The HIV/AIDS Pandemic in Southern Africa: Implications for Development

Alan Whiteside is director of the Health Economics and HIV/AIDS Research Division at the University of KwaZulu-Natal. He is a visiting professor at the University of Liverpool and Leverhulme Professor at Southampton University.

The AIDS epidemic, currently the greatest threat to human development, emerged in the past century and will be an issue for many decades to come. Most seriously affected are sub-Saharan Africa and especially the southern half of the continent. This disease is desperately worrying as Africa’s economic, political and social development has, at best, been faltering.

 

Soon, African countries will begin the cycle of celebrating fifty years since independence from colonial rule (Sudan, in 1955, was the first to achieve independence, followed by Morocco and Tunisia in 1956 and Ghana in 1957). In the 1950s, practitioners of the fledgling new discipline of “development economics” argued that Africa’s potential was unlimited; by contrast, looking at South-East Asia, they shook their heads in despair. But by the end of the 1970s it was evident that in many African countries things had gone seriously wrong.

 

The closing of the twentieth and dawning of the twenty-first centuries saw a new optimism. The end of apartheid had brought peace to southern Africa by the mid-1990s. There was a growing trend towards democratisation, and a number of countries had had their second free and fair elections. The establishment of NEPAD—the New Partnership for Africa’s Development—and the African Union seemed set to give a new lease of life to co-operation and integration across the continent. In 2000, the World Bank went so far as to publish a report, Can Africa Claim the 21st Century? The answer was a qualified yes.

 

But in the wings HIV was spreading and AIDS was waiting to take its place as one of the central actors in the development (or underdevelopment) of Africa. There were voices warning of what could happen—but they were largely ignored. Today, there is evidence of an emerging appreciation among some of the African leadership of just what AIDS might mean. For example, President Festus Mogae of Botswana has warned of the threat that AIDS poses to his country’s very existence. In May 2004, shortly after South Africa’s third democratic election, Mangosuthu Gatsha Buthelezi, leader of the largely KwaZulu-Natal–based Inkhata Freedom Party, openly announced that his son had just died of AIDS. United Nations Secretary-General Kofi Annan has established a special Commission on HIV/AIDS and Governance in Africa. Thus, there are grounds for cautious optimism.

 

This article will assess the scale of the problem and the validity of the data concerning it. I go on to look at the current state of the epidemic and explore why it is so serious. The likely implications of the epidemic for Africa’s development will be examined. I will assess responses to date, touch on the role of leaders such as President Thabo Mbeki of South Africa, note where there have been successes and consider why these have occurred. Finally, I will point to some priority areas for action.

Assessing the Crisis

The figures for the global epidemic are readily available, and indeed there is international consensus on the scale of the problem. At the end of 2003 there were estimated to be between 34 million and 46 million people worldwide living with HIV/AIDS. Sub-Saharan Africa has between 25 million and 28 million people infected. There were about 3 million deaths from AIDS in 2003, of which between 2.2 million and 2.4 million were in Africa.¹ Already, says the World Health Organisation (WHO), AIDS has killed more than 20 million Africans. It is the leading cause of death and lost years of productive life for Africans aged fifteen to fifty-nine.

 

The global data on the epidemic are compiled by the Joint United Nations Programme on HIV/AIDS (UNAIDS), but are co-released by UNAIDS and the WHO. The 2003 report noted that the estimates published that year were lower than those in 2002 because better data and understanding had enabled the UNAIDS secretariat and the WHO to arrive at more accurate statistics. The apparent concessions of error from the traditional providers of such data unfortunately coincide with the re-emergence of “dissident” views on AIDS statistics, and are fuelling scepticism about the impact of HIV/AIDS in many quarters, including a number of African capitals.

Scaremongering?

This has been picked up in the popular press. The most florid expression of scepticism has been by South African journalist, Rian Malan, arguing that “Africa Isn’t Dying of AIDS”.² Others have made the same claim. These researchers, journalists and social commentators have identified data inconsistencies that appear to suggest anything from flawed projections to wilful misinterpretation. The fact that any rational analysis accommodates the variability of modelling seems to have been lost in the emerging debate. Instead, we are left with the uncomfortable implication that the “AIDS industry” has been caught out. How does this match the evidence? And does it matter?

 

There are two sorts of data that have been called into question: those produced by the international agencies giving global figures, and those for individual countries. We need to understand how these data are collected and constructed. Global data (saying, for example, that in 2003 some 40 million people were living with AIDS and that it had killed a total of 20 million people) are compiled by UNAIDS using whatever national data are available. No international agency goes out and conducts its own surveys. Furthermore, reports give the dates of the data and estimate the range of uncertainty.

 

A review of the UNAIDS/WHO December 2003 AIDS Epidemic Update shows that there are no estimates of HIV prevalence in Liberia as a whole, and that the last HIV prevalence survey in urban areas there was in 1993. By contrast, for Zimbabwe the survey used in the update was from 2000, carried out in both rural and urban areas. Here, it is estimated that between 1,800,000 and 2,700,000 adults are infected: the median figure is 2,300,000.

 

It is worth reiterating that international agencies are dependent on country-generated data, and these are very variable in quality. Until recently, the data collected and supplied by countries were mainly gathered by surveillance systems that focused on pregnant women attending antenatal clinics. There were, of course, problems with representativeness, coverage and the fact that men do not attend such clinics. These considerations were factored into the data calculation, and they constitute one reason why a range of estimates was produced.

 

Recently, national population-based surveys have been carried out in Mali, Zambia, Kenya and South Africa. In the first three countries, these were demographic and health surveys (DHS), which are nationally representative household surveys with large sample sizes of about five thousand households. In South Africa, the survey was conducted by the country’s Human Sciences Research Council (HSRC). Population-based surveys are those in which samples are taken randomly from the population. Provided this is done properly, it should give an idea of prevalence across the population. In Kenya and South Africa, the results were lower than those obtained from antenatal surveys. Consequently, they were seized on by the press to suggest that national HIV prevalence has been overestimated.

 

The UNAIDS figure for Kenya was that 9.4 per cent of all Kenyans were living with HIV/AIDS, whereas the DHS estimated that 6.7 per cent of Kenyans were infected. In South Africa, the HSRC’s estimated prevalence was 15.6 per cent for those aged between fifteen and forty-nine. The UNAIDS estimate is 20.1 per cent for the same age group.

 

Do we then, as some would suggest, dismiss antenatal surveys and the data produced by UNAIDS as being too pessimistic? A hard look at the population surveys shows that they, too, are not without problems. In both Kenya and South Africa there were high refusal rates—people who were not contactable, or who would not be interviewed or provide specimens. In South Africa, of the 13,518 individuals selected and contacted for the survey, 73.7 per cent agreed to be interviewed, and 65.4 per cent agreed to give a specimen for an HIV test. In Kenya, 70 per cent of those eligible agreed to give blood samples. Epidemiologists become concerned when participation rates fall below 80 per cent.

 

Statistically, the South African antenatal clinic and HSRC “confidence intervals” overlap, that is to say, the lowest levels recorded by the former survey overlap with the highest levels of the latter, which means that either result could be right. In Kenya, the full DHS results have not been released so detailed comment is impossible, but UNAIDS notes that when the results are broken down by gender, the HIV prevalence of 8.7 per cent among women is in the same range as the 9.4 per cent prevalence estimated by UNAIDS and the WHO. What this points to is that data need to be used cautiously and open-mindedly.

 

An additional problem is the lax way in which numbers are thrown around by both the press and many AIDS activists. For example, Swaziland currently has the world’s highest HIV prevalence rate among attenders of antenatal clinics. Swaziland’s official 2002 antenatal survey found a prevalence of 38.6 per cent among those tested. But this is then presented as though 38 per cent of adults are infected, or even as though 38 per cent of the whole population has HIV. The result is complete confusion or deep despair—or both.

 

A second, previously noted difficulty is that in order to arrive at the number of men and infants infected, we are generally obliged to use antenatal clinic data. For example, in South Africa, according to an antenatal survey conducted in October 2002 by the ministry of health, 26.5 per cent of pregnant women were HIV-positive. Based on these results, and using a model developed by the Department of Health, an estimated 5.3 million South Africans are infected (2.95 million women and 2.3 million men aged fifteen to forty-nine, and 91,271 babies infected through mother-to-child transmission). Are there four million or six million infections? The answer is that we cannot know with complete accuracy; we have to work within a band of estimates. The reality is that there are millions of South Africans infected, and we will have to deal with the consequences.

Facing Facts

Finally, we are measuring HIV infections not AIDS cases, and it is the full-blown illness and deaths that will elicit a response from planners and policymakers. Because HIV is hidden—we do not know who is infected—it can be denied. An extreme example of such denial is the September 2003 interview in which President Mbeki said that no one close to him had died of the disease, nor did he know anyone infected with HIV.

 

It must be admitted that the impact of AIDS has not been as rapid as anticipated ten years ago. This is no surprise to science, given the nature of the pandemic and of the research process, but it is grist to the mill of those who have found a media niche and an audience anxious to have its doubts and nervousness assuaged. Sadly, this includes many senior policymakers. But it ignores the fact that we are still faced with a full-blown development crisis.

 

We have to keep reminding ourselves that slightly reduced numbers do not equate to “good news”: whether you drown in six inches or six feet of water doesn’t change the fact that you are dead. The great danger of this data debate is that it provides the perfect excuse for inaction. By contrast, the effective prediction and warning of impact can mobilise a response which, theoretically at least, may avert the impact. It is rather like the difference between measuring the damage after a flood or predicting the potential damage before it: if the householders fill sandbags and move the furniture upstairs, and thus reduce the damage, was the prediction wrong?

 

John Maynard Keynes reportedly said: “When the facts change, I change my mind. What do you do, sir?” We need to be honest and recognise when the facts have changed, but equally that we are not in any way suggesting there is no crisis—just that we need better to understand its scale, scope and timing.

HIV/AIDS in Africa

So how bad is the epidemic in Africa? The first and perhaps most important point is to recognise that there is not an African epidemic: there are many epidemics.

 

In north Africa and parts of the Sahel there is little evidence of an outbreak. Some countries do not report any cases and where there are data the prevalence rate is below 0.25 per cent among adults. There have been some signs of outbreaks among drug users, although sexual intercourse remains the dominant form of transmission. The intense stigma attached to HIV/AIDS, and the discrimination against those infected with it, mean the epidemic may remain hidden. Although HIV/AIDS is nascent, there is concern about levels of conflict, poverty and unemployment, which may speed its spread.

 

In eastern Africa, the epidemic appears to be stable at levels of between 5 and 15 per cent among adults. This translates into horrific numbers, though: over 2 million infected Ethiopians, 2.3 million Kenyans, and 1 million Mozambicans.

 

The 2002 UNAIDS update notes that in west and central Africa, the relatively low adult HIV prevalence rates in countries such as Senegal (under 1 per cent) and Mali (1.7 per cent) are shadowed by more ominous patterns of growth.

 

HIV prevalence is estimated to exceed 5% in eight other countries of west and central Africa, including Cameroon (11.8%), Central African Republic (12.9%), Côte d’Ivoire (9.7%) and Nigeria (5.8%)—sobering reminders that no country or region is shielded from the epidemic. The sharp rise in HIV prevalence among pregnant women in Cameroon (more than doubling to over 11% among those aged 20–24 between 1998 and 2000), shows how suddenly the epidemic can surge.³

 

The epicentre of the epidemic is southern Africa. The expectation in the early 1990s was that HIV prevalence would not exceed 25 per cent in any country. The countries of southern Africa have confounded this. In June 2002, the UNAIDS global report said:

 

Circulating in southern Africa … has been the hope that the epidemic may have reached its “natural limit”, beyond which it would not grow. Thus, it has been assumed that the very high HIV prevalence rates in some countries have reached a plateau … If a natural HIV prevalence limit does exist in these countries, it is considerably higher than previously thought.⁴

 

The update released six months later was even more plaintive:

 

The worst of the epidemic clearly has not yet passed, even in southern Africa where rampant epidemics are under way. In four southern African countries, national adult HIV prevalence has risen higher than thought possible, exceeding 30 per cent: Botswana (38.8 per cent), Lesotho (31 per cent), Swaziland (33.4 per cent) and Zimbabwe (33.7 per cent).

 

In some situations we simply do not know what is going on. For example, there is little data from states riven by armed conflict, such as the Democratic Republic of Congo or Sudan. In others, there is not a functioning government to collect, collate and disseminate information: Liberia, Sierra Leone and Somalia. In some instances, e.g., Angola, HIV/AIDS is not high on the agenda. Finally, data may simply not be credible owing to inefficiency and government failure (Nigeria), or may actually be manipulated because of political sensitivity (Zimbabwe). But what characterises HIV/AIDS in Africa is that the majority of infections are transmitted through heterosexual contact, and more women than men are infected.

 

Some idea of the scale of the problem in southern Africa can be gleaned from the antenatal clinic HIV prevalence surveys over the past decade. In South Africa, HIV prevalence rose from about 0.5 per cent in 1990 to over 25 per cent in 2002. Botswana and Swaziland both began collecting data in 1992. In Botswana, the first survey showed a prevalence rate of about 18 per cent. This rose to close to 40 per cent by 2000 and has remained at these levels. By contrast, in Swaziland prevalence in 1994 was just 4 per cent. But by 2002 it had reached 38.6 per cent—currently the highest in the world.

 

HIV infections take some years to evolve into illness and deaths, so the full consequences of the disease have yet to be felt. Nonetheless, there is growing evidence of increased morbidity and mortality. The best data come from South Africa. Here, the Medical Research Council has tracked the steady increase in deaths among young people using the death certificates collected by the South African Department of Home Affairs. South Africa is one of the few countries in the continent where there is death registration, and in 2000 over 90 per cent of adult deaths were registered. Between 1998 and 2003 there was a 150 per cent increase in deaths of women aged twenty to forty-nine, and this is adjusting for population growth and possible improvement in registration.

 

An increase in mortality is also recorded for young South Africans. The mortality rate for those under five years old is estimated to have risen to ninety-five per thousand in 2000. HIV/AIDS was believed to be the cause of 40 per cent of these deaths. An analysis of mortality in Swaziland, using death notices in the local papers, showed that the number of deaths among people aged twenty-six to forty rose nearly fourfold. So there is evidence of the extent of HIV/AIDS infection in Africa; the question is, is it believed?

 

The role of the press will be interesting. In the second week of May 2004 there were two articles in the South African Mail and Guardian Online about cemeteries filling up ahead of schedule. In eThekweni (formerly Durban), cemeteries are lasting eight years instead of the planned fifteen, while in Tshwane all current cemeteries are expected to be full by 2009.

 

It has to be reiterated that across most of Africa current HIV infections have still to become AIDS illnesses. These will, in the absence of affordable, accessible and deliverable treatment, lead to AIDS deaths. And the majority of these deaths will be among people aged twenty-five to fifty. The AIDS curve has still to climb.

Impact of the Disease

The effects of AIDS will be dramatic and far reaching. Key points are:

 

● There is no cure, and treatment is inaccessible for the majority of infected Africans, owing both to cost and the lack of health-care staff.

 

● Impact is inflicted through the consequences of illness (morbidity) and death (mortality).

 

● Most fatalities will be among young adults who have completed their education, started families and begun working careers.

 

● HIV/AIDS is a long-term event as compared to other epidemics.

 

● The true toll cannot be estimated until the full evolution of the epidemic has been seen. The social and economic effects, in particular HIV/AIDS-related poverty, will get worse over the coming decades.

Demographic Effects

The impact of AIDS will be felt across society and is demographic, economic and social. Demographic consequences are increased mortality and decreased fertility. Mortality rises among infected adults and those infants infected through mother-to-child transmission.

 

Some idea of this impact can be gleaned from a report released in September 2003 by the population division of the United Nations.⁵ It warns that for the seven countries with prevalence of more than 20 per cent (and they are all African), life expectancy with AIDS in the period 1995–2000 fell from 62.3 years to 50.2. In 2010–15 it will be 37.6 years, as compared to 67 years for people without AIDS.

 

Infected women are less likely to become pregnant and carry a child to term, and premature mortality means there will be fewer women of childbearing age. This affects fertility. Only in the very worst-affected countries (Botswana and Swaziland) might the population decrease. But it is certain there will be a change in the population structure of all affected countries as young adults die.

 

The rise in the number of orphans is a demographic impact but has social and economic consequences. UNICEF estimates that by 2010 an estimated 20 million children in Africa will have lost one or both parents to HIV/AIDS. For over 80 per cent of orphans in the worst-affected countries, the cause will be HIV/AIDS. These children face severe stress. They are less likely to attend school, more likely to be exploited and suffer premature death, and they also have a more pessimistic outlook on life.

Economic Consequences

The economic effects of the disease vary by country and level. People live and operate in families and households. The impact of the illness or death of a breadwinner is severe: AIDS treatment is expensive, there is little prospect of recovery, and the illness is physically and psychologically debilitating.

 

A survey in South Africa of seven hundred households having at least one person already sick with AIDS gives a clear indication of the impoverishing nature of the epidemic:

 

● Two-thirds of households reported loss of income as a consequence of HIV/AIDS.

 

● Half reported not having enough food and that their children were going hungry.

 

● Almost a quarter of all children under the age of fifteen had already lost at least one parent.⁶

 

Will AIDS cause national economies to grow more slowly? This is not clear, but the most optimistic projections are that economic growth will be slowed in all affected countries. It was believed that AIDS had reduced Africa’s economic growth by just under 1 per cent in the 1990s. A very different view is presented in a World Bank study on the long-term economic costs of AIDS to South Africa, which was released in 2003.⁷ This warns that previous models greatly underestimated the potential macro-economic impact of HIV/AIDS, and that if nothing is done to combat the epidemic, “a complete economic collapse” will occur “within three generations”. The authors argue that the long-term economic costs of AIDS are almost certain to be very much higher than those predicted to date and may even be devastating. They emphasise the importance of human capital and how it is transmitted across generations.

Human Development

AIDS has an adverse effect on development. Here we can see an impact through international data sets. The most generally accepted measure of human development is the human development index (HDI) of the United Nations Development Programme (UNDP). The HDI looks beyond simple economic measures. It is constructed from three indices: life expectancy, which is a proxy indicator for longevity; educational attainment, which is measured by literacy and enrolment rates; and the standard of living, which is measured by GDP per capita. The measure that AIDS will first affect is life expectancy, consequent on increased infant and child mortality and premature deaths among adults.

 

The UNDP’s human development reports track how life expectancy has fallen in African countries, with a consequent decline in their HDI and a change in their ranking. Thus Botswana, which had an HDI of 0.741 in the 1996 human development report and ranked 71st in the world, had fallen to 125th by 2003 with an HDI of 0.614. South Africa’s ranking in the same period fell from 100 to 111, while Swaziland’s fell from 110 to 133. In the case of these countries, the fall is almost entirely due to the impact of AIDS on life expectancy. In Zimbabwe, life expectancy fell from 53.4 years in 1996 to 35.4 years in 2003, and its HDI from 0.534 to 0.496. But while AIDS is undoubtedly a major contributor here it is not the only factor.

 

In 2000 at the UN Millennium Summit, 189 countries adopted eight “Millennium Development Goals”. I will not go into these goals, other than to note that HIV/AIDS means it will be very difficult for many individual African countries to achieve them; indeed, some may now be wholly unachievable for the continent.

Fighting Back

The chief question facing Africa now is how it should respond to the disease. Obviously, the first goal is to prevent the virus spreading. Most Africans become infected through sex with an infected person. There are various measures that can be put in place to reduce the risk of infection. These include sexual abstinence and fidelity, much promoted by the United States under the current Republican administration. The use of condoms greatly reduces the likelihood of transmission, as do male circumcision and the treating of other sexually transmitted infections.

 

The problem with these interventions is that they do not address the underlying reasons why people put themselves at risk. Recommending abstinence and fidelity, moreover, is to assume that these are sought-after traits.

 

We need to understand that behaviours are determined by the social, economic, political and cultural milieu in which people live and operate. This is particularly important in southern Africa. In terms of GDP per capita, South Africa, Botswana and Namibia are the respectively the second-, third- and fourth-richest countries in sub-Saharan Africa (beaten only by oil-rich Equatorial Guinea). It is therefore apparent that wealth alone is no protector against infection. This has implications for the type of development countries aspire to, and points to the need for multi-sectoral responses.

 

The second-largest group of HIV-positive Africans is children infected through mother-to-child transmission. In the absence of interventions, an infected woman has about a 30 per cent chance of passing the infection to her child. Infection may occur prior to birth, during birth, or via breastfeeding. Prevention during birth is relatively easy through provision of a single dose of certain anti-retroviral drugs to the mother during labour and to the infant after delivery. Averting infection via breastfeeding is rather more complicated. In some African communities bottle-feeding is seen as a sign of HIV infection. The use of formula feed therefore requires not only safe water, but that a bottle-feeding mother not be stigmatised.

 

So the question is, what works other than the medical/technical intervention involved in preventing infection from mother to child? Only Uganda and Senegal furnish documented examples of successful prevention. What worked there? Three main factors seem to determine successful prevention:

 

● Leadership.

 

● Ownership and the source of messages.

 

● A multi-sectoral response.

Leadership

Leadership is essential. What is required is leadership at all levels, from the president to the village or district council, and it includes religious and civil society leaders. But an important point often overlooked is that the function of leadership is to create the environment and space for discussion and action. Leaders who simply say, “Change your behaviour or else,” tend to be ignored—unless they have the capacity to enforce the rules.

 

Three divergent examples of African leadership on HIV/AIDS can be identified. Held as the model to emulate is President Yoweri Museveni of Uganda. Early on in the epidemic he recognised the threat it posed to Uganda and quickly began both talking about the disease and instructing leaders at every level and in every field to do the same. The messages were geared to Ugandan ways of thinking: “zero grazing” (stick to one partner), and “if you put your hand in an anthill without protection expect to be bitten” (use a condom).

 

By contrast, in Botswana it has taken years for the leadership to recognise the serious problem the country faces, and even now the high-level commitment does not extend to the technocratic level in ministries.

 

South Africa is the extreme of denial. It is not the purpose of this article to rehash the widely known public debate about the stance of President Mbeki and Health Minister Mshimang Tshabalala (essentially, they sought to blame AIDS on poverty rather than HIV infection), but some key points are worth noting. It took court action by the Treatment Action Campaign pressure group in April 2002 to get provision of therapy to all HIV-positive pregnant women in order to prevent transmission of the virus to their babies. Subsequently, the cabinet released a statement that government policy would henceforth be based on the assumption that HIV causes AIDS.

 

In October 2002, a task team was formed to investigate the costs and benefits of providing anti-retroviral treatment to all HIV-positive individuals. However, the team’s findings were embargoed until August 2003. In November 2003, Dr Tshabalala released a staged plan, phase one of which aimed to provide anti-retroviral treatment to 53,000 people by the end of March 2004. In February 2004, the government began to solicit proposals from pharmaceutical companies to supply the drugs. However, the delivery date was in June. It was evident that the government would neither adhere to its stated schedule nor achieve the objective of phase one.

 

The conclusion is that leadership is necessary for the HIV/AIDS epidemic to be contained. Leadership alone, however, is not sufficient.

Ownership and the Source of Messages

Why the lack of response? One likely reason is that there is no ownership of the problem. People are asked to respond to the HIV epidemic before there is evidence of an AIDS epidemic. But more than that, the message about HIV/AIDS is coming from people who do not normally have access to African leaders. Nor do the scientists—virologists, immunologists, epidemiologists, and so on—have the vocabulary or skills to communicate with the decision makers. Furthermore, most of the people giving the message are foreign.

 

Early responses to Africa’s AIDS crisis were of organisations coming in and effectively saying, “You have a problem, we know what to do and we also have the money and staff to deal with the problem.” Of course, the governments and leaderships heaved a sigh of relief and said to themselves, “At least this is one issue that we do not need to tackle.”

 

To some extent this is still the case. The agenda is being driven in Geneva or Washington. The WHO is motivating the “3 by 5 Initiative”, a plan to provide anti-retroviral treatment to three million people living with AIDS by the end of 2005. PEPFAR is a US initiative, a five-year, $15 billion AIDS-relief plan announced by President George W. Bush in 2003. In order for Africans to act on AIDS, they have to believe there is something that can be done and that they can and will be part of it.

A Multi-Sectoral Response

If AIDS is going to be tackled successfully, then it has to be treated as more than a health issue. Development that creates employment can help or hinder the spread of HIV, or do both at the same time. For example, some female textile workers in Lesotho are employed at low wages in factories that export to the United States under the latter’s “Africa Growth and Opportunities Act”. Providing women with an income should empower them and benefit their children. However, many migrate to take the jobs, and because of the low wages are forced to live in situations where men may exploit them for sexual favours. Development in this context may perpetuate the HIV epidemic.

 

Quite what a multi-sectoral response is may be open to interpretation. At the end of the 1990s, “multi-sectoral” became an international buzzword, although it meant different things to different people. What works is commitment across a society and from all types and levels of leadership. Ministries of health have to relinquish ownership of the disease. In countries where health ministries have jealously guarded their interests, success has either been slow or non-existent. Ironically, massive resource-flows to combat AIDS may make it a fought-over terrain.

 

In many African governments, the first step to becoming “multi-sectoral” was to identify someone in each ministry—agriculture, transport, trade, education, etc.—as the focal person for dealing with the impact of AIDS on that ministry’s sphere of concern. However, these officials were not given a proper mandate, a budget or any powers. (We should note that this failing has not been confined to Africa: a number of international donor organisations have established AIDS units without resources or powers and expected them to make the organisation “AIDS aware”.)

 

“Multi-sectoral” means looking beyond prevention to the whole epidemic. This includes measures to mitigate the impact of AIDS, and policies that will change the societal factors influencing long-term susceptibility and vulnerability to the disease. In government, each ministry has to ask what HIV and AIDS mean for its core businesses and what it should be doing differently. Multi-sectoral response recognises the role of social and contextual factors conditioning individual decisions.

The Social Imperative

That the AIDS epidemic is a serious issue is not disputed. That it is the most serious issue facing Africa at present may be questioned. However, in May, the WHO released its annual report. This document has a unique take. It argues that by using HIV treatment programmes to strengthen existing prevention programmes, and by improving health systems, the international community has a singular opportunity to “change the course of history” by saving millions of lives worldwide that are threatened by AIDS.⁸

 

I would not concur with the view that improving health systems will “change the course of history” in this way. But what is certain is that HIV/AIDS will change history, and how we respond to it will be crucial. We need to understand what is driving the epidemic in order to prevent it. Societies can, and do, change. Social cohesion may break down or build up. Countries may experience economic growth or decline. Governments have a substantial responsibility to intervene against HIV/AIDS at the socio-economic level. Economic growth alone is not the panacea, but must be accompanied by social development. This means addressing questions of equality, human rights and the construction of “civil society”. HIV/AIDS interventions that ignore these issues will not be effective or sustainable in the long term.

 

There are four areas of social policy that may strengthen social cohesion and so reduce a society’s susceptibility to HIV and also its vulnerability to the impacts of HIV. These areas are:

 

● The altering of social norms and standards: for example, increasing pressure to raise the age at which individuals first have sexual intercourse.

 

● Improving the status of women: for example, by changing their legal status and increasing their access to reasonably well-paid employment.

 

● Improving the performance of social institutions, especially education and health.

 

● Improving conditions in controlled social environments where people are forced to live together, e.g., army barracks, ships, and labour camps.

 

Africa is at a cusp. How it will look in another fifty years—as it begins to mark a century of independence—will largely be determined by how it responds now to today’s AIDS epidemic. 

Endnotes

1. UNAIDS and World Health Organisation, AIDS Epidemic Update: December 2003 (Geneva, 2003).

 

2. Spectator (London), 13 December 2003.

 

3. UNAIDS and WHO, AIDS Epidemic Update: December 2002 (Geneva, 2002), p. 21.

 

4. UNAIDS, 2002 Report on the Global AIDS Epidemic (Geneva, 2002), p. 23.

 

5. Population Division, Department of Economic and Social Affairs, United Nations Secretariat, The Impact of AIDS (New York, 2003).

 

6. Malcolm Steinberg et al., Hitting Home: How Households Cope with the Impact of the HIV/AIDS Epidemic (Menlo Park, Calif.: Henry Kaiser Family Foundation, October 2002).

 

7. Clive Bell, Shantayanan Devarajan, and Hans Gersbach, The Long-run Economic Costs of AIDS: Theory and an Application to South Africa (Washington, D.C.: World Bank, June 2003).

 

8. WHO, World Health Report 2004: Changing History (Geneva, 2004).