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

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