within the crisis)

• In sub-Saharan Africa, women and girls make up the majority of those living with HIV/AIDS.  There are now 15 million women infected, 58% of the total number of people with HIV in Africa.
• The differences are even greater for the 15-24 age group, with 4 times as many women infected when compared to men.

Conflict And National Security:

• National security, a prerequisite to effective development, is being undermined by AIDS in many hard-hit African nations. 
• Some hardest hit countries report HIV prevalence averages of 20-40% among soldiers
• The spread of HIV/AIDS from urban to rural areas in Rwanda was fueled by the genocide war. According to a UNAIDS report, in 1997, the prevalence rate in Rwanda was 10% or more in urban areas compared to 1% in rural areas before 1994. By 1997 the urban& rural prevalence rates were the same, 11%.

Governance And Political Leadership:

• The capacity of governments to serve their citizens is among the casualties of the epidemic, as budgets shrink and civil servants are killed by AIDS.
• In Botswana, for example, the government will lose 20% of public revenue by 2010 because of AIDS
• Provision of essential services such as health, welfare, and justice will decline in the hardest hit countries.
• Rising social tensions over AIDS and related economic problems could exarcebate regional and ethnic tensions, especially in countries such as Nigeria, Ethiopia, leaving the governments less able to manage the problem.

POLICY INTERVENTIONS – Rethinking the problem: What needs to be done?

A framework for interventions in the HIV/AIDS epidemic- click on the figure below

Africa needs to develop regional initiatives on HIV/AIDS

It is impossible to seriously talk about a renewed economic growth in Africa without paying attention to the number one threat for development on the continent, HIV/AIDS. Therefore the African Union (AU), New Partnership for Africa’s Development (NEPAD), South African Development Community (SADC), The East African Community (EAC) and other bodies in Africa need to be involved in creating regional initiatives, for dialogue, communication and exchange of ideas to accelerate the fight against HIV/AIDS.

Africa needs to develop and implement common approaches to develop regional based initiatives to fight AIDS.  HIV/AIDS must become an integral part of whatever new policies they formulate. Regional initiatives have the potential of providing the basis of broad based intervention programmes to tackle HIV/AIDS. One idea maybe to create an African body to fight AIDS on the continent. Such an African led and managed institution could responsible for  providing support to governments in setting priorities both for locally and externally funded activities; helping to resolve  issues about access to care and treatment; helping to overcome infrastructure impediments; and, implementing information, education and communication strategies. Most importantly African governments need to be talking to each other to find out what works and what doesn’t.

HIV/AIDS must be part of policy development

Governments will need to strengthen the scientific and empirical bases for their policies. Governments, especially health ministries, should play a stronger role in formulating risk prevention policies, including more support for scientific research, improved surveillance systems and better access to global information. They will have to improve public dialogue and communications, and develop greater levels of trust for risk prevention among all interested parties. Without strong national policies, regional initiatives will not succeed.

Food security and food shortages

African leaders should focus on measures to mitigate the effects of natural disaster such as drought as well as focusing on accelerated food development. Within the wider debate of globalisation, the effect of western agricultural subsidies in preventing African agricultural exports in competing fairly on world markets needs to be addressed. International organizations should also design and structure their famine disaster policies and plans to include the effects of HIV/AIDS. There should be greater coordination between and within these organizations in mounting a response to famine within the context of the HIV/AIDS epidemic.

Poverty Alleviation programmes

Poverty is a major underlying factor in many of the current problems facing Africa, including the AIDS epidemic. Dealing with poverty is therefore a critical part for a long term solution to the AIDS problem. As part of poverty alleviation, reduction or elimination of Africa's unsustainable debt will be a step in the right direction. In the short to medium term it will enable governments to meet the basic needs of their citizens. Debt reduction could be done in exchange for a commitment from African governments (perhaps with matching funds) to devote increased expenditures in health care and social services

Better Leadership and communication both within and without Africa

African governments and leaders to the fight against HIV/AIDS. Africa needs to be actively seen to be mobilising its resources-home and abroad-in the fight against HIV/AIDS if it is to keep the confidence of its developmental partners and ensure continued developmental funds. High level support from African leaders requiring openness, communication and strong leadership is needed to foster a widespread multi-sectoral response.  The West will not step up its developmental assistance to Africa if there are persistent doubts about the commitment of the leaders.

A multisectoral approach; Mobilising different sectors 

There is a need to widen the debate on the AIDS epidemic to include all sectors of governments and populations and civil society because the AIDS epidemic now affects almost very sector. All sectors of the government such as Finance, Education, Defense, Labour, Agriculture as well as civil society  need to be included in this dialogue. There also needs to be balance between government, community and individual action is necessary. For example, community action and grass roots movements should be supported by nongovernmental organizations, local groups, the media and others.

Removing stigma – Mobilizing people living with AIDS (PLAs)

People living with AIDS (PLAs) are a vast and underutilized resource. Stigmatisation and discrimination have prevented many PLAs from coming forward and being included in the fight against the epidemic. Removing stigma is a priority because it helps PLAs reveal themselves without fear, to come forward and help themselves and keep others educated. Mobilizing this resource multiplies and increases the army of people dedicated to eradicating the scourge of AIDS. World AIDS day 2002 was devoted to removing stigma, highlighting the need to tackle this important issue.

Access to care: Anti-retroviral drugs and treatment of opportunistic infections

In this regard access to care is also very important. Antiretroviral drugs and treatment of opportunistic infections will keep PLA’s alive longer, and able to continue in the fight against HIV/AIDS. It will encourage more people to undergo testing, and more people will receive “potentially life saving education.”  In the long run they will use fewer resources. By remaining healthier, PLAs will require fewer instances of hospitalization thereby reducing the demand on already overburdened health care systems, they will continue to be able to work and make a contribution to the economy. By staying healthy PLAs will require less care from friends and relatives reducing the social, emotional and financial burden. By living longer the family unit remains together for longer, they will be able to continue to provide and care for their families, thereby slowing down the increase in numbers of AIDS orphans, thereby reducing the social burden on the state. Studies have also shown that anti-retrovirals themselves are an effective tool in preventing the spread of the virus.

Capacity development and skills replacement: the need for accelerated education & training programmes

Africa is losing it professionals at frightening rate. “Recent studies of education and health point to exceptional and large losses of human resources and more are predicted” according to a report compiled for the International Labour Organisation (ILO). If Africa is to have any chance for the future it will have to replace these people in a very short time. This will require the creation of accelerated training programmes of all types. Universities, Institutions of Higher education, educational establishments in richer countries have a vital role to play in this effort. Mobilising the African diaspora will be a crucial component of this effort.

The future, long term

HIV/AIDS has had effects much like war, and has quite often been associated with conflict. And as in conflict the aftermath of effects are long lasting especially on populations and population growth. As an example, Uganda lost more than a million people to war, and over a million to HIV/AIDS. But Uganda has just had a census, which showed that its population had registered an increase of 7.9 million in the last decade (1990 –2000). More than offsetting the losses due to war and disease. That is almost a 50% increase, an astonishing growth rate of 3.3% (the doubling rate is 21 years). Preliminary assessment suggest that population growth has been mainly amongst teenagers in urban areas. This means a return to the days of a population with a very high dependency ratio, with all the implications that implies for development.

Changes in population distribution in urban and rural areas, are going to have an effect on existing health services and, the provision of safe water supply and sanitation (themselves important factors in health), on agriculture and food security and nutrition. Providing education will be important as populations become increasingly younger.

It is evident there is a lot of overlap in the kind of interventions required at the various different stages of the epidemic. It is also clear that different sectors of society and government need to be involved in all the different stages, though the level of involvement or engagement of may vary at different times. This is because of the nature of the epidemic, it involves all sections of the population, all sectors of the economy and this increases with time, and it also illustrates how extensive the epidemic has become.

Despite the gloomy picture being painted about HIV/AIDS, encouraging evidence from Uganda and other countries shows that the HIV prevalence can be reduced substantially with vigorous and aggressive prevention programmes.  There are positive trends from South Africa where the prevalence rate of young women under 20 years (attending ANC) fell for the third year running, from 21% in 1998 to 15.4% in 2001. HIV prevalence rates have also been falling among inner city women in Addis Ababa in Ethiopia. It can be done, but it requires committed leadership, political will and sustained efforts to prevent the worst of the disaster. The figures sometimes have such a hypnotic, numbing effect we often tend to forget this fact. All the measures, policies and programmes put in place are there not only to save as many of our brothers and sisters who already have HIV but also to protect those who are free and uninfected from befalling the same fate.

Most importantly one thing we should not forget:  NINETY PERCENT (90%) OF AFRICANS ARE NOT INFECTED WITH HIV.

References:
Akukwe C. (2002) “HIV/AIDS and Africa  - Back to the drawing board” Constituency for Africa, November, accessed allafrica.com
Clinton W. J., (2002), “AIDS is not a death sentence”, New York Times, NY, December
Cohen. D. (2002). “HIV epidemic and other crisis response in Sub-Saharan Africa”, Working Paper 6, Recovery and Reconstruction Department, Geneva. April
Kiwanuka Ssemakula J. (2002) “Anti retroviral therapy in HIV/AIDS - update 2002”, http://medilinkz.org, December
Kiwanuka Ssemakula J. (2002) A Deadly Embrace: Famine and AIDS in Southern Africa, ”, http://medilinkz.org, August
MSF.(2002) “Access to drugs: Untangling the Web of Price Reductions: a Pricing Guide for the Purchase of ARVs for Developing Countries” June 2002; 2nd edition
UNAIDS. (2002) “AIDS Epidemic Update, December 2002”, December. United Nations, New York

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