X HIV/AIDS Prevention and Care in Resource-Constrained Settings

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E C ONOMIC IMPACTEarly research on the economic impact of AIDSfocused on the macroeconomic aspects. This showedthat increased deaths and decreased investment couldbe expected to slow economic growth and reduce percapita income, albeit not dramatically. 2There have also been attempts to examine howAIDS would affect the private sector and households.Not surprisingly, it has proved difficult to collect completeand credible data. Indeed, poor managementinformation systems were a constant source of frustrationfor researchers who were working with companiesin affected countries. 3 AIDS clearly had measurablecosts in the private sector, mainly through absenteeismand the payment of benefits. These costs could be ashigh as eight percent of the payroll, depending on thenature of the industry and scale of the problem. Butin general the impact was not great, manageable ortransferred onto the households. 4The relatively limited number of studies of householdimpact have shown that HIV/AIDS leads toimpoverishment of those affected. In Ethiopia andTanzania, the average cost of basic symptomatic treatment,funeral and mourning expenses amounts to severaltimes the average annual household income.Affected children are more likely to be malnourishedand, particularly the girls, removed from school. 5Although the importance of these dramatic increasesin the number of orphans has been recognized, theirlong-term economic implications have not beenassessed.Part of the problem in assessing the impact ofHIV/AIDS is that it is long term and the data havenot been available. But in the last few years a numberof new publications have appeared that give a muchmore pessimistic view of the potential and actualimpact of the disease at all levels. The most significantmay be studies suggesting that the impact on nationaleconomies and growth is more complex and seriousthan previously modeled, perhaps because the speedand scale of HIV/AIDS have been much worse thanexpected; HIV/AIDS reduces the stock of human andphysical capital because it also reduces the incentive toF igure 12Infant Mortality With and WithoutThe AIDS Epidemic in 2000BotswanaZimbabweSouth AfricaNamibiaGhanaKenyaBurundiLesothoCameroonTogoNigeriaZambiaTanzaniaUgandaCôte d’IvoireSwazilandBeninGabonEthiopiaCongo (Brazzaville)CARCongo (Kinshasa)Burkina FasoMalawiRwandaMozambiqueBahamasHondurasBrazilGuyanaHaitiThailandCambodiaBurmaWithout AIDSWith AIDS0 50 100 150Infant deaths per 1,000 live birthsSource: U.S. Census Bureau, International Data Base and unpublished tables.HIV/AIDS Prevention and Care in Resource-Constrained Settings XIX
invest; and feedback further amplifies the impact ofHIV/AIDS on economic growth.This can result in a vicious cycle in which AIDSreduces growth and increases poverty, thereby acceleratingthe spread of HIV. 6 These concepts have beenenumerated in a recent paper from the HarvardInstitute of International Development which suggeststhat the impact of AIDS has been systematicallyunderstated because these feedback effects have beenignored. 7 The impact on productivity due to HIVstatus is particularly important. The study focuses onZambia and suggests that by “stripping countries ofsome of their best talent and undermining the incentiveto invest, these difficulties may be condemningAfrican countries to extended periods of stagnationand decline.” Macroeconomic analysis is clearly enteringa new phase.Recent work on the private sector shows that companiesalso are beginning to take AIDS more seriously.But the tendency—which is economically rational—isto avoid or shift the costs of the disease, though thismay not be in the interests of the national economy orworkforce. A classic example is a company in SouthAfrica that diversified to Eastern Europe after lookingat the impact of AIDS on its market. 8The worst impact is at the household level, andhere the data are limited. Mitigation will need to focuson the household level because it is there that caremust be delivered and prevention messages may havethe most meaning.RESPONSE TO THEHIV/AIDS EPIDEMICS:COMPONENTS FOR ANEXPANDEDCOMPREHENSIVERESPONSEEven as we recognize the devastation of AIDSduring the nearly two decades since HIV was firstidentified, it is important to note that there has beenremarkable progress in our understanding of variousaspects of the global HIV/AIDS pandemic. There isnow an abundance of information on the basicpathogenesis of the infection; the epidemiologicadvancement of the disease around the globe; themultiple factors that determine vulnerability; the scopeof the pandemic’s macro- and microeconomic impacts;the development and use of highly active antiretroviraltherapies (HAART) to retard the clinical progressionof HIV-related disease; the financial and politicalenvironment that can facilitate an effective response;and, most critically, the constellation of interventionsneeded to achieve a national-level impact on HIVtransmission.R EDUCING RISK BEHAVIORSOur ability as a global community to achievereductions in new HIV infections is predicated on avery basic principle: We can reduce unsafe sexual andother risk behavior in a sustainable way. We nowhave ample evidence that public health programs canaffect change in the most private and basic of humanbehavior—sex. While it is impossible to attributedeclining national HIV rates to any single program, itis increasingly evident that people are responding towidespread, consistent education messages aboutHIV/AIDS prevention and care, and to dramaticincreases in the availability of key tools and services.In poor urban neighborhoods in the DominicanRepublic, for example, rates of sexually active youthdeclined from 73 percent in 1993 to 30 percent in1996, and rates of participation in “transactional sex”(exchanging food, money, school fees, etc. for sex)declined from 27 percent to 7 percent among males.In Bali, Indonesia, a peer education project with sexuallyactive 15- to 25-year-olds led to an increase inconsistent condom use from 22 percent to 72 percent.Sustained investments in a select number of countrieshave resulted in two kinds of national-level success:maintaining low HIV rates in countries at riskand reducing national-level HIV prevalence during asevere generalized epidemic. Senegal has maintainedone of the lowest HIV prevalence rates in sub-SaharanAfrica, with rates rising only slightly—from 1.2 percentfor the general adult population in 1995, to 1.8percent at the end of 1999.XX HIV/AIDS Prevention and Care in Resource-Constrained Settings
Page 1 and 2: Edited byPeter R. Lamptey, MD, DrPH
Page 3 and 4: © 2001 Family Health International
Page 5 and 6: SECTION II:Chapter 6PAGE 137Chapter
Page 7 and 8: Chapter 21PAGE 501Chapter 22PAGE 51
Page 9 and 10: I N T R O D U C T I O NPAUL R. DE L
Page 11 and 12: F igure 1Factors That InfluenceThe
Page 13 and 14: F igure 3HIV Seroprevalence for Pre
Page 15 and 16: F igure 5HIV Seroprevalence for Com
Page 17 and 18: F igure 7HIV Seroprevalence for Pre
Page 19 and 20: F igure 9Life Expectancy With and W
Page 21: F igure 11Population of Zimbabwe,Wi
Page 25 and 26: R EDUCING MOTHER-TO-CHILDTRANSMISSI
Page 27 and 28: F igure 13HIV Seroprevalence in Adu
Page 29 and 30: ACKNOWLEDGEMENTSWe wish to express
Page 32 and 33: SOFIA GRUSKIN, JD, MIAAssistant Pro
Page 34 and 35: THOMAS M. PAINTER, PHDBehavioral Sc
Page 36 and 37: glossary of A C R O N Y M SACTG AID

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