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It is now well accepted that HIV/AIDS is a challenge for the world community as it transcendsboundaries of nation, class, ethnicity and sexual preference.Over the years, research has shown that HIV is not random in its spread or its impact. An intersectionof several variables—poverty, urbanisation, gender inequality and stereotypical gender roles—impacts upon vulnerabilities. Significant factors—such as lack of autonomy for women and girls,discrimination against sexual minorities, abuse of power, lack of basic services, and violence againstwomen—play a key role in determining the most vulnerable constituencies in society.Human poverty reduces the ability of people to control their circumstances and make choices.Poor people are forced by economic imperatives into living conditions and occupations in whichrisks to life and health are endemic. In countries that are experiencing widespread impacts ofHIV/AIDS, it has been found that prevention initiatives can work only if enabling environmentsare created for people to effect change in their lives that would help them practice safe behaviourconsistently.Linking HIV/AIDS-related indicators to human development parameters representing long andhealthy life, knowledge and a decent standard of living, would support dialogue with policymakersand stakeholders to set the course for considered action.This report highlights South Asia’s substantial challenge, both in terms of human deprivation andvulnerability to the epidemic. It argues for a comprehensive intersectoral response based on therecognition of the linkages between human development and HIV/AIDS.This document has been prepared by the UNDP’s Human Development Resource Centre and theRegional HIV and Development Programme in collaboration with UNAIDS.ointhe debate!http://hdrc.undp.org.in Jhttp://www.youandaids.org

REGIONAL HUMAN DEVELOPMENT REPORTHIV/AIDSandDevelopment in South Asia 2003

© United Nations Development Programme, 2003All rights are reserved. The document may, however, be freely reviewed, quoted,reproduced or translated, in part or in full, provided the source is acknowledged. Thedocument may not be sold or used in conjunction with commercial purposes withoutprior written approval from UNDP. The views expressed in documents by namedauthors are solely the responsibility of those authors.The analysis and policy recommendations of this Report do not necessarily representthe views of the United Nations Development Programme, its Executive Board or itsMember States.ISBN No. 81-88788-03-1Price: INR 395.00Designed and Printed by New Concept Information Systems Pvt. Ltd., New Delhiii

orewordThe Regional Human DevelopmentReport on “HIV/AIDS and HumanDevelopment in South Asia 2003” is thefirst report prepared under the aegis ofUNDP’s Asia Pacific Regional Initiativeon Human Development Reports(HDRC) and the Regional Programmeon HIV and Development (REACHBeyond Borders).This Report builds upon an extensivecorpus of research on humandevelopment in South Asia, pioneeredby the late Dr Mahbub-ul-Haq andstrengthened by successive national andsub-national HDRs. The challenge of HIVin South Asia has been examined inseveral documents prepared by UNorganizations, national Governments,research institutions, NGOs, activistsworking with HIV programmes andpositive people’s networks.It is heartening that this complex anddifficult issue is being addressed by a largenumber of people who recognise thepressing importance of fighting thisepidemic before it reaches catastrophicproportions. We do not have the luxuryof waiting for a crisis to be thrust uponus before we devise solutions for it.The Report argues that just as HIV canreverse the gains of human developmentin the region, largely through thevector of life expectancy, morbidityand prejudice, the lack of humandevelopment can also trump the fightagainst HIV. This Report is the first attemptto examine the dynamics of HIV andhuman development through a commonlens, and suggests possible arenas foraction that may lie outside a strictlyepidemiological approach. It is also truethat a classic public health response thatfocuses upon “disease control”,important as that is, may not be adequategiven the fact that there is thus far novaccine against HIV and the health careinfrastructure in the region is in need ofever greater reform and rejuvenation.The analysis in the Report indicates thatthe two-way relationship between illhealthand poverty holds particularly truein South Asia. In this context, humandevelopment concerns, particularlythose of social security, livelihood andhuman dignity are required to bemainstreamed into efforts to combatthe epidemic. As a corollary, it wouldbe essential to include HIV concernsinto policies and programmes forhuman development. A comprehensiveresponse cannot be a mere catch-word orslogan, it needs to become a living reality —on this hinges the success of the struggleagainst human deprivation and theepidemic in South Asia.Hafiz PashaUN Assistant Secretary GeneralUNDP Assistant AdministratorDirector, Regional Bureau for Asia and the Pacificiii

OverviewGlobally, the Human DevelopmentReports (HDRs) have placed people at thecentre of development discourse andflagged the urgency of focused public actiontowards international development goals.Several regional, national, and indeed subnationalHDRs pioneered in India havecontributed to a worldwide alliance towiden people’s choices and meet thechallenges of poverty, ill-health andignorance.The Regional HDR on HIV/AIDS andDevelopment in South Asia examines thecomplex interplay between disease anddeprivation in a scenario where majorsuccesses in human development areundermined by persistent challenges. TheReport brings together for the first timean analysis of HIV and humandevelopment under a common lens inSouth Asia. The linkages between the twoare mutually reinforcing in the sense thatHIV can undo gains of humandevelopment, and the lack of humandevelopment can trump any strategyagainst HIV.The Report assesses the adverse impactof HIV on the Human Development Index(HDI) and also the parameters of the HDIviz. literacy, school enrollment, lifeexpectancy and per capita income. It alsopoints out that successful humandevelopment in terms of improvedliteracy, a more functional health systemand enhanced livelihoods make for a moreeffective response to the epidemic inSouth Asia.It is vital that dialogue in the region,between statesmen, governments andcivil society, be harnessed to focus uponcooperation in arenas such as affordabledrugs and treatment through tradeagreements, sharing best practices inharm reduction and an enabling policyenvironment where the struggle againstthe epidemic is an integral part of the roadmap for human development.The Report documents the price of inertiain the fight against HIV and showsthat the micro-level impacts at thelevel of individuals, households andcommunities are more significant thanthe macro-level impact, given the currentrates of HIV prevalence. It points out thatthe impact of HIV on firms and businessesaffects not only corporate profits but alsothe livelihoods of workers and theprospects of social security for organisedand unorganised workers.The case is made in the Report thatsuccessful outcomes for HIV may alsorequire an enabling framework whererights of people living with HIV/AIDS(PLWHA) are guaranteed and stigma anddiscrimination are minimised. Itanalyses the legislative and judicialframework of HIV in South Asiaand argues for a closer integrationwith mainstream constitutional and rightto development mandates andinstitutions.The Report examines the debate overprevention versus treatment andiv

Overviewoverturns the argument that the former isthe responsibility of the state and thelatter is to be taken care of by privateprovisioning and market forces. It arguesthat the success of prevention efforts oftendepends on effective care and supportespecially in the light of the principles ofGreater Involvement of People with AIDS(GIPA). It also shows the feasibility ofaccess to Highly Active Anti-retroviralTherapy (HAART) in resource-poorsettings. It examines the issues pertainingto provision of drugs at affordable pricesthrough mechanisms such as compulsorylicensing and parallel country importing,an issue which could be taken up forregional cooperation in South Asia.The Report points out that the formidablechallenge of HIV in the region can be metonly when the credo of multi-sectoralresponses is translated into reality byensuring that the concerns of positivepeople are reflected not only in dedicatedpublic health interventions but also inprogrammes and policies for livelihoodpromotion, social security and access tobasic services.While this Report does not purport toconvey the views of any of the nationalGovernments in the region, it doessignpost, however, the urgency of meetingthe challenge of HIV and humandeprivation in a region that is critical tothe world’s ability to meet the MillenniumDevelopment Goals. It is hoped that thefindings of the Report could spark publicdebate and help build an enabling policyenvironment for more effective action.We look forward to wider discussions inSouth Asia, within and across countries,which could provide policy options onpractical modalities of a multi-sectoralresponse, access to treatment in resourcepoorsettings, demystifying the epidemicby building advocacy and informationnetworks for advocacy and ensuring a highpriority for HIV and human developmentin the political agenda.Brenda Gael McSweeneyUNDP Resident Representative &UN Resident Coordinatorv

AcknowledgementsCombating HIV/AIDS is a criticalchallenge for human development inSouth Asia, and as such one of the keyMillennium Development Goals that theworld community has set for itself. Thereis now a consensus that public policy isrequired to address not only the medicalor public health issues, but also the socioeconomiccontext, including issuespertaining to human dignity andelimination of stigma and discrimination.This Report is an attempt to utiliseUNDP’s principal advocacy platform tomake a compelling case for coherent,practical action across sectors andstakeholders, keeping in mind the groundrealities of South Asia and the possibilityof the epidemic reversing the gains ofhuman development in the region. Itmarshalls relevant facts and evidence andanalyses the two-way linkage betweenhuman development outcomes and thetrajectory of the epidemic. It is hoped thatthis would help widen the currentdevelopment debate on the subject andpromote experience sharing acrosscountries and contribute to the ‘humandevelopment movement’ worldwide.The leadership of Mark Malloch Brown,UNDP Administrator and his vision of thenew UNDP as a knowledge network hasinspired the preparation of this Report inone of UNDP’s key practice areas.The encouragement by the RegionalBureau for Asia Pacific (RBAP), under theleadership of Hafiz Pasha was valuable.This is the first Report funded under RBAP’sRegional Initiative on HDRs in Asia andthe Pacific. This Report has been preparedby the Human Development ResourceCentre (HDRC), and Regional HIV andDevelopment Programme (REACHBeyond Borders), New Delhi incollaboration with UNAIDS. SubinayNandy, Joanna Merlin-Scholtes, KanniWignaraja and Arusha Stanislaus at theBureau have extended useful support.Sarah Burd-Sharps and SharmilaKurukulasuriya from the National HDR(NHDR) Unit at the Human DevelopmentReport Office (HDRO) have been ourcomrades-in-arms, not only facilitating apresentation on the Report at the XIVInternational HIV/AIDS Conference atBarcelona, but also in facilitatingdiscussions on the NHDR network. We aregrateful to members of the NHDRNetwork, particularly the CambodiaNHDR team and Hakan Bjorkman fortheir detailed comments, which helpedimprove the draft. Gillman Rebello andBarbara Lemoine at the United NationsOffice for Project Services (UNOPS) weremost helpful.The support from the country offices ofUNDP and UNAIDS in the regionincluding the HIV/AIDS focal points forfacilitating the sharing of the draft isacknowledged. David Miller, K. Pradeep,Pernilla Berlin from UNAIDS IndiaCountry Office, Vidya Ganesh fromUNAIDS, South Asia Inter-Country Team(SAICT), Sunita Dhar from UNIFEM,South Asian Regional Office (SARO),vi

AcknowledgementsJai Narain, Subhash Hira from WHO,South-East Asia Regional Office (SEARO)and Roma Bhattacharjea from UNDP,Sub-Regional Resource Facility (SURF),Kathmandu, deserve special thanks.The Asia Pacific Regional HumanDevelopment Reports Initiative andREACH Beyond Borders Programme,both hosted by the Government of India,New Delhi, have in the course ofpreparation of this Report benefitedfrom the continuous advice and supportof Meenakshi Datta Ghosh and herteam from National AIDS ControlOrganisation, India.This Report would not have been possiblewithout the contribution, support andencouragement from a large number ofpeople and institutions. Theircontribution is acknowledged without inany way making them responsible for thecontents. The guidance of the membersof the Advisory and TechnicalCommittees is gratefully acknowledged.Thanks to all the resource persons andinstitutions who contributed backgroundpapers. Special thanks are due to EileenStillwaggon and Robert Cassen for theirintellectual guidance that helped sharpenthe perspectives in the Report.The process of preparing this Report wasas fruitful as the end product. Theparticipants at the regional NGOconsultation at Goa enriched the contentsof the Report and provided a grass-rootsperspective of activists and people livingwith HIV/AIDS. We wish to put onrecord our appreciation of Caitlin Wiesenand the CSO Division for there supportof the partnership initiatives, and ofIshwar Shrestha, Sharmini Boyle,U. Nobokishore Singh, Rohan Edrisinha,Gunjan Sharma, Shyamala Ashok, BitraGeorge, Elizabeth Sivakumar, Priya Dias,John Pinheiro, Prakash Nadkarni, MariottCorrea, Sangita Sonak, Ashwin Tombatand Sabina Martin. We wish toacknowledge the following groups andnetworks of people living with HIV/AIDS(PLWHA) in South Asia for deepening ourknowledge and analysis: Asia PacificNetwork of PLWHA (APN+), IndianNetwork for PLWHA (INP+), PositiveWomen Network of South India (PWN+),En-Joy, Affected Infected Women’sAssociation in Churachandpur (AIWAC),Nepal Plus, Makwanur Group of Infectedand Affected women, Lanka+, Ashar AloSociety and New Light AIDS ControlAction Awareness Group.Draft versions of the Report were sharedwith several experts whose feedback isacknowledged. We would particularly liketo mention Michael Hahn, P.L. Joshi, RajivSadanandan, Julie Hamblin, DesmondCohen, D.C.S. Reddy and Mukul Saxena.Readers including policy-makers andplanners from across the region, helpedin improving the presentation andsharpening the analysis. This process,though time consuming, helped inbuilding a constituency for theperspectives and messages of the Report.A special thanks to our fellow travellerswho have already initiated the process ofsharing the human developmentconcept and messages arising fromthis analysis.Editorial inputs from SeethaParthasarathy and Jaya Shreedhar, andprinting by New Concept InformationSystems Pvt. Ltd against very tightdeadlines are duly acknowledged.vii

The TeamHDRC: K. Seeta Prabhu, Suraj Kumar, Trishna Satpathy, Alka Narang, AnuradhaRajivan, Kalyani Menon-SenREACH Beyond Borders Programme: Sonam Yangchen Rana, G. Pramod Kumar,Uffe Gartner, Rie Debabrata, Clare Castillejo, Chandrika Bahadur, Meera MishraAdvisory BoardDavid BloomRobert CassenKhadija HaqS.R. OsmaniPeter PiotNihal RodrigoWerasit SittitraiTechnical CommitteeMeenakshi Datta GhoshReeta DeviRohan EdrisinhaAnand GroverD.C. JayasuriyaDavid MillerS.V. Joga RaoPrema RamachandranElizabeth ReidSwarup SarkarMonica SharmaGita Senviii

Partners for this ReportHuman Development Resource Centre, UNDPUNDP’s Human Development Resource Centre (HDRC) is a centre of excellencededicated to human development research, training and advocacy since August 2000.The Centre’s objectives are (1) translating the concept of human development intopolicy-oriented action; (2) creating awareness among national and local policy makersabout tools and techniques to mainstream Human Development Report (HDR)analyses into policies and programmes; and (3) facilitating learning and exchange ofideas by strengthening regional and local networks and capacity building. This Reporthas been prepared under the Regional Initiative on HDRs in Asia and the Pacific, aproject sponsored by the Regional Bureau of Asia and Pacific (RBAP), UNDP, New York.REACH Beyond Borders Programme, UNDPREACH Beyond Borders is UNDP’s Regional HIV and Development Programmecovering 13 countries in the South and North-East Asia region. The programmeaddresses the development and trans-border challenges of HIV/AIDS in the regionand supports integrated and rights based responses that promote gender equality,sustainable livelihoods and community participation. Focus areas of work includepolicy advocacy and outreach, mobility and HIV/AIDS, capacity development andGreater Involvement of People Living with HIV/AIDS (GIPA) and human rights.UNAIDSThe Joint United Nations Programme on HIV/AIDS (UNAIDS) brings together the effortsand resources of eight United Nations organisations. As the main advocate for globalaction on HIV/AIDS, UNAIDS leads, strengthens and supports an expanded responseaimed at preventing the transmission of HIV, providing care and support, reducing thevulnerability of individuals and communities to HIV/AIDS, and alleviating the impactof the epidemic.ix

ContentsCHAPTER 1Introduction1.1 The Terrain 31.2 The HIV Epidemic in South Asia: A Systems Analysis 61.3 Rationale for a Human Development Approach 71.4 HIV/AIDS and Human Development Reporting 81.5 Purpose of this Report 9CHAPTER 2Nexus between Human Development and HIV/AIDS2.1 Introduction 152.2 Linkages 172.3 The Price of Inertia: The Costs of HIV at the Sectoral and National Level 312.4 Implications of the Analysis 352.5 Conclusion 37CHAPTER 3The HIV/AIDS Epidemics of South Asia3.1 Status of the Epidemic 413.2 Conflict and Development in South Asia 503.3 Current Response to HIV/AIDS in South Asia 563.4 Challenges and Imperatives 66CHAPTER 4Human Rights and HIV/AIDS4.1 Introduction 734.2 HIV/AIDS, Stigma and Discrimination and Human Rights in South Asia 774.3 Social Violence and Human Rights Violations 804.4 The Scope of Human Rights 884.5 Access to Treatment, Care and Support 934.6 International Human Rights ramework 1044.7 The Role of the State 1084.8 Recommendations 1084.9 Conclusion 114CHAPTER 5The Way Forward5.1 The Context of HIV and Human Development:Policy Challenges for South Asia 1175.2 Policy Action for HIV/AIDS 1185.3 Emerging Policy Issues for HIV/AIDS and Human Development inSouth Asia 1195.4 Addressing Drug Use 124x

Contents5.5 Adolescent Sexual Health Needs 1255.6 Towards Gender Justice and Empowerment 1255.7 Strengthening Partnerships 1275.8 A Renewed Call for Action: Prevention, Care and Development 1315.9 Possible Policy Initiatives on HIV/AIDS 1335.10 Regional Agenda 1355.11 Conclusion 136AnnexuresAnnexure 1 Concluding observations by treaty monitoring 159bodies on issues relevant to the right to health and theresponse to HIV/AIDSAnnexure 2 International Guidelines on HIV/AIDS and Human Rights 162Technical Note A Methodology for computation of indices in the HDR 164Technical Note B Assessing the impact of HIV/AIDS on Human Development 167Statistical TablesTable 1a Human development indicators and indices 186Table 1b Trends in HDI 186Table 2 Demographic health indicators 187Table 3 Profile of incomes, poverty and inequality 188Table 4 Information and communication indicators 188Table 5 Profile of military spending 189Country Fact SheetsAfghanistan 193Bangladesh 194Bhutan 195India 196Islamic Republic of Iran 197Maldives 198Nepal 199Pakistan 200Sri Lanka 201Boxes1.1 Evolution of HIV epidemiology 31.2 Understanding human development 81.3 Millennium Development Goals and HIV/AIDS 102.1 Balance sheet of human development and HIV in South Asia 172.2 Exclusion of HIV-positive children from school in response to boycott 192.3 The Greater Involvement of People Living with HIV/AIDS (GIPA) 212.4 Women and HIV 252.5 Coping with HIV: different realities 282.6 Poverty, gender and HIV/AIDS 292.7 The availability of formal health and life insurance 302.8 HIV prevention efforts and human development: NGO experiencefrom Sangli 312.9 The impact of AIDS: business as usual? 342.10 Does it pay to intervene early? 363.1 Afghanistan: blood transfusion, injecting drug use are suspectedtransmission means 43xi

Contents3.2 African AIDS is not a special case 443.3 India addresses the problem of unsafe blood transfusions 453.4 The rapid spread to the general population 463.5 HIV/AIDS vulnerability amongst Afghan drug users 473.6 Trafficking of women is a serious problem in South Asia 483.7 How do perceptions and language reinforce HIV relatedmisconceptions and stigma? 513.8 Conflict impedes HIV prevention 523.9 actors contributing to the spread of HIV in conflict situations 543.10 The Indian Army addresses HIV 553.11 Sex education for Sri Lankan soldiers 563.12 Policy response to HIV in South Asia 583.13 The right to confidentiality for PLWHA in India 623.14 The Global und to ight AIDS, Tuberculosis and Malaria (GATM) 643.15 Critical role of political leadership in the response to HIV/AIDS inSouth Asia 684.1 Sexual negotiation as empowerment: the Sonagachi approach 764.2 Ethical issues related to HIV/AIDS 774.3 Stigma and discrimination in South Asia: an illustrative study 794.4 The three phases of the AIDS epidemic 804.5 Badi communities in Nepal: surviving social ostracism and violence 814.6 India addresses the problem of trafficking of women 874.7 Mandatory testing 884.8 Indian courts exhibit sensitivity towards PLWHA 914.9 Sex workers in Bangladesh: human rights violations and legal redress 924.10 Vaccine development 944.11 International Treatment Access Coalition 954.12 Meeting the challenge of drug pricing 974.13 Lessons from the Brazil experience 984.14 The role of equitable pricing in ensuring access 1004.15 Clarifications under the Doha Declaration 1034.16 The United Nations General Assembly Special Session (UNGASS)on HIV/AIDS and the UNGASS Declaration of Commitment 1074.17 Human rights violations and systemic harassment 109Tables1.1 Regional estimates of HIV/AIDS–2002 41.2 Estimates of HIV/AIDS in South Asia–2001 52.1 Human development and HIV/AIDS in South Asia (by country) 162.2 Human development indicators in South Asia, 2000 (by country) 163.1 Drug use and HIV infections in South Asia 483.2 Persons of concern to UNHCR in South Asia 533.3 Policy responses to HIV/AIDS in South Asia, 2001 653.4 Policies and practices on selected HIV/AIDS-related issues 674.1 Legal and human rights of those affected by HIV/AIDS 784.2 Important human and legal rights and their implementation 894.3 Coverage of anti-retroviral treatment in developing countries,December 2002 954.4 Comparative analysis of patent laws 1044.5 Status of ratifications of main international human rights instruments 105xii

AbbreviationsAIDSANCARTARVCEDAWCGEGDIGDPGNPGIPAHAARTHDHDIHDRHIVIDUILOIMFMDGMSMMTCTNACONACPAcquired ImmunodeficiencySyndromeAntenatal clinicAnti-retroviral therapyAnti-retroviral drugsConvention on theElimination of All forms ofDiscrimination AgainstWomenComputable GeneralEquilibriumGender Development IndexGross Domestic ProductGross National ProductGreater Involvement ofPeople Living WithHIV/AIDSHighly Active Anti-retroviralTherapyHuman DevelopmentHuman Development IndexHuman DevelopmentReportHuman Immuno-deficiencyVirusIntravenous drug users/Injecting drug usersInternational LabourOrganizationInternational Monetary FundMillennium DevelopmentGoalsMen who have sex with menMother to child transmissionNational AIDS ControlOrganisationNational AIDS ControlProgramme/sNGO Non-governmentalorganisationOLS Ordinary Least SquaresPPP Purchasing Power ParityPLWHA People Living WithHIV/AIDSSAARC South Asian Association forRegional CooperationSACS State AIDS Control SocietySHIP STD/HIV InterventionProjectSTD Sexually TransmittedDiseaseSTI Sexually TransmittedInfectionTRIPS Trade-Related IntellectualProperty RightsUN United NationsUNAIDS Joint United NationsProgramme on HIV/AIDSUNDP United NationsDevelopment ProgrammeUNDCP United Nations DrugControl ProgrammeUNFPA United Nations PopulationFundUNGASS United Nations GeneralAssembly Special Session onHIV/AIDSUNICEF United NationsInternational Children’sEducation FundUNIFEM United NationsDevelopment Fund forWomenVCT Voluntary Counselling andTestingWHO World Health OrganizationWTO World Trade Organizationxiii

GlossaryAIDSAcquired Immuno-deficiency Syndromeis a physiological or medical conditionwhereby the body’s immune system isweakened by Human ImmunodeficiencyVirus (HIV) to the extentthat it is no longer able to defend itselfagainst attacks by ordinary (and other)ailments. A cure for AIDS has not beenfound, although research is underway fordeveloping an AIDS vaccine.AIDS-related deathsDeaths linked to AIDS-related diseasessuch as tuberculosis, pneumonia anddiarrhoea.AntenatalOccurring before birthAnti-retroviral DrugsSubstances used to kill or inhibit themultiplication of retroviruses such as HIV.CohortIn epidemiology, a group of individualswith some characteristics in common.Combination TherapyTwo or more drugs or treatments usedtogether to achieve optimum results.EndemicThe standard epidemiological definitionof the term endemic is the constantpresence of a disease in a given geographicarea or within a given population.EpidemicAn epidemic is the occurrence of a greaternumber of cases of a disease than wouldnormally be expected to occur in apopulation, community or region.EpidemiologyStudy of the occurrence, distribution anddetermining factors associated with healthevents and diseases in a population.Gross Domestic Product (GDP)The total output of goods and services forfinal use produced by a economy, by bothresidents and non-residents, regardless ofthe allocation to domestic and foreignclaims. It does not include deductions fordepreciation of physical capital ordepletion and degradation of naturalresources.Gender Empowerment Measure (GEM)A composite index measuring averageachievement in the three basic dimensionsof empowerment: economic participationand decision-making, political participationand decision-making and power overeconomic resources.Highly Active Anti-retroviralTherapy (HAART)Treatment regimens that suppress viralreplication and progress of the HIV. Thesetreatment regimens have been shown toreduce the amount of virus so that itbecomes undetectable in the blood.xiv

GlossaryImmune DeficiencyInability of certain parts of the immunesystem to function, thus making a personmore susceptible to infections.IncidenceThe number of new cases (e.g., of adisease) occurring in a given populationover a certain period of time.HIV incidence is the number of new HIVinfections occurring in a specified periodof time in a specified population.Incidence RateThe incidence rate is the rate at which newevents, or new cases, occur in a specifiedtime in a defined population that is “at risk”of experiencing the condition or event.existing cases of a disease at a specifiedtime divided by a defined population thatis “at risk” of experiencing the conditionPrevalence Rate =Number of existing eventsin a specified periodNumber of people exposedto risk in this periodSentinel SurveillanceSentinel surveillance is a type ofsurveillance activity in which specificfacilities such as offices of certain healthcare providers, hospitals or clinics acrossa geographical region are designated tocollect data about a disease, such as HIVinfection. These data are reported to acentral database for analysis andinterpretation.Incidence Rate =Number of new events ina specified period of timeNumber of people exposedto risk in this periodSeroconversionIn HIV/AIDS research, seroconversionrefers to the development of detectableantibodies to HIV in the blood as a result ofHIV infection.Men who have sex with menThis includes men who report eitherhomosexual or bisexual contact.Purchasing Power ParityA rate of exchange that accounts for pricedifferentials across countries allowinginternational comparison of real outputand incomesPrevalenceTotal number of people cumulative witha specific disease or health conditionliving in a defined population at aparticular time.Prevalence RateThe prevalence rate is the number ofSeroprevalenceThe term seroprevalence refers to theprevalence or prevalence rate of a diseasedetermined by testing blood rather thanby testing saliva, urine, or sputum.SurveillanceSurveillance is the ongoing collection,analysis and interpretation of data abouta disease such as HIV or about a healthcondition. The objective of surveillanceis to assess the health status ofpopulations, detect changes in diseasetrends or changes in how the disease isdistributed, define priorities, assist in theprevention and control of the disease, andmonitor and evaluate related treatmentand prevention programmes.Source: UNDP, 2002 & Canadian AIDS Society, 2002xv

Introduction2Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Introduction“The microbe is lessimportant, the terrainis most important ”Louis PasteurChapter 1Introduction1.1 The TerrainIn a span of less than three decades,HIV/AIDS has emerged as the single mostformidable challenge to public health,human rights and development in thenew millennium. Already, over 25 millionpeople have died of AIDS worldwide, with3.1 million deaths in 2002. The number ofdeaths is certain to rise in the future. Anestimated 42 million people are presentlyliving with HIV/AIDS (with womenaccounting for 50 per cent of adults livingwith HIV/AIDS worldwide) and 5 millionnew infections occurred in 2002 alone(See Table 1.1). 1 The Global Commissionon Macroeconomics of Health hasrecommended that the strategic responseto HIV be invested with the seriousnessof a mission whose philosophy is oneof approaching health as ‘globalpublic good’. 2The South Asian region may have onlyaround 25 per cent of the world’spopulation but it is home to 40 per centof the world’s absolute poor subsisting onless than $1 a day. 3 Besides, at 4.2 millionBox 1.1Evolution of HIV epidemiologyEarly approaches to HIV/AIDS in the 1980s tended tofocus on forms of behaviour (and, therefore, vulnerablegroups) as the determinants of the ‘epidemic’. Indeed,the early nomenclature for HIV/AIDS included ‘GayRelated Immuno-Deficiency Syndrome’, therebyassociating the syndrome with homosexual activity.Subsequently, this notion was falsified by the fact thatmulti-partner heterosexuals as well as groups such aschildren from middle class households could also sufferfrom the virus. It is now well accepted that HIV/AIDSis a challenge for the world community as a whole sinceit transcends boundaries of nation, class, ethnicity andsexual preference.Over the years, research has shown that the HIV is notrandom in its spread or in its impact. An interaction ofseveral variables-poverty, migration, urbanisation,inequality (particularly gender inequality) andstereotypical gender roles – influence vulnerabilities.Significant factors such as lack of autonomy for womenand girls, violence against women, discrimination againstsexual minorities, abuse of power and lack of access tohealth services play a key role in determining the worstaffectedconstituencies in society.Even so, studies on HIV/AIDS have conventionallytended to treat HIV in terms of epidemiology, diseaseprevalence and estimates of infected persons. Theprimary focus has been on strategies for awarenessand public education, along with public health issuessuch as pharmaceutical research, drug prices, and theprivacy versus disclosure debate for healthcareproviders. However, the arena of discussion onHIV/AIDS must be widened, given the fact that theepidemic has a social context and there are inter-groupdifferentials in vulnerability to and impact of the virus.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 3

Introductioncases, the region has the second largestprevalence of HIV/AIDS in the world(because of the large population base), aproblem that can get exacerbated by thehigh levels of inequality, poverty, socialstigma and discrimination that couldenhance the vulnerability of people to theinfection. There are several reasons forthis. Low and inappropriate compositionof public expenditure on basic services inmost countries limits the access of thepoor to health facilities. This reflects thepressure of competing priorities onlimited public resources. The quality ofpublic services is also a matter of concern.The high proportion of the informal sectorin economic activity and lack of adequatesocial security also add to the vulnerabilityof the poor. There is very high mobility ofpeople in the region, especially asTable 1.1Regional estimates of HIV/AIDS–2002Region Epidemic Adults and Adult Percentage of Main mode(s) ofstarted children living prevalence women among transmission for adultswith HIV/AIDS rate*(%) HIV- positive living with HIV/AIDSadultsSub-Saharan late 1970s– 29,400,000 8.8 58 Heterosexual sexAfricaearly 1980sNorth Africa and late 1980s 550,000 0.3 55 Heterosexual sex,West Asiainjecting drug useSouth and South late 1980s 6,000,000 0.6 36 Heterosexual sex,East Asiainjecting drug useEast Asia and late 1980s 1,200,000 0.1 24 Heterosexual sex,Pacificinjecting drug use,sexual transmissionamong men who havesex with menLatin America late 1970s– 1,500,000 0.6 30 Heterosexual sex,early 1980sinjecting drug use,sexual transmissionamong men who havesex with menCaribbean late 1970s– 440,000 2.4 50 Heterosexual sex,early 1980ssexual transmissionamong men who havesex with menEastern Europe & early 1990s 1,200,000 0.6 27 Injecting drug useCentral AsiaWestern Europe late 1970s– 570,000 0.3 25 Sexual transmissionearly 1980samong men who havesex with men, injectingdrug useNorth America late 1970s– 980,000 0.6 20 Heterosexual sex,early 1980sinjecting drug use,sexual transmissionamong men who havesex with menAustralia and late 1970s– 15,000 0.1 7 Sexual transmissionNew Zealand early 1980s among men who havesex with menTotal 42,000,000 1.2 50* The proportion of adults (15 to 49 years of age) living with HIV/AIDS in 2001, using 2001 population numbers.Source: UNAIDS/WHO, 20024Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Introductionmigrant labour, and this creates a largeconstituency whose movement—in theabsence of adequate information, servicesand choices—increases their vulnerabilityto HIV.Table 1.1 compares the magnitude of HIVprevalence in South Asia with that of otherregions of the world. It shows that HIVprevalence rates in South Asia (which,for the purposes of this report, includesIran and Afghanistan) and South East Asiaare significantly lower than in regionslike sub-Saharan Africa where theepidemic is rampant.Table 1.2 shows that the estimates of HIVprevalence among adults aged 15–49years in the nine countries that this studycovers range from negligible levels inBhutan to 0.8 per cent in India, figuresthat are well below the 8.8 per centprevalence rate among similar agegroups in sub-Saharan Africa. 4These low prevalence rates, however,mask a more complex picture and shouldnot be a source of complacency, forseveral reasons.llThe first relates to scale. Nine South andAsian countries account for nearly25 per cent of the world’s population,so that even small rates of HIVincidence translate into large absolutenumbers. With an estimated 3.97million infections, India alone hasnearly 10 per cent of all the peopleliving with HIV/AIDS (PLWHA) in theworld, with sentinel surveillancesurveys showing an advance ofHIV/AIDS in several parts of thecountry. 5 Several urban areas in thewestern state of Maharashtra and insouthern India already have HIVincidence rates among pregnantwomen coming to antenatal clinics inexcess of 2 per cent. 6The second reason is growth rates. Thetotal number of PLWHA in Asia andthe Pacific grew by 10 per cent since2001 to 7.2 million. 7 Nepal has seenrapid increases in HIV prevalencerates among sex workers and injectingdrug users in recent years. 8 Althoughthe proportion of pregnant womenwho are HIV-positive – a barometer ofthe spread of HIV into the generalpopulation—in Nepal is negligible, itThese lowprevalence rates,however, mask amore complexpicture and shouldnot be a source ofcomplacency.Table 1.2Estimates of HIV/AIDS in South Asia–2001Country Number of Number HIV prevalence Number of Number of Number ofadults and of adults rate among women children deaths (adultschildren (15–49 adults (%) (15–49 age (0–14 age and children)age group) group) group)Afghanistan N.A. N.A. N.A. N.A. N.A. N.A.Bangladesh 13,000 13,000

IntroductionAlthough theHIV/AIDS infectioncuts across socioeconomicgroups,its transmissionfollows the pathscreated byeconomic, socialand politicalinequalitiesbetween womenand men.lwould be only a matter of time beforeHIV moves from vulnerable groupsinto its general population.Third, the epidemic is still relativelyrecent in South Asia, at least incomparison to sub-Saharan Africa. Sothe current relatively low HIVprevalence rate in the seven countriesother than India and Nepal may just bea temporary reprieve. Fortunately, thisgives the South Asian countries anopportunity to arrest the epidemic atits present stage rather than waiting forit to become generalised in nature.The following features are associated withthe spread of HIV in all these countries.l High rates of poverty and consequentpoor living conditions.l Gender inequality.l Incomplete epidemiologicaltransition with high prevalence ofcommunicable diseases such astuberculosis (TB).l Low levels of knowledge as a result ofwhich populations will be less thanfully aware about methods of reducingrisk of HIV infection.l Migrant and displaced populations.These relationships will be examined infurther detail subsequently.1.2 The HIV Epidemic inSouth Asia: A SystemsAnalysisBoth immediate and structural factorscontribute to the spread of HIV/AIDS. Mostof the responses to date, including acrossSouth Asia, have dealt with the immediatefactors. These include sexual and socialbehaviors that place people at risk,inadequate screening of donated blood andmultiple uses of invasive instrumentswithout effective cleaning between uses.Most information and behaviour changeinterventions focus on sexual and drugtaking habits and primarily targetindividuals. In effect, such interventionsrespond to the consequences of theepidemic rather than addressing the rootcauses. The persistence of the vulnerablegroup approach demonstrates that thereis still a lack of understanding about theactual dynamics of the epidemic,especially for the general population.Clearly, a systems analysis within a humandevelopment framework—rather than anarrower medical or health approach—would be useful here.Structural factors that contribute to theepidemic are associated with prevailingsocio-economic conditions, access toquality health facilities, and the opennessof society to face the epidemic and itssexual and behavioural attributes. Socioeconomicinequalities (along class,gender, and ethnic lines) have long beenknown to be constraints to development.Those inequalities shape the patterns ofHIV/AIDS as well.Although the HIV/AIDS infection cutsacross socio-economic groups, itstransmission follows the paths createdby economic, social and politicalinequalities between women and men.Over the past three decades, as the processof economic liberalisation gathered steam,the inequalities that foster the spread ofHIV/AIDS have intensified. Some of thoseinequalities may appear unrelated—lackof easy access to diagnosis and treatmentof sexually transmitted infections (STIs);living away from a family; or working tosurvive in marginal and insecure jobs—butthey are extremely conducive to the rapidspread of HIV/AIDS.These inequalities present majorchallenges to policy makers in all sectorsand at all levels. It is well known thatpolitical decisions about resourceallocation and response to diverse needs6Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Introductionand interests have a profound influenceon socio-economic conditions. Pastexperience across the region indicates acertain reluctance on the part of policymakers to tackle these inequalities and atendency to postpone action because theproblems appear insurmountable.However, the issues can be broken downinto more manageable and actionablecomponents.Policy makers should be more sensitive tothe importance of creating an appropriate‘enabling environment’ for a moreeffective response to the epidemic. Thiswill include policy changes in areas suchas human rights that may not strictly liewithin the domain of ‘public health’. Forexample, the shift from public-supportedhealth systems to a mixture of public andprivate services and cost-recoverymeasures, such as user charges for once freeor low-cost services, is an essential part ofthe economic liberalisation process,stemming from the decision to reducepublic expenditures on health. However,this limits access to health facilities formany people or forces them to re-prioritisetheir spending to pay for services. It hasbeen argued that the use of health facilities,especially by the lower income groups,tends to decline sharply with increases infees at public facilities. Thus, the revenuemodel of ‘health sector reforms’ mayfurther exclude the poor from adequatehealthcare. In India, privatisation isincreasing corporate involvement in theprovision of healthcare, and there is a riskthat concerns of profitability could seelow-income groups being left out ofquality healthcare. 91.3 Rationale for a HumanDevelopment ApproachHuman poverty 10 reduces the ability ofpeople to control their circumstances andmake choices. Poor people are forced byeconomic necessity into living conditionsand occupations with a high level of risk tolife and health. It has increasingly beenfound in countries that are experiencingwidespread impact of HIV/AIDS thatprevention initiatives can work only ifenabling environments are created forpeople to change their lives in a mannerthat would help them practise safe andprotective behaviour consistently. There is,therefore, a need to look at the epidemicfrom the perspective of its socio-economiccauses and consequences, and analyse itsimpact on the overall development indicesat the national and regional level.Analysis of HIV/AIDS within a humandevelopment framework can offer newinsights not only for determining issuesfor ‘bridge populations’ (groups that linkthe vulnerable groups with the generalpopulation), but also to offer mainstreamdevelopment solutions to the challengeof the epidemic.There are two sets of issues relating to thelinkages of HIV/AIDS with poverty:(a) the combined effect of poverty andincome inequalities on socialinteractions including sex, patterns ofvulnerability and patterns of riskbehaviour; and(b) HIV/AIDS as a cause of furtherimpoverishment of poor people,which can have a devastating impacton communities and the potentialto reverse any gains in humandevelopment.Studies indicate that gender issues are atthe heart of the epidemic, as women areincreasingly being infected. Women aredoubly vulnerable to HIV/AIDS. Forbiological reasons, they are four timesmore prone to STIs than men. 11 Inaddition, their low social and economicstatus and their dependence on men limittheir control over their lives, includingPolicy-makersshould be moresensitive to theimportance ofcreating anappropriate‘enablingenvironment’ for amore effectiveresponse to theepidemic.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 7

IntroductionBox 1.2Human development goes beyond the standard notionof economic development that has come to besynonymous with growth in real income per capita. Itincludes dimensions such as knowledge (education) andlongevity that reflect non-material aspects of ‘the qualityof life’. Based on the statement in Aristotle’sNicomachean Ethics, that “we value wealth not for itsown sake but for the sake of something else” the humandevelopment framework allows for enhancements in noneconomicareas to be a comprehensive measure of wellbeing. Thus, improvements in health, besides beingvaluable in themselves, have the potential of expandingearnings opportunities for the individual, and alsocontribute to improved cognitive abilities at school.Improvements in education could, similarly, contributeto improved economic opportunities, besides enablingan individual to be empowered, whether by learning aboutthe means to improve one’s health or fight for one’srights in the public sphere. Again, improvements in basicrights–speech, religious freedom, life and liberty–areexamples of improved capabilities that would be naturalingredients in the notion of development as discussedby Amartya Sen.The most popular usage of the human developmentconcept is as an index, referred to as the HumanDevelopment Index (HDI). This combines threeelements–life expectancy at birth, educationalattainment (a weighted average of adult literacy andcombined—primary, secondary and tertiary-enrolmentUnderstanding human developmentMulti-levelinterventions thatseek to involve arates) and per capita Gross Domestic Product (GDP).Thus, changes in HDI capturevarietychangesofinpartnersthree elementsthat would go into any reasonable in coordinated interpretation of‘development’ as defined action above–income, have been health andeducation. To calculate shown HDI, each to be of more the threecomponents is reduced to a dimension index, rangingbetween 0 and 1, and thensuccessfula simple arithmeticthanaverageof the three is used to compute isolated, the HDI.segmented efforts.In addition to the HDI, UNDP has developed a numberof other indices to capture the degree of ‘deprivation’that populations or specific groups face. These includethe gender-related development index (GDI) and twoversions of the Human Poverty Index (HPI) (one fordeveloped countries and another for developingcountries). 12 The human poverty index for developingcountries is an arithmetic average of the illiteracy rate,the probability of not surviving to age 40, plus anindicator of standard of living (a mean of the proportionof population without access to safe water and healthservices and proportion of under-5 children who areunderweight). In contrast to the HDI and the HPI, theGDI focuses on inequalities within populations–in thiscase the inequalities between men and women. Thereason for the development of these myriad indices isnot surprising, given the extremely broad way in whichthe expansion of capabilities can be interpreted. But itis clear that they are unlikely to be able to capture theentire gamut of freedoms that one could think of asgoing into ‘development’.over exposure to HIV. It has also beenobserved that the vulnerability ofpopulations to the virus increases inregions where macro policies are lesssensitive to gender issues. Furthermore,HIV/AIDS prevention efforts need toaddress culturally rooted ideas of maleidentity and behaviour. These areintrinsically linked to gender issues andneed to be addressed within theprevention strategies for the epidemic.1.4 HIV/AIDS and HumanDevelopment ReportingSeveral authors and policy makers haveargued that, apart from the obviousimplications for the health of PLWHA,HIV/AIDS will have significant impactson the affected countries, along a numberof dimensions. These effects includeadverse implications for the rate of growthof real income per capita. 13 Potentialeffects could also include impacts onthe distribution of economic resources,the educational achievements ofpopulations, and other freedoms thatpeople value, including basic humanrights such as life and liberty. 14In short, HIV/AIDS influences societiesin ways that go beyond the purely healthor purely economic dimension and intothe realm of human development, a goal8Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Introductionthat societies cherish. Linking HIV/AIDSrelatedindicators to development andpoverty alleviation indicators wouldprovide necessary information foradvocacy with policy makers as well asstrategic direction for action.Political commitment has been shown tobe essential for the success of preventionprogrammes for HIV. Multi-levelinterventions that seek to involve a varietyof partners in coordinated action havebeen shown to be more successful thanisolated, segmented efforts. Moreover, anenhanced and coordinated political,economic and social effort is required toreduce societal vulnerability alongsideprogrammes operating at the individualand community levels.Mainstreaming HIV and the issues thatexacerbate the effect of the epidemic intonational poverty reduction programmesas well as gender programmes has beenrecognised as the key to reducing itsimpact. This can happen only througheffective advocacy tools that will spurground-level action by the policy-makers.Since 1990, UNDP’s HumanDevelopment Reports (HDRs) haveemerged as the principal advocacyplatform for Sustainable HumanDevelopment for UNDP and otheragencies. Global, regional and nationalHDRs have contributed towards raisingawareness and generating debates onpolicies and activities. It has been anextremely useful tool for policy makers,agencies working in the field ofdevelopment as well as multilateral andbilateral donors to assess the efficacy ofcurrent approaches and strategies inorder to implement innovative andbetter programmes. A case in point isthe Botswana National HumanDevelopment Report on HIV/AIDS,which spurred a public discussion on theaccessibility of anti-retroviral (ARV)drugs and the responsibility of thegovernment in providing them. Thisultimately led to a decision in 2001 bythe country’s President to provide freeaccess to ARV drugs. The President alsohad an abridged version of the reportproduced for distribution in all seniorprimary and junior secondary schools.1.5 Purpose of this ReportThis report, which is also the first RegionalHDR on HIV/AIDS, attempts to examinethe connection between the epidemicand the larger challenge of humandeprivation in South Asia. In the light ofthe United Nations General AssemblySpecial Session on HIV/AIDS (UNGASS)Declaration and the MillenniumDevelopment Goals (MDGs) (See Box1.3), it is especially imperative that theattempt to halt and reverse the spread ofHIV goes hand in hand with theeradication of human poverty in theregion. However, policy analysis on HIVand human development has, thus far,treated the two separately. This reportattempts to explore the conceptual andempirical links between HIV and humandevelopment. The objectives of thisreport, therefore, are:l to create an understanding of thecauses and consequences of HIVwithin a development framework andthereby to advocate for a shift indevelopment priorities andapproaches to HIV;l analyse convincing data and evidenceregarding the socio-economicdimensions of HIV/AIDS, includingfactors that heighten vulnerability;l in the light of the analysis andexperiences, identify key points forHIV/AIDS and development strategiesin the region;Multi-levelinterventions thatseek to involve avariety of partnersin coordinatedaction have beenshown to be moresuccessful thanisolated,segmented efforts.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 9

IntroductionBox 1.3Millennium Development Goals and HIV/AIDSThe Millennium Development Goals (MDGs)encapsulate the development targets agreed atvarious international conferences and world summitsduring the 1990s. At the Millennium Summit of theUnited Nations (UN) held in September 2000, worldleaders distilled these key goals and targets into the'Millennium Declaration', which was adopted by 147Heads of State and Government and 191 nations.Based on the Declaration, UNDP has worked withother UN departments, funds and programmes, theWorld Bank, International Monetary und and theOrganisation for Economic Cooperation andDevelopment on a concise set of goals, numericaltargets and quantifiable indicators to assess progress.These MDGs include eight goals, 18 targets and over40 indicators.The vital importance of HIV/AIDS within the globaldevelopment agenda has been recognised in the sixthMDG, which is to halt and begin to reverse the spreadof HIV/AIDS by 2015. However, not only is reversingthe spread of HIV/AIDS a goal in itself, but there arealso close linkages between the HIV/AIDS epidemicand the other MDGs. It is clear that the achievementof all the MDGs depends in part on progress in turningaround the HIV/AIDS epidemic, while success in theresponse to the epidemic will not be possible withoutthe achievement of the other MDGs. These linkagesfurther demonstrate the close relationship between HIVand human development, as well as the pressing needfor broad-based multi-sectoral responses.Linkages between HIV/AIDS and the other MDGs:1. Eradicate extreme poverty and hungerThe loss of productive capacity among families affectedby HIV/AIDS has a major impact on economic growth,food production and nutritional well being (in thehardest-hit countries, economic growth has fallen by 4per cent and labour productivity has been cut by up to50 per cent).2. Achieve universal primary educationThe quality of education services and teaching is affectedbecause of higher absenteeism among teachers due toillness. More school children are caring for their sickparents and such responsibilities force them to drop outof school. AIDS-related illness eats into family budgets,making it more difficult to pay school fees.3. Promote gender equality and empower womenGirls are more likely to be kept out of school to providecare, or when resources are limited. Women take onthe greater burden of caring and face greater economicinsecurity when wage earners fall ill. While genderequity, both social and economic, is a critical factor inreducing risk, HIV/AIDS exacerbates gender inequalitiesand burdens on women.4. Reduce child mortalityInfant and child mortality will continue to increase forthe next decade, and possibly longer, due to parent-tochildHIV infection.5. Improve maternal healthHIV/AIDS is increasingly a cause of death amongmothers.6. Ensure environmental sustainabilityIllness, increased labour demands for caring for patients,and lost labour reduce time for fetching water,especially for women. Human resource losses andcosts in water supply services affect delivery andincrease the cost of services to households.7. Develop a global partnership for developmentHIV/AIDS continues to place additional resourceburdens on developing countries.l document good practices inindividual countries and create a casefor adapting those that are relevant tothe region; andl to advocate integrated approaches topolicy makers and implementers inthe region for reducing the spread andimpact of the epidemic by mainstreamingHIV response into povertyalleviation, gender equality and otherdevelopment programmes.The subsequent report structurehighlights the complex interrelationshipsbetween dimensions of humandevelopment and HIV/AIDS issues,based upon multi-variate regressionanalysis in Chapter 2. A treatment of the10Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Introductionstatus, trends and prospects of theepidemic in the context of humandeprivation and inadequacy of publichealth systems in South Asia isundertaken in Chapter 3. It indicates thatthe region cannot avoid potentiallycatastrophic consequences unless thereis a political will to galvanise resourcesand catalyse reform for placing highpriority on health and humandevelopment. The creation of an‘enabling environment’ that guaranteeshuman rights and eliminates socialstigma and discrimination againstPLWHA is imperative. Chapter 4examines the legal and human rightsframework for a response to HIV in SouthAsia. It argues that there is a need toensure that the strategies for ‘harmreduction’ are backed by suitablemodifications of laws so that the PLWHAare guaranteed a life with dignity andcare, free of social stigma and dailyharassment. Emerging issues such asstigma and discrimination, conflictsituations and affordability of HighlyActive Anti-retroviral Therapy (HAART)in the resource-poor setting of SouthAsia, dealt with in the previous chapters,form the backdrop of discussion on theway forward in Chapter 5. In the case oftreatment, it is argued that there is notrade-off between prevention and careand support. Indeed, effective care andsupport based on the principles ofGreater Involvement of People withAIDS (GIPA) can guarantee more effectiveprevention strategies. The chapterconcludes with a call for greater regionalcooperation on HIV issues such as drugpricing, mobility and the integration ofHIV into mainstream developmentprogrammes. It provides specificrecommendations for policy action andprogramme implementation to furtherstrengthen the public agenda on HIV andhuman development in South Asia.Building on the analysis of the foregoingchapters, the way forward on thisimportant issue involves buildingalliances of national, state and localgovernance with civil societyorganisations, media and researchinstitutions. A comprehensive responseto the challenge of human deprivationin general and the epidemic in particularmust involve a widening of the debateacross disciplines, specialisations and“single focus” initiatives.This report does not claim to offer auniversal solution or monolithic strategyto tackle what is admittedly a very largechallenge. It does however emphasise theurgency of mainstreaming HIV responsein all human development-relatedprogrammes and, conversely, the criticalimportance of combatting the epidemicthrough an integrated human developmentframework.“The epidemic in Asia threatens to become the largest in the world. Withmore than half the world’s population, the region must treat AIDS as an issueof regional urgency. The question is no longer whether Asia will have a majorepidemic, but rather how massive it will be.“HIV has already spread to more than six million people across Asia. By nottackling it now, while it is still manageable, the epidemic will have farreachingeffects, destabilising societies and damaging productivity.”— Dr Peter Piot, Executive Director of UNAIDS, addressing the World Economicorum’s (WE) East Asia Economic Summit, October 2002Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 11

Nexus between Human Development and HIV/AIDS14Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Nexus between Human Development and HIV/AIDS“AIDS is devastatingin terms of creatingand deepening poverty,reversing achievementsin education anddiverting meagre healthbudgets away fromother priorities. And bycutting deep into allsectors of society,HIV/AIDS underminesvital economic growth:”Mark Malloch Brown,UNDP Administrator,African Developmentorum, December 2000Chapter 2Nexus between HumanDevelopment and HIV/AIDS2.1 IntroductionThis chapter brings out the mutuallyreinforcing relationship between thevulnerability to HIV and the persistenceof human deprivation and the manner inwhich the HIV/AIDS epidemic shapes,and is, in turn, shaped by the patterns ofdevelopment in South Asia. “Thesituation is worst in regions and countrieswhere poverty is extensive, genderinequality is pervasive, and public servicesare weak. In fact, the spread of HIV/AIDSat the turn of the twenty-first century is asign of maldevelopment-an indicatorof the failure to create more equitableand prosperous societies over large partsof the world.” 1Conventionally, the analyses of theepidemic and human development inSouth Asia have been done in a segregatedmanner. The former has focusedprimarily on the identification ofvulnerable groups, seropositivityestimates and concomitant socioeconomicprofiles of ‘people at risk’. TheHDRs, for their part, have analysedliteracy, vital statistics and indicators ofincome, employment and poverty,albeit within an integrated framework.There is, however, a growingrecognition that HIV/AIDS is not just ahealth issue but a fundamental issueunderlying the sustainability of humandevelopment. This has widened the scopeof the present discourse.2.1.1 Status and trends ofHIV/AIDS and humandevelopment in South AsiaWhere do the countries in the region rankin terms of development achievements?Tables 2.1 and 2.2 shed light on some of thecomponents of HDI, and HIV prevalence.There appears to be considerablevariation in achievement, in terms ofaggregate indicators such as the HDI andGDI and in individual components ofHDI, across even this small group of ninecountries. Sri Lanka, Maldives and Iranare at the upper end of the spectrum, withIndia in the middle and the others(Bangladesh, Bhutan, Nepal and Pakistan)at the lower end.The same appears to hold true for SouthAsia’s economic indicators such as theproportion of population living below theinternational poverty line of $1 (1993PPP), with the exception of Sri Lanka.These already low levels of developmentindicators are likely to be furtheraffected by HIV, with recent gains indevelopment reversed.Table T1 (see Technical Note B) highlightschanges in some of the indicators ofhuman development in the last twoRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 15

Nexus between Human Development and HIV/AIDSTable 2.1Human development and HIV/AIDS in South Asia (by country)Country HDI Gender Development Index HIV PLWHA as a(GDI)prevalence proportion ofValue Rank # Value Rank * (in nos.)population2000 2001 2001 (15–49 years)(per cent)Afghanistan N.A. N.A. N.A. N.A. N.A. N.A.Bangladesh 0.478 145 0.468 121 13,000

Nexus between Human Development and HIV/AIDSin recent years. The low rate of growth ofadult literacy in the Maldives reflects, asin the case of Sri Lanka, its already highliteracy rate of about 92 per cent.2.2 Linkages2.2.1 Impact of HIV on humandevelopmentThe HIV/AIDS epidemic has profoundconsequences for human development inSouth Asia. This is because HIV affects notjust the health of individuals, but has botha direct and indirect effect on theircapabilities, their family and kinshipstructures, and consequently, on theeconomic, social and institutionalarrangements. These nuanced effects ofHIV make it imperative to look at it from adevelopment perspective, rather than apurely public health one. It is alsoimportant that the impact be examinedprimarily through the individuals andhouseholds it affects, using a humandevelopment framework. Such a broaderapproach is more conducive to theprevention and management of theepidemic, a combination of which wouldreverse the incidence.Impact of HIV on differentdimensions of human developmentHuman development is, very simply, theprocess of enlarging choices. The humandevelopment framework looks at howthese choices are enlarged by enhancingthe capabilities of individuals, and at theoutcomes of these enlarged choices. TheBox 2.1Balance sheet of human development and HIV in South AsiannnAchievementsHigh rates of growth in many countries in the regionduring the past two decades. India was one of theten fastest growing economies in the 1990s, evenas global recession loomed largeRapid progress in education, life expectancy andother human development attainments over thepast four decadesSuccess of democratic governance despitechallenges of ethnicity and structural heterogeneitynnChallengesSize of economies remains small—the combinedGDP of the South Asian countries is less than 70per cent of the GDP of China and one-eighth thatof Japan. The per capita GDP of Iran, the highestin the region is less than 25 per cent of the percapita GDP of JapanHigh levels of income and human poverty and ofchild malnutrition, poor availability of basicfacilities—drinking water, sanitation, ruralinfrastructurennnExistence of a vibrant NGO movement—non-profitorganisations estimated at nearly 1 million inIndia alone 2Tradition of community caring and compassion thatprepares societies to deal with challenges of globalillnesses better 3ormation of dedicated National Programmes,which have played a major role in containing HIVat relatively low prevalence rates in the 1990s,even as the absolute numbers risennnDespite rapid progress, the average humandevelopment achievements in most countries in theregion fall far short of the improvements recordedin the East Asian countries over a similar time spanPersistent gender inequality—high levels of femaleilliteracy in all countries except Sri Lanka and theMaldivesDeclining trend in public expenditure for socialsectors in the 1990s, due to fiscal stringency andstructural adjustment pressuresnSecond highest absolute number of HIV positivepeople in the worldRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 17

Nexus between Human Development and HIV/AIDSProlonged illnessalso results in lossin savings andasset holdings,both due to anincrease in costs,as well as adecrease in thepropensity to savedue to lower lifeexpectancy.HIV epidemic affects the manner andextent to which these choices are eitherenlarged or constrained for individuals,groups of individuals and societyas a whole.Incomes, poverty and earningcapabilitiesThere are several ways in which individualsand their households are likely to beeconomically affected by AIDS. The mostvisible and immediate impact is on theearnings and incomes of households ofPLWHA, especially since HIV affectsindividuals in their most productive years.As seen in Chapter 1, more than 90 per centof the world’s PLWHA are in the age groupof 15–49 years. This group is likely to be partof the labour force, or provide in-kindsupport to the household. The impact cantake the form of lost earnings whenindividuals are sick or die prematurely dueto AIDS. In South Asia, the earnings lossesare staggering. Bloom and Mahal (1996)estimate that in Sri Lanka, lost lifetimeearnings due to an AIDS death werenearly eleven times the annual treatmentcosts. 4 In Nepal, they suggest that similarlosses were more than four times the percapita income. 5 Prolonged illness alsoresults in loss in savings and assetholdings, both due to an increase in costs,as well as a decrease in the propensity tosave due to lower life expectancy.A second, key immediate impact is thechange in the disposable income becauseof increased expenditure on treatment.Several studies have documented thecosts of treatment as being more thantwice the per capita incomes in selectedAsian countries. 6 In India, for instance,the ratio of treatment costs to per capitaincome was 2.2 while in Sri Lanka it was1.5. These estimates did not include thecosts of ARVs, which could be expectedto further push up the economic burdenon families and households.Loss of incomes and earnings can alsooccur due to the loss of a job because ofthe stigma associated with HIV infection,even if the HIV-positive individual is notlaid up with any of the opportunisticinfections associated with HIV/AIDS. Inthese cases, the discounted value of lostearnings is even greater than in the caseof an AIDS death, because treatmentcosts are incurred without any incomebeing earned. It is apparent that the lossof a job for a young adult has negativeeconomic and, possibly, psychologicalconsequences both for PLWHA and theirdependants. It is not the consequencesof job loss, however, but the relationshipbetween an individual’s HIV-status andjob loss that is of concern here. AMumbai-based NGO in India took up thecase of an individual who was dismissedfrom a public sector company after beingfound to be HIV-positive during medicalfitness tests that included testing hisblood for HIV, without obtaining priorconsent. 7 A similar example washighlighted in the Middle East Times 8 thatnoted the dismissal of a factory workerin Iran after he was found to be HIVpositive.This discrimination is notconfined to South Asia but exists in manyother countries as well. In Australia andCanada, for example, individuals weredischarged from the armed forces onmedical grounds after being found to beHIV-positive. 9At the same time, however, there arepromising signs of change in this attitude,with examples of how judicial, legislativeor policy action can readily mitigatestigma and discrimination. There havebeen several instances where the courtshave ruled in favour of reinstating HIVaffectedpeople in jobs in India. 10 In othercountries, there are statutes orinjunctions against dismissal solely forbeing HIV-positive. In Iran, for example,the health ministry appears to have18Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Nexus between Human Development and HIV/AIDS“banned the expulsion of people sufferingfrom AIDS”. 11 However, it is extremelylikely that these cases are more theexception than the rule. Since stigma anddiscrimination are deeply rooted insocietal attitudes, legislative and judicialsanctions alone will not be sufficient.Bharat (1999) documents a number ofcases where individuals resigned fromtheir jobs where they feared the reactionof other employees if found to be HIVpositive.In one case, the resignation wasprompted by the threat of a strike fromthe labour union.The HIV/AIDS epidemic also perpetuatespoverty across generations, by reducingthe economic, social and educationalopportunities available to children inaffected households. It also increases theburden on the elderly, many of whombecome responsible for orphanedgrandchildren and other dependentrelatives. This burden is now significantlyaltering social arrangements in sub-Saharan Africa. While this impact of theepidemic has not yet been documentedin the South Asian context, as theepidemic spreads, extended socialnetworks will certainly have to bear theburden of care. High levels of ignoranceleading to stigma and discriminationcould further strain these networks,leading to possible breakdowns incommunity ties and social capital asinfected people and their families facerejection and isolation.Human capabilitiesApart from affecting income, theepidemic significantly affects bothexisting capabilities of PLWHA and theopportunities available to them and theirfamily members to further enhance thesecapabilities. There is some evidence tosuggest that members of householdsaffected by HIV/AIDS, especially children,would have lower educational and healthlevels. This can happen if children haveto prematurely leave school to care forthe sick, or if the family can no longerafford to educate them after the death ofa breadwinner. Within the region,studies 12 indicate the difficulties thatchildren of HIV-positive persons face atschool, owing to stigma (See Box 2.2).Further, high rates of HIV/AIDS can alsoindirectly reduce education levels, ifpeople are unwilling to invest ineducation if there is little expectation ofchildren living long enough to benefitsubstantially from it.Spending on HIV treatment also crowdsout spending on nutritional intake andother health inputs, especially asBox 2.2Exclusion of HIV-positive children from school in response to boycottIn ebruary 2003, when two HIV-positive children,aged five and seven years, were admitted into a staterunschool in the Indian state of Kerala, media reportsindicated that the parents of the other 119 studentsdid not send their children to school because of fearsthat they would contract the virus. In response to thissustained boycott from the other children, and thesignificant media attention that it received, the Keralagovernment announced that the two children wouldbe schooled at home at state expense. NGOsresponded by challenging the state government’sdecision to remove the children from the school, arguingthat they have a clear right to be educated with otherchildren.This case raises serious questions as to how such formsof socially sanctioned abuse continue to occur even in ahighly educated and sensitised community, and how theycan be addressed. It is clear that there is an urgent needfor creative new responses that move beyond traditionalsensitisation approaches to transform the underlyingbeliefs, norms and values within communities and toensure a normative environment in which the rights ofperson living with HIV/AIDS (PLWHA) can be upheld.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 19

Nexus between Human Development and HIV/AIDSHIV/AIDS alsolimits the access ofPLWHA to healthservices, otherpublic services andfinancial and socialresources.household resources become increasinglylimited. HIV also affects the averageproductivity levels of PLWHA, as well ascommunities and firms. At the workplace,individual morale and productivitylevels are affected by the economicenvironment in which they operate.HIV/AIDS also limits the access of PLWHAto health services, other public servicesand financial and social resources. All thisaffects their capabilities to developthemselves. In an intensive study of twocities in India, Mumbai and Bangalore,Bharat (1999) documented cases wherePLWHA had difficulty in accessinghealthcare and support, even from familymembers. In some cases, familycaregivers simply abandoned them, whilein others, hospitals and medical carepersonnel actively discriminated againstthem. This included isolating HIVpositiveindividuals from other patients,delaying or avoiding surgery, replacingintravenous procedures by oralprocedures, and early discharge ofpatients from hospitals. The studyalso noted the inability of medicalpersonnel to preserve the confidentialityof PLWHA. As a result, some patientschose to voluntarily discharge themselvesrather than allow their HIV status to bewidely disclosed.In a small survey conducted amongmedical personnel in Sri Lanka in 1994,Bloom et al. 13 found that 75 per cent ofhospital staff agreed with the statementthat “AIDS patients are very infectious andshould, therefore, be isolated in separatewards to reduce the risk of infectingmedical personnel and other patients.”Thirty-six per cent also said that ifinformed about a patient’s HIV-positivestatus, they would inform otherindividuals without obtaining thepatient’s consent.HIV positive status can also deny accessto life and health insurance. This willseriously limit the ability of the affectedperson (or household members) to affordcare that is needed, and will have severefinancial implications for the family giventhe high treatment costs and thepremature death of a possiblebreadwinner. In a region where publicexpenditure on health is limited, and theprivate sector is the dominant provider ofhealth services, every incidence of illhealthcould lead to a debt trap for poorhouseholds. This situation is furtheraggravated in the absence of universalcoverage by an affordable health insurancescheme to provide for the health needs ofthe poorest sections of society.Individual libertiesHIV/AIDS and its associated stigma anddiscrimination have significantlycurtailed individual liberties in theeconomic, social and political lives ofPLWHA. Social ostracism has often beenaccompanied by State-sponsoredrestriction of liberties as well. In theIndian state of Goa, Dominic D’Souza,who had donated blood and was found tobe HIV positive, was kept in solitaryconfinement under the Goa Public HealthAmendment Act (GPHAA), 1985, whichput anyone testing positive for HIV undermandatory isolation. D’Souza wasreleased from confinement after a lengthycourt battle, in which the court held that“it would no longer be mandatory todetain positive people, except in‘justifiable’ cases”. The GPHAA was lateramended and such isolation was madediscretionary. Similarly, in Pakistan, anHIV-positive housemaid was sentencedto a three-month stay in isolation at aprison hospital in 1988. 14Such official policies also restrictindividuals’ freedom of movement and20Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Nexus between Human Development and HIV/AIDSBox 2.3The Greater Involvement of People Living with HIV/AIDS (GIPA)The GIPA principles were established at the Paris AIDSSummit in December 1994, and were articulated inthe Paris AIDS Summit Declaration. In this Declaration,representatives from 42 countries committed tosupport the total involvement of people living withHIV/AIDS (PLWHA) in the common response to theepidemic at all levels. The main commitments of theDeclaration were to:nnnnnSupport the greater involvement of PLWHA throughinitiatives to strengthen the capacity and coordinationof networks of PLWHA and community-basedorganisations (CBOs), stimulating the creation ofsupportive political, legal and social environmentully involve PLWHA in decision making,formulation and implementation of public policiesProtect and promote the rights of individuals,particularly those living with or most vulnerable toHIV/AIDS, through legal and social measuresMake available necessary resources to bettercombat the epidemic including adequate supportfor PLWHA, NGOs and CBOs working withvulnerable and marginalised populationsStrengthen national and international mechanismsthat are concerned with HIV/AIDS, human rightsand ethicsRecognising the valuable experience of PLWHA andthe importance of their meaningful involvement inevery aspect of the response is a crucial element inattempts to arrest the epidemic and mitigate theimpact of HIV/AIDS. The greater involvement of peopleliving with HIV/AIDS (GIPA) aims to create spacewithin society for active participation of PLWHA atall levels—from policy and decision-making toimplementation.GIPA has often been interpreted as giving a humanface and voice to the HIV epidemic. However, althoughthis is a first step to increase the general awarenessand recognition that all individuals, communities andsocieties are at risk from HIV, it has often led totokenism where PLWHA have become objects ratherthan subjects in the responses to the epidemic. Indeveloping nations particularly, the meaningfulinvolvement of HIV-positive is inseparable from theempowerment of PLWHA, many of whom are frommarginalised groups and already experience poverty,powerlessness and discrimination. In the South Asiancontext, therefore, GIPA is increasingly beinginterpreted as the empowerment of PLWHA to becomeagents of change in order to transform the norms andvalues that cause stigma and discrimination, promoterespect for human rights and increase the quality ofHIV prevention, care, support and treatment responses.However, despite the global acceptance of the GIPAprinciples, putting them into practice remains a toughchallenge. In South Asia, in particular, PLWHAorganisations, groups and networks have been slow toemerge due to multiple challenges such as severe andwidespread stigma and discrimination, limited capacityand very scarce resources.Support is urgently needed for the PLWHA organisationsthat are now gaining strength within the region and areincreasingly trying to influence policy-making as wellas working to enhance community-level responses.their ability to travel, within the region andbeyond, whether for employment, refuge,education or, simply, pleasure. Testingmigrants and those seeking residence forHIV is a common practice globally andthere is mandatory testing for certainpopulations. A study undertaken for theWHO’s Global Programme on AIDS, 15analysed the then existing immigrationlaws in 40 countries, in terms of their abilityto influence mobility across nationalborders. It concluded that countries haveused one or more of two sets ofjustifications–reducing public financialburden and reducing risks to publichealth–to restrict entry on health grounds.Such restrictions are common in theSouth Asian region. In Iran the standardvisa application form inquires whether theapplicant has previously suffered from acontagious illness. A worldwide survey ofimmigration restrictions suggests thatcurbs on PLWHA are also present inBangladesh, Maldives, Sri Lanka andRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 21

Nexus between Human Development and HIV/AIDSHIV/AIDS has anegativeassociation withHDI, mainlythrough a declinein life expectancyat birth.Pakistan. 16 Given that South Asiacontributes a large number of workers anddomicile residents, these restrictivepolicies curtail livelihood options forpeople in the region and violate humanrights of migrants and travellers. SouthAsian migrants working overseas are oftendeported because of their HIV status withno support or counselling provided.Marginalisation and discriminationof vulnerable groupsThe fact that it is marginalised groups—sex workers, migrants, injecting drugusers and men who have sex with men—who have so far been most severelyaffected by HIV/AIDS in South Asia hasresulted in these groups being blamedfor its spread. This has led to theirfurther marginalisation, stigmatisation,harassment and discrimination. Apartfrom violations of their rights, this alsomakes them face greater social exclusion.This, in turn, only increases theirvulnerability to HIV and allows theepidemic to spread because they are thenless able to access the information,services and support needed to protectthemselves and others from infection.They also become more vulnerable toabuse and exploitation, as seen in thesexual abuse experienced by men whohave sex with men in Bangladesh. 17 Suchincreased marginalisation also reducesthe livelihood security and opportunitiesof these groups, thereby heightening theirvulnerability to HIV/AIDS by promptingunsafe migration or sex work.Impact on womenNearly 36 per cent of all PLWHA in Southand South East Asia are women. 18 Thespread of the epidemic in a region withalready highly unequal gender relationsaffects men and women differently. Theimpact of the epidemic falls primarilyon women in four different, thoughrelated, ways:llllwomen shoulder the increased burdenof care within the household andthe community, in addition to theirdomestic work and economicresponsibilities;this increased care or the disease itselflessens the ability of women to workin the formal, informal or agriculturalsectors, leading to a further loss ofincome, reduction in child care andfood security;in cases where the male members ofthe household stop earning or die ofAIDS, the women are left to providefor the rest of the family, and this caninclude being pushed into the sextrade; andfinally, women are often blamed fortheir family’s and their own sickness,and are ostracised by the extendedfamily and community, leading to theirbearing the social and psychologicalburden of the disease as well. 19Measuring the impact of HIV onhuman developmentThere have been several attempts tomeasure the aggregated impact ofHIV/AIDS on human development. Thissection assesses the statistical relationshipbetween HIV and human developmentand some of its components—lifeexpectancy, educational achievements,and real GDP per capita, 20 particularly forSouth Asia.The estimates show that HIV/AIDS has anegative association with HDI, mainlythrough a decline in life expectancy atbirth. For the countries in South Asia,however, the estimated impact ofHIV/AIDS on overall human developmentis likely to have been small, owingsimply to the relatively small scale of theepidemic thus far. For instance, in Indiaas a whole, the effect of the AIDS epidemicbetween 1980 and 1998 would havebeen to reduce the HDI in 1999 by about22Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Nexus between Human Development and HIV/AIDS0.003—or about 0.6 per cent below whatit would have been in the absence of AIDS.For other countries in the region, with thepossible exception of Nepal where itwould be 0.4 per cent, the effects will beeven smaller, given the currently smallscale of the epidemic there. 21Given the comparatively sparse coverageof data on HIV, this is likely to be anunderestimation and reflects a lower limitof the impact spectrum. Tables T3, T4a and b and T5 (see Technical Note B)examine three individual components ofHDI and their relationship to HIV toidentify the main ways by which HIV hasinfluenced HDI, thus far. The HIV/AIDSepidemic has a statistically significantassociation with life expectancyat birth. 22In India, the country most affected byHIV/AIDS in the region, the adverseeffect on life expectancy at birth is milder,given the relatively recent origin of theepidemic (about 0.4 years). For India andNepal, the reductions in life expectancydue to HIV/AIDS turn out to be small,relative to what they would have been inthe absence of HIV/AIDS—0.7 per centand 0.35 per cent, respectively of theno-AIDS case life expectancy. 23Table T4 presents Ordinary Least Squares(OLS) results of regressions of adultliteracy rates in 1998 on its lagged valuesand indicators of the HIV/AIDS epidemic.This relationship tends to go in a directionopposite to what intuition mightsuggest—that is, towards increasing themeasured levels of average achievement. 24On the other hand, disproportionatenumbers of AIDS deaths among peoplewho are educated (and rich), as some haveargued, may also cause average levels ofeducational achievement to decline. Atthe same time, average educationalcapital might also go up on account ofHIV, if the epidemic is disproportionatelyconcentrated among the poor who mayhave less than average amounts ofeducational capital in the short term. Thisis consistent with the hypothesis that HIVis disproportionately concentratedamong the poor, but further analyses totest the robustness of these findings areobviously warranted. Careful reflectionwould suggest, however, that thedirection of influence could go eitherway. In the case of children who are HIVpositive, a reduced expected length oflife, by reducing the returns that theymight receive over their lifetime,might cause parents to spend less oneducational capital.In an exercise to study the relationshipof HIV/AIDS with the GenderDevelopment Index (GDI), it is clear thatHIV/AIDS has a statistically significantnegative association with GDI. TablesT7, T8, T9 (see Technical Note B)demonstrate that, as in the case of theHDI, the influence of the AIDS epidemicon GDI is primarily through the lifeexpectancy index, and not by measuresof educational achievement. The abovefinding is not surprising given that boththe HDI and GDI values in the SouthAsian region are comparatively low andthe vector of patriarchy is common to allthe countries of the region.These low levels of association are notsurprising given the current stage of theepidemic in the region. However, asindicated earlier, this should not be asource for complacency. Examples fromother regions, ranging from sub-SaharanAfrica to Eastern Europe, have shownthat the epidemic spreads rapidly, andonce it reaches a certain scale in acountry, it has a devastating effect on theeconomy, the productive capacity of itspeople and the sustainability of itseconomic growth.In the case ofchildren who areHIV positive, areduced expectedlength of life, byreducing thereturns that theymight receive overtheir lifetime,might causeparents to spendless on educationalcapital.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 23

Nexus between Human Development and HIV/AIDSSpecifically,indicators such asincome, assetholdings, quality ofhousing,occupation and thelevel of educationalachievement wereall strongly andpositivelyassociated withawareness ofHIV/AIDS.2.2.2 Impact of humandevelopment on HIV/AIDSIn this section, the focus is on theobverse of the relationship highlightedpreviously—the role that variables relatedto human development play ininfluencing the spread of HIV, as well asthe possible linkages between humandevelopment strategies and the responseto HIV.Impact of different dimensions ofhuman development on HIVThere are several ways in which humandevelopment can influence HIVtransmission—the level of economic andeducational achievement, standards ofhealth and access to health services,income inequalities, gender relations andthe treatment of vulnerable subgroups ofthe population and basic legal rights toprivacy, life and liberty.It has been argued that the differentdimensions of human development affectthe vector of HIV transmission. “Therate of HIV transmission is not simplya function of sexual behaviour.Epidemiological, clinical and laboratoryevidence shows that HIV infection isevidenced by the same factors thatpromote the transmission of otherinfectious diseases. There is an establishedliterature in public health and a centuryof clinical practice demonstrating thatpersons with nutritional deficiencies,with parasitic diseases whose generalhealth is poor, who have little access tohealth services, or who are otherwiseeconomically disadvantaged have greatersusceptibility to infectious diseases,whether they are transmitted sexually, byfood, water, air or other means.” 25Socio-economic conditionsWithin South Asia, there are four sets ofanalyses whose findings relating to theimpact of income levels and educationalattainment on protection measuresagainst HIV risk are especially instructive.Basu, Gupta and Krishna (1997), in theirexamination of the impact of adult deathon households in India, foundconsiderable socio-economic variation inAIDS awareness among individuals.Within the South Asian region, they foundthat although there are adverse impactsof the epidemic, the responsemechanisms tend to vary according to thecharacteristics of the household. Richerhouseholds tend to be able to cope betterthan poorer households, and householdswhere the adult was ‘self-employed’ tendto cope better than where the adult wasemployed as wage or salary-worker.Specifically, indicators such as income,asset holdings, quality of housing,occupation and the level of educationalachievement were all strongly andpositively associated with awareness ofHIV/AIDS. The study also found that theuse of disposable needles for injections inthe sampled households increased withsocio-economic status. Studies of thegeneral population, sex workers, overseasmigrant returnee workers in Sri Lanka allshowed that HIV/AIDS awareness wasmuch lower among individuals with lowerlevels of economic and educationalachievement. Sex workers in Sri Lanka whoearn higher wages (and who were alsorelatively better educated) were muchbetter informed about HIV/AIDS thanbrothel-based sex workers andstreetwalkers who serve the lower end ofthe sex market. This was reflected incondom use—only 44 per cent of thestreetwalkers used condoms “always”,compared to 87 per cent for those whoearned more. 26 Another study, using datafrom a 1993 survey of nearly 600 sex workersin Kolkata, India, found that condom useis negatively linked to the price of a sexualact and positively associated with thelevel of education. This suggests the key24Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Nexus between Human Development and HIV/AIDSrole that economic returns and educationplay in the implementation of HIVprevention policies. 27It is not always clear to those engaging inmulti-partner sex that sexual activity canbe safe if condoms are always used.Education and awareness levels matter,as indicated in a recent survey of theliterature on the roots of HIV. 28 Schoolenrolment rates and illiteracy rates in themajority of the developing world, andparticularly in Africa, are substantiallylower than in richer countries. Analysesof household data from Cambodia,Vietnam, Nicaragua and Tanzania showsa strong correlation between both wealthand education on the one hand andknowledge that condoms prevent AIDS,of where condoms can be obtained, anduse of condoms on the other. 29Gender inequalityLiving as they do on the margins of society,poor men, women and girls have to copewith vulnerable environments. Genderdiscrimination and inequality expressthemselves in many forms acrosssocieties. It is also established now thatvulnerability to the infection is notrandom, nor is the impact. Theseinequalities not only facilitate the spreadof HIV but they also get reinforced in thoseinfected and affected.There is a growing recognition that thedisempowerment of women—because ofwhich they have no control over decisionsabout their bodies or sexual health—islargely responsible for the pace at whichthe infection is spreading in this group. UNSecretary General Kofi Annan summed upthe problem in his ‘Report of the Secretary-General’, 2001: “The gender dynamics ofthe epidemic are far-reaching due towomen's weaker ability to negotiate safesex and their generally lower socioeconomicstatus.” Girls and youngwomen show a higher rate of acquisitioncompared to men of similar ages.Box 2.4Women and HIVCare of the Sick: The care of family members who fallsick as a result of HIV/AIDS adds to the existing burdenof domestic and economic duties.Loss of Livelihoods: As care of the sick of dying takeswomen’s time, or a woman becomes sick herself, shemay be forced to abandon work in formal or informalsectors, with consequent reduction in family incomeand food security. Lack of time and resources, sicknessand exhaustion may lead to the neglect of children.Economic support of the family: With loss of income asa result of illness or death of the earning member, womenare often to support the family and children in whateverway they can. This may include using sex as one of thefew avenues of economic support open to her.Alienation and stigmatisation: It is often the womanwho is blamed for her husband and/or child falling sick,as well as being railed for her own infection, leading torejection and expulsion by the family and community.Socio-economic, cultural and legal conditions influencethe degree of decision making capacity a woman hasregardingn the extent and nature of her education;n the timing and nature of the onset of her sexualactivity;n whether, when and whom she marries;n the nature of her sexual relationships;n whether, when and how often she becomespregnant;n whether she is allowed to keep her female child;n whether and where she receives treatment forreproductive health problems;n whether she is informed about HIV/AIDS andwhether she can act if informed; andn how she survives economically.In such a context, how can a woman in South Asiaprotect herself and her unborn child from HIV infection.Source: AIDS in South Asia: A development challenge, UNDP HIV and Development Programme, 2001Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 25

Nexus between Human Development and HIV/AIDSPositive andaffected womenend up fending forthe family,repaying debts,and meetinghospital costs ofthe spouse.The gendered face of HIV/AIDS isintegrally connected to the fact thatwomen bear the major brunt of thepsychological, social and economiconslaught related to loss of livelihoods,poverty and care of the sick. Gendernorms impact the way in which infectedmen and women are perceived, thusinfluencing ways in which individualscope with HIV/AIDS. 30 Effectiveimplementation of gender sensitiveprogrammes in HIV/AIDS requires ananalysis of the differential politicaleconomy of risk in the region.Women constitute the most deprivedsections of society and have very limitedaccess to resources, education, trainingand labour markets. A total of 44 per centof the world's illiterate women are inSouth Asia and the region accounts forone-third of the world's maternal deaths. 31Only some countries like Bhutan havebeen able to achieve some gender parity,particularly in issues of property andinheritance and women are, therefore,seen to have a greater role in decisionmaking.However the impact of this is yetto be seen in the context of HIV/AIDS inthe country.The low economic and social position ofwomen in the South Asian region hasprofound implications on the HIVepidemic. Women typically have limitedaccess to reproductive health services andare often ignorant about HIV, the ways inwhich it can spread and preventionoptions. Social and cultural norms oftenprevent them from insisting onprevention methods such as use ofcondoms in their relations with theirhusbands. The congruence betweenindicators of women’s poor status andtheir vulnerability to HIV demonstratesthe close link between patriarchy and HIVin South Asia. The lack of decision-makingis reflected in the increasingly high ratesof infection among what are traditionallyconsidered low risk population groups.The vulnerability of women is evident inthe high rates of unwanted pregnanciesand high prevalence of SexuallyTransmitted Diseases (STDs). 32 Womenare thrown out of their homes or desertedby their husbands and are forced intosituations where they are sexuallyexploited, whether for work or foodsecurity. Employers and recruiters ofwomen working outside their homecountry often withhold passports andearnings. In Sri Lanka, girls left in the careof friends and relatives, when theirmothers have gone abroad as maids, areoften vulnerable to sexual abuse. 33The impact of HIV is also more severelyfelt by the women in the family. Positiveand affected women end up fending forthe family, repaying debts, and meetinghospital costs of the spouse. A study oftheir clients by Lawyer's Collective, anNGO in Mumbai, India, found that out ofthe 67 positive women respondents, atleast 60 per cent were economicallydependent and unemployed and 56 percent were widows. 34In several cases, it is the natal family thatprovides more support to the positiveperson than the marital family. Thisseems an extension of the dowry demandsmade on the wife's family. As such, theeconomic costs incurred by the natalfamily tend to be invisible. 35A study conducted by UNICEF indicatesthat most HIV-positive women becameaware of their status only after theirhusbands are diagnosed to be HIVpositiveor even as late as the death oftheir husbands. Such female-headedhouseholds are unable to afford evenbasic medicines to treat opportunisticinfections. A woman experiences dual26Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Nexus between Human Development and HIV/AIDSstigmatisation—as a widow andespecially a widow of a positive man.Discriminatory access to property rights,shelter and care facilities are some issueswith which single and widowed womenare confronted. If the child is alsodiagnosed as HIV positive (a likelihood,given the increase in mother to childtransmission), the burden on themother increases.Studies indicate that the level ofeducation in women is linked tothe information they access aboutHIV/AIDS. A study analysing HIV/AIDSawareness and prevention amongstwomen in India from the SecondNational Family Health Survey (NFHS-II, 1998) found that only 18 per cent ofnon-literate women had heard of HIVwhile 54 per cent of women with aprimary level of education had heard ofit. Even here there are regional variations.Women in states such as Tamil Nadu andKerala with higher rates of female literacyreported higher awareness as comparedto states like Bihar. 36Unequal access to resourcesThe dualistic pattern of development inSouth Asia has meant an incompleteepidemiological transition, with thesimultaneous prevalence of diseases ofpoverty (caused due to poor livingconditions and poor nutrition) along withdiseases induced by affluent lifestyles.This is reflected in the skeweddevelopment of health infrastructure andfacilities in these countries. Thus, the richin South Asia access the relatively betterequippedprivate hospitals while the poorrely to a greater extent on public hospitals.Since the services rendered there areunsatisfactory, they turn to privatehospitals for curative treatment thoughthe costs are far higher. Primary healthcareis, thus, a neglected area as is thetreatment of communicable diseases.More often than not, the lack of insurancecoverage has serious implications foraffordability of care (see Box 2.7).The study by Bloom et al. (1996), usinginterviews with the staff of insurancecompanies in Sri Lanka, demonstratedthat, as of 1995, individuals withHIV/AIDS were excluded from health andlife insurance schemes, with limitedexceptions in circumstances wherepremium requirements had been fulfilled.Rural–urban economic differences,unequal opportunities, conflict, naturalcalamities, social factors and exploitationare the main factors behind migration. Inmany cases, the economic inequalityreflects an underlying social inequality –like the lower status of women relative tomen, which is reflected in their lowereducational status, fewer remunerativeopportunities and assets, and access tohealth. Migration, in itself, does not havean inevitable correlation with HIV, but inthe absence of information and access toservices and adequate preparedness,mobile populations become vulnerableto exploitation, trafficking and HIV.Economic deprivationEconomic deprivation and HIV/AIDSincidence appear to be linked, and thereare a number of reasons why one canexpect low levels of economicachievement to be rooted in HIV. 37 Thedynamics of the sex industry, for example,illustrates this linkage starkly. Extremepoverty often forces women and younggirls into the sex trade, which increasestheir risk of exposure to HIV. In one studyof female sex workers in Sri Lanka, nearly37 per cent of the women intervieweddescribed the need for “survival” as amajor reason for their entry into the sextrade. The numbers were even higher—48 per cent—for streetwalkers. 38 One studyin Ichok village in the Sindhupalchowkdistrict of Nepal quotes an interviewee asMore often thannot, the lackof insurancecoverage hasseriousimplications foraffordability ofcare.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 27

Nexus between Human Development and HIV/AIDSBox 2.5While the virus does not respect boundaries—betweennations, classes, gender, ethnicity or culture—both thevulnerability to HIV and the ability to cope with it areinfluenced dramatically by levels of income. The impactof HIV on individuals is not anecdotal but systemic.Judge Edwin Cameron from South Africa describes howhis access to good healthcare and treatment enabledhim to lead an active, healthy and productive life:“I can take these tablets because of the salary I earnas a judge. I am able to afford their cost…my presencehere embodies the injustices of AIDS in Africa …inwhich 290 million Africans survive on less that 1 US$a day, I can afford monthly medication costs of aboutUS$ 400 per month. Amidst the poverty of Africa Istand before you because I am able to purchase healthand vigour. I am here because I can afford to pay forLife itself”.In striking contrast is the following testimony of HarkanMaya, a woman from a poor Nepalese household.“My sister’s elder son is bed-ridden with AIDS now.He must be only about 30 years old but he’s about todie. Not only he, my sister is also suffering. We didn’tknow what AIDS was, so when we were told that itwould be cured slowly we borrowed money fortreatment. We also took him to Siliguri [a large town inIndia] for treatment where we were told that it wouldmake no difference whether he took medicines or not.When we asked him what we should do, he said thatsince the doctor had said medicines would not make adifference, he would not take them. He’s not takingmedicines now but his wound is being dressed regularly.Every few days, 80-90 rupees has to be spent onSources: Barnett and Whiteside, 2000; oreman, 2002Coping with HIV: different realitiesbandages and ointment for him. Instead of being cured,he’s losing weight. My sister must feel terrible. Herson has wounds all over his body. Water drips fromthem, he has to be given medicines, and his woundsneed dressings. So my sister doesn’t have the time tostay in the shop.“Income has gone down. A lot of money was spent inthe hospitals too. People give all sorts of advice on wherehe can be cured and once we hear that, even for hissake, we have to take him there. Otherwise, he couldfeel hurt. In that way, a lot of money was spent. Hiselder sister took loans and spent it on him. In the hospitalhe had to have all sorts of tests for his blood, his pus,his bones. So many X-rays were taken. Sometimes theysaid his hand was broken so it had to be put in a cast,sometimes they wanted the chest X-rayed.“They had his blood tested three or four times. We hadto go from Biratnagar to Dharan, so there weretransportation expenses. His hand was swollen, so hewas operated upon twice in Dharan. He had to be givenfour injections a day and they cost 200 rupees each.Then there were the cost of medicine and hospitalexpenses. The patient had to have good things to eat—fried liver, anta, yoghurt. There’s no income, justexpenses. My sister is fed up. Before her son fell sick,she had no trouble feeding herself. Now my sister isnot very well either.”Clearly the impact of HIV has a class bias, with thepoor at a great disadvantage when it comes to copingwith the high cost of treatment and the loss of livelihood.However it needs to be borne in mind that here we arespeaking not only of individual misfortune but a tragedyfor the households, communities and society.saying, “No one can survive on farmingonly…There would be a famine herewithout the sex trade.” 39 Examples ofeconomic need leading to entry into sexwork can be found in Bangladesh andPakistan as well. 40Of course, as the Sri Lankan study suggests,not all women enter the trade for ‘survival’.Levels of remuneration are also adetermining factor, especially if alternativeeconomic opportunities are not asattractive. For instance, a study of Bangkokmassage parlours in 1980 indicated that theaverage earnings of masseuses exceededwhat they earn in occupations elsewhereby nearly 1,700 per cent. 41 This alsoindicates that quality of employment is asimportant as the quantity in the context ofexpanding employment opportunities.28Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Nexus between Human Development and HIV/AIDSGlobal economic processes and macroeconomicpolicies serve as a factor inincreasing the vulnerability of certainsections of society. Increasing mobility inresponse to demands for cheap labour andthe absence of safe mobility options createsituations of vulnerability for migrantworkers. Long periods of separation fromthe family, marginalisation withinreceiving communities and absence ofsocial capital often lead to the migrantworkers seeking multi-partner sex inorder to meet their physical andemotional needs. Infection rates amongNepalese workers who had worked inIndia were found to be substantiallyhigher (10 per cent) than those who hadnot (2 per cent). 42Indeed, a study of the region found thattruck drivers routinely “stop at roadsidehotels which provide food, rest, alcohol,drugs and sex.” 43 Some countries in theregion—for example, Bangladesh,Pakistan and Sri Lanka—have notexperienced high rates of HIV infectionamong truck drivers thus far. The evidenceavailable indicates, however, that truckdrivers, even in these countries, are at highrisk of HIV infection, with some 60 percent in a recent sample of Bangladeshitruck drivers reporting engaging incommercial sex twice a month. 46 There isalso evidence that, based on the relativelysignificant numbers of reported cases ofHIV infection, overseas migrant workersmay be at high risk of HIV infection inBangladesh, Pakistan and Sri Lanka. 47Evidence of high-risk sexual behavioramong domestic migrant workers in Indiacan be found in one study of the Wazirpurindustrial area in Delhi. 48Institutional development andpolitical freedomsIn all of the above cases, it could be arguedthat punitive measures associated withHIV status, the role of legal and otherrestrictions related to the practice of sexwork or drug use actually contribute to thespread of HIV, rather than curtailing it. Forsex workers under the control of madams,this is self-evident, as the former havelittle choice in terms of partners andprotection from HIV infection. Inaddition to the anecdotal evidence citedabove, a study of sex workers in Nepalfound that women who had been ‘coerced’into entering the sex trade were threetimes as likely to be HIV-positive thanthose who had not. 49 The incarceration ofsex workers in rehabilitation homes andprisons is also likely to result in theirremaining “underground”, an approachthat could prevent them from accessinghealth messages. 50The impact of coercive laws can beexpected to increase the risk potential ofdrug user behaviour for three reasons.l The illegality of drug possessionmeans that drug users might prefer tostay underground, and so are unableto obtain ready access to preventionmessages associated with HIVBox 2.6 Poverty, gender and HIV/AIDSSex work that is driven by poverty is likely to foster behavioursthat are more risk-taking than might otherwise be the case. Povertyis a compelling reason to accept a client who refuses to use acondom. The journal article by Wawer et al. on their study ofcommercial sex workers in Thailand quotes one woman sex workeras saying: “Sometimes I will allow it (sex without condom).Sometimes not. If I have no alternative, no money to buy food, Iwould accept it”. 44 Sex workers who are poor are likely to work inlow-class establishments or on the street. They are less likely tohave access to treatment for other STIs, with such untreatedinfections being a key co-factor in susceptibility to HIV. Their clientsare less likely to be aware of or to take seriously the risks of HIVand other STIs and to take precautions by using a condom. Theirown poverty might well play a role here. In a disturbing indicationof risk-taking behaviour induced by desperation born of poverty,some commercial sex workers have reportedly opposed the useof condoms on the grounds that it could prolong sexual intercourse,thus reducing the total potential number of clients. 45Source: Extract from Collins and Rau, 2000Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 29

Nexus between Human Development and HIV/AIDSBox 2.7The availability of formal healthand life insuranceIn general, formal insurance is not accessible to people withHIV/AIDS due to a variety of excludability clauses 53 . In any event,private insurance coverage is typically quite low in most SouthAsian countries, as are safety nets offered by the public sector,or public sector insurance coverage. Even the low levels ofcoverage are hampered by the poor fiscal situation in many ofthese countries and the predominance of informal sectoremployment that lies outside the ambit of the formal public sector.One of the few ways in which households can reduce the impactof AIDS is by using public sector health facilities that are oftenavailable at subsidised rates to the poor. However, theunsatisfactory functioning of the public health systems in mostcountries implies that the poor may not be able to access therequired treatment at these facilities. Even assuming the requiredtreatment is available, as the epidemic spreads, it placesconsiderable strain on the already stretched capacity of the publichealth system. This is evident from other developing countrieswith an advanced HIV/AIDS epidemic, where it has resulted inoverburdening the capacity of the public health sector. HIV-relatedbed occupancy rates in public hospitals in several countries insub-Saharan Africa range from 25-70 per cent, with obviousimplications for the health budget. In any event, it appears thatnot all households can access services at subsidised rates. ANational AIDS Accounts study in Rwanda indicates that less than30 per cent of the AIDS-affected households had to meet theirhealthcare treatment expenditure needs from their own resources.Source: Guinness and Alban, 2000llDrug users might prefer to move tomore efficient methods of drug use—injection as against inhalation orsmoking—so as to reduce thetransaction costs of being caught whilepossessing drugs. 51When either drug or paraphernaliapossession is illegal, it would bebeneficial for injecting drug users toshare injecting equipment, and nothave everyone carry their ownequipment in order to reduce the riskof being suspected of carrying drugs.Family and community health levelsHealth status too, can affect HIVtransmission. There could be behaviouralfactors as individuals with a lower lifeexpectancy may have low self-esteem andlow levels of health-seeking behaviour andmight take risks with their health—including exposure to HIV infection—compared to those in better health. Thishas adverse implications not only for theindividual but the household andcommunity as well. Lower investmentin human development in terms ofhealth and education would lead to lowerhuman capital. Thus, even from thenarrower human capital perspective, “thelower the optimal investment in healthhuman capital, the fewer are the periodsin which a return to the investment canbe expected”. 52 This indicates that theconstraints and opportunities in theenabling environment of humandevelopment have a direct bearing on theongoing relation to HIV (See Box 2.8 as abest practice example).2.2.3 Human development andHIV infection: cross-countryevidenceAt a macro level, there is a systemic linkbetween human development and HIVacross countries. The analysis showsthat human development achievements,including a higher real incomeper capita and lower degree of economicinequality as measured by the ginicoefficient, 54 tend to contain the extentto which HIV prevalence is increasedowing to the duration of its presence ina population.Treating the time span of the epidemic asconstant, the analysis also indicates thatthe major indicators of humandevelopment achievements are alsostrongly associated with HIV incidence,and their effect is to lower HIV incidence.The other variable that has a statisticallysignificant effect on the HIV prevalencerate (at 5 per cent or 10 per cent levels ofsignificance) is economic inequality asmeasured by the gini coefficient. The30Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Nexus between Human Development and HIV/AIDSBox 2.8HIV prevention efforts and human development:NGO experience from SangliThe case of Vaishya AIDS Muqabla Parishad (VAMP)formed in 1996 in southern Maharashtra in India provideslessons for addressing the problem of HIV/AIDS amongcommercial sex workers. There are two collectives–with 2,000 to 3,000 sex worker members in each group–both emerging out of the work of an NGO calledSANGRAM based in Sangli, Maharashtra.SANGRAM’s goal was to create a sustainable responseto the AIDS epidemic by treating women in sex work asindividuals who could be empowered to change theircircumstances. It had its basis in the belief that sex workerscould become agents for change for both themselves andthe broader community. The activities of VAMP andSANGRAM involve peer education programmes in whichsex workers disseminated information about HIV/AIDS toothers in the trade, distribution of condoms, training andcounselling women who were unable to enforce condomuse by clients and helping women get access to medicalcare. One immediate outcome is that members of VAMPdo not think of themselves as victims but rather asmembers of a community with mutually beneficial goals.Apart from running the condom distributionprogramme, VAMP members represent the interestsof their community in different ways. They arbitratecommunity disputes, lobby with the police, helpwomen access government programmes and developleadership potential. or example, they frequentlymediate disputes between sex workers and thepowerful brothel owners. Through discussions withthe crime investigation units of the state and localpolice, raids on sex worker establishments have beengreatly reduced*. By slowly building a common identitywith other women in sex work, VAMP members arebeginning to place their own demands on policy platforms.These relate to de-criminalisation of sex work, bettermedical care at public hospitals in regions where VAMPoperates, and ending police raids on brothels. Moreover,one key HIV-related outcome appears to have been highrates of condom-use based on self-reports in a recentsurvey carried out among 600 sex workers in areas whereVAMP operates.* communication with Meena Seshu, SANGRAMSource: Mahal et al., 2001; Misra, Mahal and Shah, 2000results of Table T6 (see Technical Note B)indicate that, all else being the same, agreater degree of economic inequality isassociated with higher HIV incidence andprevalence in the adult population.Further, the effects of all these variablesbecome larger in size the greater the lengthof time an epidemic is prevalent in a givenpopulation. This is a desirable outcome,given that an initial infection of HIV islikely to be associated with severalsecondary infections. 552.3 The Price of Inertia: TheCosts of HIV at the Sectoraland National LevelIn addition to impacts at the level of theindividual and the household, HIV/AIDScan also have implications at the level ofspecific sectors and national economies,which, in turn, have direct and indirecteffects on human development. The highcosts to the government in the form oflost services, lower national productivityand output, loss in skills and experience,depletion of workforce in specificsectors, increased demands on healthand social sectors, and loss of humancapital can push the country into avicious circle of poverty. The epidemiccan lower human developmentoutcomes as resources are used up incombating the disease, leaving futuregenerations worse off, and underminingthe premise of sustainable humandevelopment. This section presents adiscussion of the impacts of HIV on foursectors—health (including healthinsurance), agriculture, private industryand transport—and the costs to thecountry as a whole.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 31

Nexus between Human Development and HIV/AIDSA national AIDSaccountingexercise recentlyconducted forRwanda suggeststhat nearly10 per cent of allhealth spending,public or private,was accounted forby HIV/AIDS.Health sectorThe relationship between HIV and healthis obvious. But have its impacts beenreflected at the sector-level, say, in termsof an increased burden on health services,increased share of health budgets, and onthe health insurance sector? Publicexpenditures on HIV/AIDS for countriesin the South Asian region are small, as inSri Lanka and India. 56 Scenario analysesundertaken in Bloom et al. (1997) indicatethat the effect of HIV/AIDS on bedoccupancy, while small in magnitude,could still be severe given that excesscapacity (supply of inpatient days relativeto demand) appears to be extremelylimited at present. This study also pointsout that an expanded HIV/AIDSepidemic could constrain the supply ofmedical personnel, many of whomrevealed that they would need to becompensated monetarily for increasedrisk of HIV infection. 57There is more evidence from countrieswith a longer experience with theepidemic, particularly from sub-SaharanAfrica, which hold useful lessons for SouthAsia. Guinness and Alban (2000) citestudies from Burkina Faso, the DemocraticRepublic of Congo, Uganda and Tanzaniaindicating that bed occupancyattributable to HIV/AIDS exceeded 50 percent in selected hospitals in countrieswith HIV-prevalence rates of 5-10 per centaround the time the study was conducted.For countries with HIV prevalence ratesin excess of 10 per cent (Cote d’Ivoire,South Africa, Swaziland, Zambia andZimbabwe), available data suggests thatbed occupancy due to AIDS ranged from25-70 per cent in urban hospitals. 58Guinness and Alban also summarisestudies that indicate significant shares ofthe health budget being accounted for byHIV/AIDS—20 per cent of the Malawihealth budget in 1996 and 13 per cent ofthe Swaziland health budget in 1994. InCote d’Ivoire, about 5.7 per cent of publichealth spending in 1995 was AIDSrelated,the corresponding figure forTanzania being 3.1 per cent. 59Public health spending is not the onlycasualty. A national AIDS accountingexercise recently conducted for Rwandasuggests that nearly 10 per cent of allhealth spending, public or private, wasaccounted for by HIV/AIDS. Besides,over 90 per cent of all spending ontreatment and prevention of HIV/AIDStook the form of out-of-pocket spendingby households. 60Compared to studies on the impact ofHIV/AIDS on health services and publichealth spending, there are very fewanalyses of the effect on the private healthinsurance sector. A major reason for thiscould be the exclusion of HIV-positiveindividuals from the pool of insurableindividuals, as suggested by a study for SriLanka. 61 Examples from other regionsmay be instructive in this regard. OneZimbabwean insurance companyestimated that 45 per cent of its healthinsurance claims in 1995-96 were AIDSrelated.62 Insurance companies’ reactionto HIV/AIDS is another way to discernpotential impacts of the epidemic.Thailand’s American InternationalAssurance (AIA) works with NGOs topromote HIV-prevention among factoryowners. The company gives financialincentives and discounts to companieswith strong workplace and communityprevention programmes.Agricultural sectorGiven its disproportionately high impacton young adults, it is safe to assume thatHIV/AIDS will have a significant impacton agricultural activities, which are largelylabour intensive. Studies from Africa maynot be completely indicative for the region,but they illustrate possible scenarios for the32Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Nexus between Human Development and HIV/AIDSfuture. A study for Rwanda estimated thatthe loss of a female adult member of anagricultural household could lead to anearly 50 per cent decline in its farm labourinputs, and similar results have beendocumented elsewhere in sub-SaharanAfrica. 63 Some of the consequences of thishas been a shift to less labour-intensivecash crops, declines in cultivated areas,and less animal husbandry. 64 In Zimbabwe,household survey results suggest thatAIDS-affected households experiencedsignificant declines in production onaverage—61 per cent in maize production,47 per cent in cotton production, and37 per cent in groundnut production. 65The effects of HIV/AIDS on national orregional agricultural production levels,however, have not been as welldocumented. A major reason couldsimply be the substitution of this lostproduction by increased agriculturalproduction among households notaffected by AIDS, a process facilitated byland transfers/sales from AIDS-affectedfamilies to such households. The onlysector-level estimates available are fromcomputable general equilibrium (CGE)model-based simulations undertaken byArndt and Lewis (2001) for South Africa,which show that value added in theagricultural sector in that country wouldbe 17 per cent lower in 2010 under aprojected AIDS scenario compared to asituation of no AIDS.Private sectorHIV/AIDS has the potential ofinfluencing private firms’ operating innon-agricultural sectors along these samelines—costs of worker replacement,absenteeism, insurance expenses, andhealthcare expenditures. In addition,there is the possibility of legal actionrelated to discrimination against HIVinfectedemployees and possible loss ofcustomer base. Non-economic factors, inthe form of loss of morale in the work forceas workers lose many of their colleaguesto AIDS or if HIV-positive workersare stigmatised, could also affectproductivity. 66 The evidence on theeconomic impact of HIV/AIDS on theprivate sector thus far is, however, mixed.Using data from a survey of nearly 1,000firms in sub-Saharan Africa, Biggs andShah (1997) concluded that the impact ofAIDS on staff turnover was minimal.However, they did find that replacingprofessional staff—often thought to be athigh risk, based on early studies in Africa—to be a significant problem, with firmstaking 24 weeks to replace a deceasedprofessional, compared to two to threeweeks for less skilled staff. Indeed, thereare examples of multinationals in SouthAfrica hiring three workers for each skilledposition to ensure that replacements areon hand when trained workers die. 67HIV/AIDS could adversely affect thecustomer base of companies, since thegroup hardest hit by AIDS—young adultsof working age—is also the group withmore purchasing power. Spending willbe redirected away from a host of sectorsto the health sector, which could seeincreased demand. Such effects are notreadily detected by individual firmsbecause of the dissipation of spendingimplications across local and internationaleconomies. Effects on thecustomer base are more likely to betransparent if there are dominant firms, orfirms organised into business associations.Transport sectorSeveral analyses have focused on the roleof people involved in the truckingindustry as a facilitating factor in HIVtransmission. 68 There are also a fewanalyses of the impact of HIV/AIDS onthe transport sector, relating to railwaysand the trucking industry. A study 69 of thesocio-economic impact of HIV on theA study forRwanda estimatedthat the loss of afemale adultmember of anagriculturalhousehold couldlead to a nearly50 per cent declinein its farm labourinputs.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 33

Nexus between Human Development and HIV/AIDSBox 2.9The impact of AIDS: business as usual?In the early years of the AIDS pandemic little thought was givento the role that businesses might play in HIV prevention, and theworkplace was not seen as a major venue for interventions.Globally, as the impact of HIV becomes more visible, businessleaders are increasingly seeing the advantages of creatingHIV/AIDS programmes. At the broadest level, businesses aredependent on the strength and vitality of their workers andcustomer base. HIV/AIDS increases the cost of doing business,reduces productivity and depresses overall demand. The visibleeffect of AIDS at the workplace is a concern for managers at alllevels, from the shop floor supervisors to the top management.Apart from loss of experienced personnel, increased recruitmentand training costs and higher labour turnover, there is also evidenceof absenteeism due to AIDS-related illnesses, the need to carefor others, and to attend funerals. In Chennai, capital of India’ssouthern state of Tamil Nadu, industrial labour absenteeism wasexpected to double because of AIDS. Given the vulnerability offirms to HIV, their individual workers and the households andcommunities to which they belong, it makes eminent sense toinvest in preventive care and support programmes to stem decliningbusiness productivity, profitability and workers’ incomes.Source: UNAIDS, 1998transport sector in India identified anumber of economic weaknesses withinthe industry, influenced by thedetrimental effects of HIV/AIDS. It arguesthat the loss of productivity of drivers withHIV will lead to revenue losses, forcingcompanies out of business since the“cost of maintaining the current level ofdeath benefits may overwhelm manybusinesses”. The study also noted that onlya few companies are prepared to cope withHIV and may insist on mandatory testingor end medical benefits.Giraud (1993) developed a methodology toassess and predict the impact of HIVamong long-haul truck drivers onThailand’s trucking industry in the 1991 to2000 period. The scenario undertaken inthat study led to Giraud concluding thatHIV/AIDS-related costs to the truckingindustry would increase from an estimated$40,000 to nearly $14.5 million by 2000.Another more recent study, of the UgandaRailway Corporation, concluded thatHIV/AIDS had substantially increased thelabour turnover rate for the Corporationand that nearly 10 per cent of itsemployees had died of AIDS in the yearspreceding the study. 70 Another set ofresults is available from the CGE analysisof Arndt and Lewis, who report that thetransport sector in South Africawould have 20 per cent lower value addedin 2001 under a projected scenario of theAIDS epidemic, relative to a no-AIDSscenario. Although few in number, thesestudies taken together suggest that thetransport sector could be a possiblemajor casualty of HIV/AIDS. Availabledata do indicate, however, high riskbehaviour being common among truckdrivers in the region. 71Cost to nationsImpacts on national economiesTwo types of impacts are worth notinghere—on aggregate outputs (or outputsper capita) and the distribution ofnational income. The two, taken together,have implications for the proportion ofnational population living below thepoverty line, as well. This sub-sectionassesses primarily the impact ofHIV/AIDS on national economic growthfor the countries of the region.Impacts on growth of real income percapita: some new evidenceNew evidence on the links betweenHIV/AIDS and growth of real income percapita, shows that the epidemic wouldhave reduced the worldwide annual rateof growth of real GDP per capita by nearly0.06 percentage points below what itwould have been in the absence of AIDSduring the 1980-98 period. In the countriesof sub-Saharan Africa, the reduction in theannual rate of growth of income per capitais estimated to be of the order of 0.15percentage points in this same period.Given the exceedingly small rate of growth34Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Nexus between Human Development and HIV/AIDSof cumulative AIDS prevalence amongcountries in the South Asian regionduring 1980-98, the AIDS epidemic has hada negligible impact on economic growththus far, even in India, the country withthe highest number of HIV cases inthe region.The returns to policy action inHIV/AIDSThe tools of cost-benefit and costeffectivenessanalyses—that compare thebenefits of a policy to its opportunitycosts—are standard methods usedby economists to evaluate alternativepolicy options.Cost-benefit analysis compares thebenefits of a policy action to its costs, bothof them evaluated in monetary terms. InSri Lanka, studies have shown thatpreventing HIV transmission via thescreening of blood used for transfusion,and the use of disposable, instead ofreusable, injecting equipment in hospitalsettings can yield benefits that are muchgreater relative to costs. 72Cost-effectiveness analysis typicallycompares an outcome indicator such aslives saved and disability adjusted lifeyears averted 73 that is not measured inmonetary units, with costs that aremeasured in monetary units. There arestudies demonstrating the potentiallyhigh cost-effectiveness ratio ofprogrammes such as needle exchanges,STD prevention, informationprovision. 74 Cost-effectiveness analysesfor health interventions (includingHIV/AIDS) are not always useful forpolicymakers when comparing withpolicies in sectors other than health,since the former have outcomeindicators in units other than money.Thus, cost-benefit analyses are typicallypreferred since both benefits and costsare reduced to monetary units, provided,of course, policies in other areas aresimilarly evaluated.Impacts of HIV on poverty and equityIt is true that 95 per cent of those infectedwith HIV live in developing countries,home to 80 per cent of the world’spopulation. At the global level, there is astatistically significant associationbetween low income and HIV prevalencerates—the poorer the country, the greaterHIV prevalence rate. Moreover, absolutepoverty rates across countries—definedas the proportion of population livingbelow the poverty line of $1 per day—arepositively associated with national HIVprevalence rates. There is a positive andstatistically significant correlationbetween HIV and economic inequality aswell. 75 Nonetheless, beyond thesecorrelations, the direct impact of HIV onpoverty and inequality has not beendemonstrated empirically at the nationallevel. This is remarkable, given the globaltwo-way links between the HIV andindicators of economic well being. 76Education is not the only factor highlightedby micro-data. There is evidence thatpoverty forces people to make sub-optimalchoices and this puts them at risk of HIVinfection. As already mentioned, a seriesof small-scale studies from Sri Lanka,Brazil, sub-Saharan Africa and Haiti showhow poor women can be forced into sexwork, or be sexually exploited, and are lessable to insist on condoms use. 772.4 Implications of theAnalysisThe sections of this chapter highlighted thegamut of human development dimensionsthat are affected by, and in turn, impactHIV/AIDS. These, additionally, demonstratedthe effects of HIV on incomes, assetholdings, education, health, liberty andother elements of human development.There are studiesdemonstrating thepotentially highcost-effectivenessratio ofprogrammes suchas needleexchanges, STDprevention, andinformationprovision.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 35

Nexus between Human Development and HIV/AIDSBox 2.10Does it pay to intervene early?Are there greater returns from intervening earlier,rather than later, in the HIV/AIDS epidemic? There hasbeen little analysis of this so far, although it is possibleto visualise the challenge of choosing the optimal timingof policy as a technical problem with three keycomponents. These are:nnnThe reduction in costs (in present discounted valueterms) of waiting one more period instead ofimplementing the policy immediately;the added benefits of implementing the policyimmediately in terms of the lower number of HIVinfections in the current period; andthe difference in the number of HIV infections (ifany) from implementing the policy now versus oneperiod later, in all future periods than the currentperiod.To see this decision problem clearly, suppose that acountry has two new HIV infections in time period 1,and that the number of new infections doubles eachyear in the absence of any intervention. So there aretwo new HIV infections in year 1, four in year 2, eightin year 3, 16 in year 4, 32 in year 5, and so on. Nowsuppose, there is an intervention that costs C in eachyear starting from the date it is first implemented andwhich reduces the number of new infections by halfeach year. Then, if the intervention is introduced inyear 1, the time profile of new HIV cases is 1,1,1,1,1…if the intervention is introduced in the first year. Iffirst introduced in the second year, the time profile is2,2,2,2,2… If the money value of an averted HIVcase is V, then the problem of waiting one more periodbefore implementing the policy becomes one ofcomparing V/r (r is the discount rate and V/r is theadded discounted benefit of implementing the policyimmediately versus waiting one more period) and C. IfV/r exceeds C, then the policy ought to be undertakenimmediately. Otherwise, it might be worthwhile to waitone more period.The above example suggests that the nature of the policyintervention is also likely to be a crucial factor in thedecision on whether or not to wait before implementinga policy. Where individual behaviour is less likely to beimportant in subverting policy, early intervention maybe useful, as in the blood screening programmes. Onthe other hand, in a regime of low HIV prevalence rate,an intervention that provides information about avertingHIV risk from unprotected sexual activity may not bevery useful in influencing high-risk behaviour if peopleperceive the risk to be small. In a high prevalence ratesetting, such information provision may actually influencebehaviour towards activities at lower risk of HIVinfection. That may call for such intervention to beintroduced a bit later. However, to the extent that peopleare more likely to undertake ‘private’ preventive actiononly when the AIDS epidemic starts becoming morevisible, publicly supported HIV prevention programmesmay have to be introduced early. The net effect on thetiming of policy is dependent on the relative strengthsof these two effects.Analyses conducted for Sri Lanka (a low HIV-prevalencerate country) suggest that it may be cost-beneficial toset up blood screening programmes and to introducedisposable, instead of reusable cutting equipment evenwhen HIV infection rates are extremely low, at 0.08per cent. 78 The study compared the returns fromintroducing a universal blood donor pre-screening andtesting programme to its costs at these low HIVprevalencelevels and found that the rate of return overcost was 16 per cent, provided downstream infectionswere included for the next ten years. Thus, the policyof introducing a screening programme could beinterpreted as saying that it was better to introducethe programme immediately, if the only comparison werea policy to be introduced ten years later.The subsequent cross-country data areconsistent with this two-way linkage. Afirst set of analyses show that the HIVepidemic has a statistically significantassociation with human development asmeasured by the HDI, primarily throughits influence on life expectancy at birth.The effects of HIV/AIDS on literacy andother indicators of educationalachievement and GDP per capita are notapparent, at least statistically, for theperiod of the study. A second set of crosscountryeconometric analyses highlightedthe relationship between humandevelopment and HIV prevalence,specifically indicating the role of literacy,36Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Nexus between Human Development and HIV/AIDShealth and economic status, economicinequality and indicators of internationalmobility as possible factors ininfluencing HIV prevalence. Thesequalitative analyses also showed that theexposure of individuals to, and adoptionof, many of the standard preventionmethods for HIV—condom use, the useof clean needles, contacts with the formalhealth system and healthcare andprevention messages—appear to becontingent on achievements in thehuman development arena.The two-way link noted above should notbe taken to mean support for aprogramme that focuses solely on HIVprevention, with the idea that this wouldpromote human development, in turnleading to reduction in HIV transmission,and so on. Rather, the key point to note isthat these relationships suggest that thesuccess of the prevention programmesthemselves may depend on gains in thehuman development arena. This isreflected in the discussion on thepotential influences on condom usepatterns, needle sharing habits and accessto healthcare and information. It is bestperceived as lending support to HIVprevention efforts that go beyond anarrow technical focus on preventionand attempt to integrate such effortswithin a broader programme of humandevelopment.The popular misconception that humandevelopment approaches to the epidemicare too time-consuming need to bereviewed and revised. On the one hand,key elements on the human developmentfront can be addressed in the short run.These include, for example, thefunctioning of law enforcement agents ina manner that protects the rights of thosevulnerable to, or living with, HIV, and oftenjust require a fairer application of existinglaws or a revision of laws that are notenabling. On the other hand, humandevelopment responses provide effectiveentry points to contain the spread of theepidemic and mitigate its impact in aregion where the epidemic is not visibleand denial and stigma and discriminationare high. They also provide sustainablesolutions having multiplier effects that gobeyond the epidemic itself.2.5 ConclusionWhile the AIDS epidemic has a definiteeconomic impact, it has not always beenpossible to measure it empirically with areasonable degree of precision. Moreover,while there is some evidence of negativeindividual, household and firm levelimpacts,the empirical evidence on theimpacts at the sector and national levelsis weak. Much of the evidence available iswith respect to sub-Saharan Africa andevidence for the countries being studiedin this report is scarce. Further work maybe necessary to provide conclusiveevidence of the size and nature of theeffects in the region.A more fundamental aspect that thisdiscussion raises is that of viewing themacro impact, which is an instrumentalapproach, located in the conceptualframework of human capital whereinvestments in people’s skills is seen asproviding a greater return in terms ofincreased productivity, improvedworkforce management etc. On the otherhand, our analysis has demonstrated that,within South Asia the micro-economicimpact of HIV—at the level of individualhousehold, communities and firms—ismore significant than the macroeconomic impact. It would, therefore,be appropriate to go beyond the cost-tonationaleconomies discourse and focusstrongly on the psycho-social dimensionsat the grass-roots level – for the individualsand households that directly confront theThe key point tonote is that theserelationshipssuggest that thesuccess of thepreventionprogrammesthemselves maydepend on gains inthe humandevelopmentarena.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 37

Nexus between Human Development and HIV/AIDSepidemic and live with the virus on a dailybasis. Clearly the human developmentframework, which places people at thecentre as empowered beings and not asfactory inputs is well suited to enshrinethe principle of GIPA. It may beinstructive at this point to listen to thevoices of PLWHA and build their concernssystematically into not only programmespertaining to HIV and public health butalso address their concerns regardinglivelihood, social security and a publicexistence cleansed of stigma anddiscrimination.“or while there is increasing evidence that the problem of the epidemic isincreasingly perceived as developmental in its origins, in that thedeterminants are fundamentally structural, there remains an enormous gapbetween a deepened perception of the problem and a commitment to effectiveaction. … An effective response to the epidemic entails more than redefiningit as a developmental problem, in that what is needed are policies fordevelopment that are themselves relevant and effective. Thus, it has beenprecisely the failures of development that have generated the conditions inwhich the HIV epidemic has thrived, and which also constrains effectiveresponses to its deepening socio-economic impact.”Sheila Smith and Desmond Cohen in Gender, Developmentand the HIV Epidemic, UNDP, 200038Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

The HIV/AIDS Epidemics of South AsiaRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 39

The HIV/AIDS Epidemics of South Asia40Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

The HIV/AIDS Epidemics of South Asia“It is no secret thatHIV/AIDS is wellspread out in SouthAsia. Although HIVprevalence rate is stilllow in the region, it isknown to have one ofthe most rapidlygrowing HIV/AIDSepidemics globally.With every SAARCnation reportinginfections today,HIV/AIDS has alreadybecome a regionalproblem”.H.E. Mr. Q.A.M.A. Rahim,Secretary-General ofSAARC at the South AsiaHigh Level Conference‘Accelerating theMomentum in the ightAgainst HIV/AIDS inSouth Asia’, Kathmandu,Nepal, ebruary 2003Chapter 3The HIV/AIDS Epidemics ofSouth Asia3.1 Status of the Epidemic3.1.1 A collage of multipleepidemicsAny analysis of the HIV/AIDS epidemicsof South Asia is limited by the sparsenessof epidemiological data. HIV is believedto have entered South Asia in the early tomid 1980s. By the late 1980s, it was clearthat HIV transmission among variousSouth Asian populations was escalatingand with disturbing rapidity in some ofthem. From all obtainable data, it appearsthat the region is a collage of miniepidemicsdisplaying considerablevariation in scope and intensity.Some 700,000 new HIV infections areestimated to have occurred in South andSouth East Asia in 2002. 1 By the end of2002, an estimated 6 million adults andchildren are living with HIV in theseregions, less than half the adults beingwomen. The South and South East Asiaregion accounted for an estimated440,000 child and adult deaths due toHIV/AIDS in 2002. 2The earliest detection of HIV infectionin South Asia was in 1986 in India. Thenext year, Iran, Nepal, Pakistan andSri Lanka also reported the presence ofHIV in their countries, followed byBangladesh in 1989. Since then, nearlyall the countries of the region haverecorded increases in HIV prevalence.In Afghanistan, the lack of reliable datain general—and epidemiological datain particular—precludes a realisticassessment of the HIV/AIDS situation. Itis clear, however, that the many factorscontributing to aggressive HIV/AIDSepidemics elsewhere are present in thiscountry as well. Afghanistan has long beena cradle of conflict and the resultantinstability has shredded the fabric ofAfghan society. The presence of local andinternational military forces, thewidespread availability of heroin and itsuse by young people, the vulnerable statusof women and the high levels of mobilityof large, displaced populations conspireto create a situation of heightenedsusceptibility to HIV.Under-reporting may be the cause of thelow estimates of HIV infections and AIDSfrom Bangladesh, Sri Lanka, Iran andelsewhere in the region. For many years,Bhutan and the Maldives remained in theranks of countries that had not reported asingle case of HIV or AIDS. Both have,however, begun to report increases inthe number of HIV infections. Apartfrom inadequacies and difficulties insurveillance and voluntary testing andcounselling, ignorance and stigmatisationobscure the true extent of HIV/AIDSin South Asia.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 41

The HIV/AIDS Epidemics of South Asia“HIV/AIDS hasdeveloped under diverseconditions around theworld with consequentvariations in the modeof transmission and therate of transmission.In the industrialisedcountries, what beganas an epidemic amongmen who have sex withmen and then needlesharingdrug users, isnow increasinglyconcentrated in poorand marginalisedsectors of thepopulation. In EasternEurope, HIV isspreading rapidly amongintravenous drug users.In Africa and SouthAsia, the AIDSepidemic is almostentirely amongheterosexual non-drugusers.Latin Americarepresents a compositeof the industrial anddeveloping worlds bothin its economicperformance and in itsHIV epidemics.”Eileen Stillwaggon inHIV Transmission inLatin America:Comparison with Africaand policy implications,The South AfricanJournal of Economics,December 2000India, the most populous country in theregion, accounts for the vast majority ofPLWHA, not just in South Asia but thewhole of Asia and the Pacific. India’s lownational HIV prevalence rate of less than1 per cent translates into millions ofinfections in absolute numbers, given theenormous size of the population.Globally, India’s HIV positive populationof nearly 4 million ranks second only tothat of South Africa. 3Though the HIV/AIDS profile of SouthAsia is biased towards both men andwomen in the 15–49 years age group,which is the prime working period andthe age in which a person is sexuallyactive, the majority of PLWHA in theregion are men in this age group. To givejust one example, the ratio of HIV positivemen to women in Pakistan in 2000 was7:1. 4 The fewer numbers of HIV positivewomen in some South Asian countriescould, however, also be due to bias insample size of the sexes. In Sri Lanka, forexample, the reported HIV infectionsamong women and men are nearly equalbecause the large numbers of womenwho form the bulk of workers travellingto the West in search of work are routinelyscreened for HIV. In any case, this trendof more HIV positive men than womenappears to be changing. By December2002, women accounted for 36 per centof all new infections reported in Southand South East Asia. 5 In the “older” 6epidemics of many African countries,women account for the majority of newHIV infections.3.1.2 The evolution of theepidemicApart from data problems, the lowprevalence rate may have something todo with the fact that the HIV epidemics ofSouth Asia are relatively young andHIV/AIDS related illnesses and deaths areonly just beginning to surface. Adult HIVprevalence rates reported from SouthAsian countries are yet to touch 1 per centand, therefore, the region imparts areassuring impression of low HIVprevalence rates.However, this ‘low prevalence rate’situation may be short-lived. AllHIV/AIDS affected countries – includingthe severely affected ones in sub-SaharanAfrica—were low prevalence ratecountries in the early years of theirepidemics. HIV prevalence rates amongpregnant women attending antenatalclinics in South Africa was less than 1 percent in 1990. By 2001, the figure had risento 24.8 per cent and the country is now inthe grip of a fast-growing HIV epidemic.The urgency of launching preventiveprogrammes is the other (albeitunintended) factor perpetuating abehavioural explanation for high levels ofHIV/AIDS in Africa. The use of condomscan directly prevent cases of HIVtransmission. Consequently, the provisionof condoms becomes the most immediateshort-term programme for HIV/AIDSprevention. Often prevention essentiallystops there, given the expense of anyprevention programme, the complexitiesof dealing with host governments withdiffering political agendas and the seemingenormity of resolving the morefundamental causes of HIV/AIDS.HIV/AIDS, like other infectious diseases,is the result of all the complex andinterrelated factors that exist in poorcountries. Leaving prevention essentiallyto condom provision (and treatment ofSTIs) reinforces the notion that HIVtransmission is narrowly the result of levelsof sexual activity and fails to address otherdeterminants, such as general health, theeffects of poverty, and gender relations.The ‘low prevalence rate’ label is alsodeceptive as it obscures the reality of sub-42Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

The HIV/AIDS Epidemics of South Asiaepidemics of greater degree amongsizeable segments of the populations. 7For example, though India’s HIVprevalence rate among adults isreported to be 0.8 per cent, the states ofMaharashtra, Andhra Pradesh and TamilNadu have reported prevalence rates ofover 1 per cent among pregnant womencoming to antenatal clinics, a statisticconsidered indicative of its spread intothe general population. 8Thus, even within this overall lowprevalence rate setting, many SouthAsian countries have both concentratedand generalised epidemics in respectivesituations of high risk such as injectingdrug use, commercial sex and sexbetween men. The prevalence rateamong female sex workers in Nepal alsoincreased from less than 2 per cent in1990 to current rate of 20 per cent. 9However, the epidemic is not restrictedto these groups, and expectant mothersand children are now increasinglyvulnerable. Indeed, MTCT rates are onthe upswing across the region.It is virtually impossible to predictprecisely how the HIV epidemics of SouthAsia could expand and intensify.Generalised epidemics have beenreported from six Indian states and severaldistricts in these states have prevalencerates of more than 5 per cent. This showsthat the epidemic can emerge quickly andunexpectedly.Although the epidemics in individualSouth Asian countries are varied andgrowing at different rates, it is clear thatthe factors playing a key role indetermining their course are similar.These are:l the magnitude of people in risksituations;l the frequency and numbers ofunprotected risk behaviours such asllBox 3.1 Afghanistan: blood transfusion, injectingdrug use are suspected transmission meansAfghan and international health authorities are beginning a study ofthe prevalence of HIV/AIDS in Afghanistan and how best to control it.A 9 June 2002 press release from the World Health Organization(WHO) says that little is known about the occurrence of the diseasein Afghanistan. The country’s recent turbulent history makes itvulnerable to HIV/AIDS transmission. Other countries that have beencaught up in conflict or have a high number of refugees and displacedpersons have experienced rapidly spreading outbreaks of HIV/AIDS.Because of the country's seriously damaged healthcare system,improper blood transfusion may prove to be a likely route oftransmission. WHO reports that testing blood supplies for HIV is nota standard course in Afghan surgical procedures. Besides,Afghanistan is among the world's largest producers of opium poppiesfrom which heroin, that is usually injected, is derived.Source: Office of International Information Programs, U.S Departmentof State(http//usinfo.state.gov)sex without condoms or sharing ofinjecting equipment;the extent of networking among the sexand injecting drug use circuits, and thesize of bridge populations that share riskbehaviours with these circuits and thegeneral population; andthe reach and effectiveness ofprotective responses by governmentsand civil society.In India, the virus was foundpredominantly among sex workers andinjecting drug users in the early years. Itthen started spreading into segments ofsociety not recognised as being at risksuch as wives who were monogamousbut whose spouses had contracted thevirus from sex workers or other sexpartners belonging to the bridgepopulations. It is argued that whatmakes married women vulnerable isbasically their inability to negotiate safersex, a problem that is part of thegeneralised lack of control over theirsexual and reproductive decisions, whichRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 43

The HIV/AIDS Epidemics of South AsiaBox 3.2African AIDS is not a special caseAn unfortunate intersection of Western notions ofAfricans and the need to address the spread of HIV asdirectly and quickly as possible has created theimpression that African AIDS is a special case. Westernstereotypes of African sexuality are reproduced inacademic literature with a much lower standard ofevidence than would be required of other academicwork. Several works on the spread of AIDS in Africaassert high levels of partner change without providingdata to support their hypotheses. Those assumptionsare then treated as established fact and becomethe scholarly foundation for a behaviour-basedAIDS policy.In fact, such misconceptions had initially lulled policymakers in South Asia into a false sense of securityregarding the magnitude of the epidemic. It had beenargued that the epidemic in the region is self-limiting,given the differences in behaviour patterns incomparison with other regions.The data that does exist leads to quite the contraryconclusion. UNAIDS data show remarkable similarityin reported rates of partner change among countrieswith very different HIV prevalence rates. or example,in both the United Kingdom (HIV rate, 0.09 per cent)and Zambia (HIV rate, 19.07 per cent), 27 per cent ofmen reported having a non-regular sex partner. Similarly,Switzerland (HIV rate, 0.32 per cent) and Ivory Coast(HIV rate, 10.06 per cent) reported virtually identicalproportions of men and women with non-regular sexpartners. 10The urgency of launching preventive programmes is theother (albeit unintended) factor perpetuating abehavioural explanation for high levels of AIDS in Africa.The use of condoms can directly prevent cases of HIVtransmission. Consequently, the provision of condomsbecomes the most immediate short-term programmefor AIDS prevention. Often prevention essentially stopsthere, given the expense of any prevention programme,the complexities of dealing with host governments withdiffering political agendas and the seeming enormity ofresolving the more fundamental causes of AIDS. AIDS,like other infectious diseases, is the result of all thecomplex and interrelated factors that exist in poorcountries. Leaving prevention essentially to condomprovision (and treatment of STIs) reinforces the notionthat HIV transmission is narrowly the result of levelsof sexual activity and fails to address otherdeterminants, such as general health, the effects ofpoverty, and gender relations.Source: Stillwaggon, 2000is also reflected in other indicators ofpatriarchy, such as high fertility rates.3.1.3 Shared vulnerabilities,shared realitiesIn South Asia, vulnerability to HIV is a‘shared reality’. Hundreds of refugees andmobile populations in search oflivelihoods who move within andbetween Afghanistan, Bangladesh, Nepal,Pakistan, Bhutan and Sri Lanka areexposed to situations that increase theirvulnerability to HIV/AIDS.Unsafe blood transfusions andinjectionsAccording to a WHO estimate, more than50 per cent of blood transfusions in theregion were not screened for HIV in 1995.Mandatory HIV screening of blood has yetto establish itself in many countries in theregion, despite the enormous volume ofblood transfusions. Bangladesh, whichtransfuses close to 200,000 units of bloodeach year, does not screen for HIV,according to the provisional report of theMonitoring of AIDS Pandemic (MAP)Network Symposium, 1997. In Pakistan,an estimated 40 per cent of about1.5 million annual blood transfusionselude HIV screening. 11 Maldives has thehighest incidence in the world ofThalassaemia minor. This hereditaryblood disorder requires frequent bloodtransfusions, rendering the countryvulnerable to HIV if blood is not tested forHIV. However, there are examples ofpositive State action on this issue, such44Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

The HIV/AIDS Epidemics of South AsiaAffected populationsnnnnVulnerablePopulationsSex workersTrafficked womenMen who have sexwith menInjecting drug usennnBridgePopulationsClients of sexworkersMobile populationsPopulations inconflictnnnGeneral populationYouthWomenMenas the improvement in the blood safetyprogramme and quality of blood bankingservices in India (see Box 3.3).Injections are a popular method ofmedical treatment in South Asia and areoften given or demanded even when notnecessary. Studies show that Pakistanhas a high annual ratio of 4.5 injectionsper capita and used injectingequipment is re-used for 94 per cent ofthe injections. According to WHOestimates, unsafe injections accountfor 62 per cent of cases of Hepatitis B,84 per cent of Hepatitis C, and 3 per centof new HIV cases. 12Injecting drug usersHIV infection is common amonginjecting drug users since the sharing ofneedles rapidly spreads the infection.Injecting drug use followed theintroduction of heroin and has expandedsignificantly in South Asia since the 1990s.It is replacing traditional modes of drugintake such as smoking. The shift fromtraditional drugs such as opium to lifeendangeringdrugs such as heroin andbrown sugar and further to pharmaceuticaldrugs is linked with the legal,social and economic developments in thelast few decades. The fall in the availabilityand quality of drugs and rise in prices areamong the factors that have led toincreasing levels of injecting drug use. Todate, the most serious co-existence ofinjecting drug use and HIV-positivepeople is seen in the states of northeasternIndia, notably Manipur (See Box 3.4).Box 3.3India addresses the problem ofunsafe blood transfusionsThe Drug and Cosmetics Acts/ Rules of India (3 rd Amendment),2002, makes the universal screening of blood units for fivetransmissible infections – HIV, Hepatitis B, Hepatitis C, syphilisand malaria – mandatory. The rules also stipulate that blood bankscan be set up only after obtaining a license from the competentauthority and this license has to be renewed at regular intervals.In 2002, the Government of India also approved a National BloodPolicy, which aims at ensuring easy accessibility and adequatesupply of safe and quality blood and blood components collectedfrom well-informed and non-remunerated regular blood donors inwell-equipped premises. National AIDS Control Organisation(NACO) has also developed a comprehensive Action Plan-2002for nation-wide implementation of the strategies laid down in theNational Blood Policy in a phased but time-bound manner.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 45

The HIV/AIDS Epidemics of South AsiaBox 3.4The rapid spread to the general populationAn example of the spread of HIV from a concentrated epidemic inan especially vulnerable group to the general population may befound in Manipur, a northeastern state in India. The HIV prevalencerate among injecting drug users in the state rose from undetectablelevels in 1988 to an overwhelming 70 per cent in four years. HIVsubsequently spread through the sexual route to the wives andsex partners of injecting drug users and by 1999, HIV prevalencerate among pregnant women in Manipur reached 2.2 per cent.Source: UNAIDS 2000aNumerous drug users began usinginjections as heroin became moreavailable from fields in Afghanistan andtrade networks in that country andPakistan. In eastern India andBangladesh, drug trade with Myanmarcontributed to increases in injecting druguse. There are an estimated 60,000 to100,000 injecting drug users (IDUs) inPakistan, 20,000 to 25,000 in Bangladesh,98,000 to 118,000 in India and nearly300,000 in Iran. 13 In the Maldives, too,rising drug use among youth is a causefor concern. The Maldives HumanDevelopment Report, 2000, says that theislands reported a 40-fold increase in druguse between 1977 and 1995.Injecting drug use does not seem to be afactor in Bhutan and Sri Lanka, and onlya minor factor in Bangladesh. Thoughthere is limited evidence about HIVinfection among injecting drug users inBangladesh, the potential certainly existsas needle sharing among injecting drugusers is at a very high rate of up to 97 percent. 14 In central Bangladesh, needlesharing was found to be a routine matteramong 93.4 per cent of over 500 injectingdrug users. These drug injectors are notinsulated from the general population—they are often married and are sometimescommercial sex workers or professionalblood sellers. 15In Pakistan, an initial study 16 of injectingdrug users found no cases of HIV infection.However, it was found that 63.3 per centshared needles and half of them weresexually active. Among the latter group,49.5 per cent had sex with commercialsex workers. 17Iran also has a major drug problem thathas led some authorities to suggest thatthe number of HIV infections is greaterthan available data indicate. In fact, themajority of HIV infections have beendetected among injecting drug users. AnIslamic Republic News Agency (IRNA)report, “More than 3000 people affectedby AIDS” quotes recent estimates thatsuggest that some 300,000 people injectdrugs. Besides, prisons pose a high riskenvironment for the spread of HIVbecause of the sharing of smuggledinjecting equipment. Rates of HIVinfection rose from 1.37 per cent in 1999to 2.28 per cent in 2000.Sex workersIn South Asia, the magnitude of men andwomen offering, or forced to offer, sexualservices for payment or other forms ofbenefit is unknown. Besides sex workersthemselves, there are a large number ofpeople who make an indirect living fromthe sex trade. It should be noted thatestimating numbers is difficult because ofthe covert manner in which the trade takesplace. In Nepal, for example, there are noidentifiable red light areas and sex workersoften shift their operations upondiscovery, which leads to theirpersecution by society and the police. 18Street children are also vulnerable.Enforcement of existing internationalagreements and national laws has beenlax, in part because of the perception thatmany of the children drawn into the sextrade are willing participants or belong tosocially marginal groups. 1946Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

The HIV/AIDS Epidemics of South AsiaBox 3.5HIV/AIDS vulnerability amongst Afghan drug usersIn order to assess the vulnerability to HIV among thedrug users of Afghan origin living in the Pakistani townof Quetta, an NGO, Nai Zindagi, conducted a researchstudy in May 2002 in collaboration with UNDP. The focusof the study was on the prevalence of risky behaviouramong this group that may lead to them getting infectedwith HIV and other blood-borne diseases.Of the 152 Afghan drug users selected for interview ona random basis, 15 per cent were those who had cometo Pakistan during eight months preceding the study, asa result of the war-like situation in Afghanistan. Amajority of the respondents were living on streets atnight, and were financing their drug purchases throughbegging, theft, selling of junk or casual work. Although,32.2 per cent of the respondents had injected drugs atsome point in time, only 15 per cent said that they wereinjecting drugs at the time of the interview. However,the trend of injecting drugs is on the rise among thisgroup and needs to be addressed immediately as 76 percent of the injecting drug users were sharing syringes.A majority of respondents said that their immediatepriority was getting treatment for use of drugs.However, since most of them were using drugs for avery long period, the chronic stage of their drug usebehaviour suggests a substantially long-term drugtreatment programme to make them drug free.Sexual activity with commercial sex workers, streetchildren and men who have sex with men is prevalentamong Afghan drug users. Very low ratio of condomuse, and lack of knowledge about safety measuresexposes them to all kind of STIs, including HIV/AIDS.What is of concern is that more than 50 per cent of therespondents had never heard about AIDS. Even amongthe 23 per cent respondents who claimed that they knowhow HIV/AIDS is prevented, the majority had no answerwhen asked to list the different methods of prevention.Source: Nai Zindagi ‘Study to assess HIV/AIDS vulnerability both through sexual patterns and injecting drug use among thedrug users of Afghan origin in Quetta’, May 2002The notion that young girls are less likelyto be infected with HIV than women whoare more experienced sexually hasincreased the recruitment of minor girlsinto the sex trade. A 1998 InternationalLabour Organization (ILO) studyestimated that there were 30,000 childrenwho are sexually exploited in Sri Lanka. 20Male child sex workers—also referred toas `beach boys’ because they operate inthe coastal resort areas patronised, inparticular, by European nationals-figurein travel advertisements.Men who have sex with men (MSM)Sex between men is not uncommon inSouth Asian societies. 21 Studies such asthose carried out by the NAZ Foundation,a New Delhi-based NGO, highlight thewidespread occurrence of such sexualpractices in India, Bangladesh, Pakistanand Sri Lanka.HIV prevention efforts among men whohave sex with men have focused onproviding information on safer sex, in thehope that an awareness of the risk of HIVwould enable them to choose saferoptions. Bandhu, a community-basedorganisation in Bangladesh, carriedprevention information to the generalpopulation through public campaignsand to MSM populations throughpeer educators. These efforts weresupplemented with the provision of STIdiagnoses and treatment, condoms andlubricants. Studies from India andBangladesh show that while theavailability of increased informationcertainly leads to greater awarenessamong MSM, it has not necessarilyresulted in safer behaviour. The failureto effect behaviour change has beenattributed to poverty and the lack ofskills to negotiate safer sex, as well assexual abuse, stigmatisation andthe criminalisation of homosexualbehaviours.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 47

The HIV/AIDS Epidemics of South AsiaTable 3.1Drug use and HIV infections in South AsiaCountry Number of Injecting Drug Users HIV prevalence rates among(IDUs) IDUs (%)Afghanistan N.A. N.A.Bangladesh 20,000–25,000 1.7Bhutan N.A. N.A.India 98,000–118,000 N.A.Iran (I.R.) 200,000 to 300,000 75Maldives N.A. N.A.Nepal 20,000 2% in 1990 exceeded 50%in 1999Pakistan 60,000–100,000 11Sri Lanka 600 No reported casesNote: N.A. indicates not availableSources: Data on Bangladesh: World Bank, 2002a and Reid and Costigan, 2002; Data on Iran: Reidand Costigan 2002; Data on Nepal: World Bank 2002a; Data on Pakistan: World Bank 2002a; Dataon Sri Lanka: World Bank 2002bnnnTrafficking of women is a seriousproblem in South AsiaBangladesh: In 1994, 2,000 women were trafficked to six citiesin India. An estimated 200,000 women have been trafficked toPakistan over the past 10 years, and the trafficking continuesat the rate of 200 to 400 women each month.Box 3.6India: Of the 2 million women in sex work in India, 25–30 percent are minors. It is estimated that there are more than 1,000‘red light areas’ all over the country.Nepal: 5,000–10,000 girls and women are trafficked into Indiaevery year.Source: CATW, 2002Governmental policies for HIVprevention are often at odds with thepenal laws. For instance, homosexualbehaviour is a cognizable offence in SouthAsian countries such as India. At the sametime, governmental AIDS programmesare committed to protect the rights anddignity of people living with HIV,irrespective of their sexual orientation.These conflicting governmental policiesand programmes detract from theeffective utilisation of HIV preventiveservices by men who have sex with menwho fear exposure and subsequent legalpersecution.Youth sexualityA related problem is the denial of youthsexuality and of their reproductive healthneeds. A large number of young peoplealso form part of mobile populations, withassociated vulnerabilities. A recent surveyin Bangladesh showed that adolescentsin both rural and urban settings hadlimited knowledge of STIs/ReproductiveTract Infections (RTIs). Urban youth weresomewhat more aware, though notnecessarily better informed, than theirrural counterparts, a good understandingof STI and HIV was limited. 22 Thegovernment and a small number of NGOshave begun an information, education,communication (IEC) programme toinform adolescents about STI and havebegun to improve reproductive healthservices for the youth. In India, some pilotcurricula for ‘life skills’ education, whichincludes sex education, have begun.However, across South Asia there is awidespread view among influential48Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

The HIV/AIDS Epidemics of South Asiagroups (teachers, parents, spiritualleaders, some politicians) that sexeducation for young people onlycontributes to the early onset of sexualrelations.India’s reproductive health policies, whileusing the latest jargon and concepts, arestill influenced by traditional attitudesand mindsets. The reason often given bygovernment authorities for not addressingadolescent sexuality and sexual healthneeds is that these issues are not relevantas young people are not sexually active. 23In Iran, social and policy changes haveaffected youth (including adolescent)sexual health, although no aspect ofnational policy explicitly speaks aboutsexual health. Both young men andwomen are marrying later than inprevious decades, in part because ofcontinuing formal education, in partbecause of economic constraints, and inpart because of national policy raising thepermitted age of marriage. 24 Couples whoregister to marry are required to undergomedical tests for STIs. Premarital sexualrelations and pregnancy amongadolescents (particularly amongunmarried girls) are strictly censured andsubject to severe punishment.Sri Lanka, like India, has adopted aPopulation and Reproductive Healthpolicy. However, the Sri Lankan policyhas specific provisions aboutadolescents. The strategies includethe following:l providing adequate information onpopulation, family life includingethical human behavior, sexuality, anddrug abuse in school curricula at theappropriate levels;l strengthening youth-workereducation by including informationabout drug abuse and sex-relatedproblems at vocational traininglllcentres, institutions of higher learning,work places, and free trade zones;encouraging counselling on drug andsubstance abuse, human sexuality,and psychosocial problems,especially by NGOs, CBOs, and theNational Youth Services Council;promoting informed constructivemedia coverage of youth-related socialproblems; andpromoting productive employmentopportunities for youth.The country has moved ahead withimplementing the policy and relatedstrategies. An interesting objective withinthe programme is to contribute to creatinga socio-political and value climate, clearlyan activity within which policy makers andinfluential authorities will play a role,especially with parents and conservativeelements in society. 25Many Nepalese adolescents are aware ofHIV/AIDS and the means of transmissionand prevention, indicating activecampaigns to reach youth and adults withbasic messages. Young people in Nepalare, in general, sexually active in theirteenage years, according to surveyfindings. However, without extensivehealth services targeted towardsadolescents, to complement awarenessand information, the vulnerability to HIVcould be significant. 26Migrant and mobile populationsMobility and migration is often a survivalimperative in South Asia, as abject povertyand lack of employment opportunities athome compel people to migrate.Although there has been little research onthe impact of intra-and inter-countrymigration on the spread of HIV, and itwould be wrong to label migrant andmobile populations as being a source ofinfection, the fact remains that this groupis vulnerable to HIV. The link betweenMobility andmigration is often asurvival imperativein South Asia, asabject poverty andlack ofemploymentopportunities athome compelpeople to migrate.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 49

The HIV/AIDS Epidemics of South AsiaIn a scenario offiscal constraintsand oftenmisplacedspending priorities,the notion ofguaranteeinghuman securitycan be aneffective way ofplacing theconcerns ofpovertyeradication,universal literacyand health for allat the forefront ofSouth Asia’s publicagenda.HIV and mobility is shown by the rise inHIV incidence in remote areas of Nepalwhose contacts with the outside world areconfined to people who frequentlymigrate for work to cities like Mumbai andDelhi in India. 27HIV prevention efforts focusingexclusively or extensively on especiallyvulnerable people might worsen thestigmatisation of some groups. Vulnerableand bridge populations such as sexworkers, migrant workers and longdistance truckers struggle to survive withina hostile social structure that shapes theirbehaviour and that of the authorities whointeract with them. Sex workers mightrequire a large number of clients to earn alivelihood and do not have the ability tonegotiate safer sex and better payment.For mobile populations, long absencesfrom the home environment, housing insingle-sex hostels, lack of access to STItreatment, the use of alcohol or drugs inorder to ‘belong’ to the peer group andharassment or indifference from serviceproviders are all factors over which theyhave no control. The preventionapproaches of many HIV programmes inSouth Asia assume that raising awarenessabout HIV and providing condoms orclean needles will enable people to switchto safer behaviours. Given the situationalnature of risk, however, it is clear thatpeople are more likely to adopt–and sustain–safer behaviours whenthe underlying risk situation issimultaneously made safer. This isespecially true wherever individuals arepowerless to protect themselves, despitebeing aware about HIV/AIDS.The challenge, then, is to bring aboutsocietal changes to reduce HIV risk amonghighly vulnerable populations and lessenthe social stigma surrounding them. Thisentails the inculcation of caring socialattitudes, improving the availability,accessibility and sensitivity of HIVservices and introducing legal andregulatory measures that can protect thesegroups. Vulnerable groups may then feelencouraged to avail of healthcare servicesand support mechanisms offered bygovernments and NGOs. The usage ofnon-judgmental language in expandedmedia coverage of the epidemic, forinstance, can help transform negativeattitudes to people in risk situations.3.2 Conflict andDevelopment in South AsiaHuman security, a concept thatcombines peace and development, isgaining relevance in the policy agendasof South Asia due to its critical rolein building human capabilities. Thelinks between human security anddevelopment are increasingly being feltin the area of health and are acquiringpre-eminence in research. 28 In a scenarioof fiscal constraints and often misplacedspending priorities, the notion ofguaranteeing human security can be aneffective way of placing the concerns ofpoverty eradication, universal literacyand health for all at the forefront of SouthAsia’s public agenda.Human security presumes freedom fromwant and from fear, as well as access to andcontrol of resources and opportunities. Thebasic elements of human security includesurvival, safety, opportunity, dignity,agency and autonomy. Thesepreconditions for human security areessential in reducing vulnerability to HIVinfection and to its impact.The underlying causes of internalconflicts have seldom been addressed.The most contentious issues revolvearound ethnic status, religion, language,demarcation of land, distribution ofassets, and the absence of meaningful50Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

The HIV/AIDS Epidemics of South AsiaBox 3.7How do perceptions and language reinforce HIV-relatedmisconceptions and stigma?nHigh risk groups: Can further marginalise people incertain vulnerable situations and create a falsesense of security in the general population.traumatic experiences like rape or trafficking topassive individuals who cannot change the courseof their lives.nPromiscuous behaviour: A derogatory term thatmakes a value judgement about people’s behaviour.nHIV patients: Does not recognise that people withHIV can lead normal, healthy lives.nnnDrug abusers: The use of this term implies thatdrug users deliberately misuse drugs and thisincreases the blame associated with drug use.Prostitutes and drug-addicts: Judgmental termswith traditionally negative connotations that labelcertain vulnerable populations.Powerless victims: Reduces people subjected tonnTargeted interventions: An exclusionary term thatsees people as `others’ and thus discourages theirparticipation in and feeling of ownership of HIVprevention and care.The killer disease: A fear-based message whichhas not only been proven ineffective but also madefamilies and communities fear normal socialrelations with people living with HIV/AIDS.employment. The unequal distribution ofwealth and imbalances in regional growthhave routinely fuelled discontent. “Whentimes are hard, the sense of injustice isoften borne along ethnic, religious, andcaste lines. Violence thrives in poorsocieties where politics is weaklyinstitutionalised, law and order is fragile,and where the parallel economy is strong.South Asia, at least for the moment, fitsthe bill perfectly.” 29In the South Asian context, the potentialof conflict to disrupt development andviolate human rights needs to be closelymonitored to enable pre-emptivecountermeasures. Conflict may also beviewed as an aggravated form of socialtension, which clouds constructivethinking and prevents people from the fullenjoyment of their human right to a long,healthy and productive life. Conflict andviolence in South Asia are often viewed aslaw and order problems and theirdevelopment implications are usuallyneglected. 30 UN documents view conflictas a violent physical and socialconfrontation between inter-state orintra-state entities, inhibiting peoplefrom the full enjoyment of their humanrights in terms of the UN InternationalCovenant on Economic, Social andCultural Rights (1966).Conflict has become a crucialdevelopment concern in South Asiatoday. The region is torn by both interstateas well as intra-state conflicts. Intrastateconflicts, which are larger innumber, are socially divisive andundermine the integrity of the nationstates leading to a vicious cycle of violenceand social disintegration. Warring factionsresort to looting, drug trafficking,arms smuggling, plundering of theenvironment and other internationalcrimes. Much of this escapes notice inliterature on development.The South Asian countries have largepopulations living in or fleeing fromconflict situations. The situation is causingconcern to the affected countries, theirneighbours and humanitarian aidRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 51

The HIV/AIDS Epidemics of South AsiaBox 3.8Conflict impedes HIV preventionEven where HIV prevention work is underway, it can be easilydisrupted by conflict. Efforts to raise awareness about HIV/AIDSin Nepal’s Achham district have been hindered by fighting betweenMaoist rebels and government forces. The programme hadmanaged to reduce HIV-related stigma in the district by enlistingvolunteers. In September 2001, the programme had 856volunteers, half of them children. Since ebruary 2002, most ofthe district has been under Maoist control. All NGO offices havebeen burnt down; infrastructure and government offices have beendestroyed. NGO workers and volunteers are afraid to work, andthe programme’s impact is under threat. As a strong communitybasedprogramme with little input from outside, it is hoped thatprogramme will survive amid conflict. The people of Achhamdistrict are determined that the programme will carry on as bestit can. 31HIV prevention efforts among refugees is also fraught withdifficulty. In the early 1990s Afghan rebels had reportedlyterrorised women in refugee camps in Pakistan and forced themto abandon training and education courses. 32organisations. Any form of civil conflictthat results in the displacement of peoplewill fuel the epidemic.3.2.1 Sources of conflictConflict in South Asia is aggravated by avariety of factors such as ambitiousprojects of ‘nation-building’, the failureof representative democracies andinadequate governance. The latter halfof the twentieth century has witnessedthe parallel emergence of sectarianand fundamentalist ideologies andglobalisation, which have beenaccompanied by the wide dispersal ofarms and narcotics, the progressivemilitarisation of the establishment andof subversive groups, and increasedmilitary spending. At the same time,natural resources have been grosslydepleted and certain developmentinterventions have led to communitiesbeing displaced from their naturalhabitats. Large parts of the region, whichtoday consist of independent nationstates,were once part of one colonialempire. Besides, the political, ecological,social and human security implicationsof conflicts in one country are carriedover into neighbouring countries, a readyexample being the movement of hugenumbers of Afghan refugees across thefrontiers into Iran and Pakistan.The region is an ethnic and culturalmosaic characterised by the traditionallyclose interaction of indigenouscommunities, castes, races and religions.Porous borders enable the movement ofpeople across frontiers, facilitating notonly cultural and social contact but alsothe movement of drugs, arms, moneyand insurgent groups. These have abearing on internal developments in theadjoining countries.In development terms, wide-rangingmaterial and psychological deprivationsare associated with conflict, includingentitlement failures, health crises,physical violence and forceddisplacements. Conflict also disruptsdevelopment prospects by destroying theproductive infrastructure, public services,settlement patterns, environmentalresources, social capital and theinstitutions of governance. 33 Given theenormity of the task of providing foodsupplies, shelter and basic medicines toan ever-growing refugee population,there is need for the mobilisation ofresources on an unprecedented scale.Competing demands on limited publicrevenues in South Asia result in influentialgroups accessing a larger share ofresources. Besides, non-merit subsidies,making for losses of public sectorcorporations and external defence alsoabsorb a significant portion of resources.With the notable exception of Maldives,social sector expenditures in South Asiaremain low at less then 5 per cent of GDP.Endemic deprivation that becomes the52Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

The HIV/AIDS Epidemics of South AsiaTable 3.2Persons of concern to UNHCR in South AsiaName of country Main origin/Type of population Total in countryAfghanistan Afghanistan Internally displaced persons 1,200,000(IDPs)Returnees from Iran 18,000Returnees from Pakistan 8,000Bangladesh Myanmar (Refugees) 21,000Bhutan N.A. N.A.India Tibet 110,000Sri Lanka 110,000Myanmar 42,000Bhutan 15,000Afghanistan 19,000Other countries 1,000Iran (I.R.) Afghanistan (Refugees)(Note: According 1,482,000to the government, the number of Afghans 386,000is estimated to be 2.3 million)Iraq refugeesMaldives N.A. N.A.Nepal Returnees (from Bhutan) 110,800Tibetans (Refugees) 20,100Pakistan Afghanistan (Refugees) (Note: According 2,198, 800to the government., the number of Afghansis estimated to be 3.3 million)Sri Lanka Sri Lanka (IDPs) 683,300Note: N.A. indicates not availableSources: UNHCR, 2001; SAHRDC, 2001breeding ground for crime and violencein South Asian societies are resulting intheir further polarisation.3.2.2 The gendered impact ofconflict: violence, sexual coercionand vulnerability to HIVBesides threatening all aspects of humansecurity, war and conflict greatly increasevulnerability to HIV for all involved,particularly for women and girls oftenthrough systematic rape and other warcrimes. Girls and boys are especiallyvulnerable to abuse and exploitationboth as civilians and as child soldiers. Thepowerlessness of women and girls tonegotiate safety in their sexual and socialrelations is a key issue for HIVprevention.Studies have found that the vulnerabilityof women to HIV gets heightened inconflict situations in South Asia. TheBeijing Platform For Action (PFA), 1995,states that in armed conflicts “women andgirls are particularly affected because oftheir status in society and their sex”. Theresult of such conflicts are devastating,ranging from brutal killings of children,women and elderly, disabling others and,in addition, increasing the vulnerability ofchildren to malnutrition, illness and death.Further, they worsen all the health indicesnegatively due to inadequate nutrition,Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 53

The HIV/AIDS Epidemics of South AsiaBox 3.9Factors contributing to the spread of HIV in conflict situationsnnnnSexual violence: In refugee camps and othersettlements with displaced people, women and girlsrisk the loss of personal security in the course oftheir daily duties such as collecting firewood orwater.Breakdown in social structures and legal protection:Sexual relationships become more transitory andmay involve a greater number of partners. Youngpeople become sexually active and marry at a muchearlier age in the absence of leisure, education andemployment opportunities. In such circumstanceswomen and young girls are often sexually abusedand not protected from sexual violenceHealth infrastructure: The impairment or destructionof health infrastructure means that blood may betransfused without proper screening, access tocondoms is limited, STIs are not treated and drugsare not available to prevent mother-to-childtransmission. Also, trained staff and confidentialityare hard to find as are care and support for HIV positivepersons. This is especially true of temporaryhealthcare facilities, Moreover, soldiers and membersof uniformed services are more likely to receivehealthcare and treatment than their families. Womenand girls have especially limited access to healthfacilities and face more public discrimination becauseof the absence of medical and social support.Gender inequity: The ability of women and girls tonegotiate safer sex or abstinence becomes evenSource: UNPA, 2000nnnmore limited during times of insecurity and strife,rendering them even more vulnerable than in normaltimes to sexual and gender-based violence,discrimination and HIV infection.Basic needs and economic opportunities: Womenand children sometimes exchange sex for food,resources shelter, protection and money. Thus, inthe absence of human security, refugee clusterscan become sites of sex work.Education and skills training: More women and girlsengage in risky behaviours because a lack ofeducation and skills training leaves them with fewoptions and income-generating opportunities.Displacement: During armed conflict, largepopulations are often displaced, while healthcareservices are disrupted, closed or becomeunreachable. Most social services such as schoolsand health education also shut down, leavingcommunities bereft of the very institutions that formthe core of social cohesion and interaction.Moreover, people from different regions andbackgrounds are thrown together leading toadjustment problems, personal security deteriorateswhile sexual and gender violence becomes morefrequent as social norms and patterns are put understrain, even dissolved, by the desperate situationthat people face. When the conflict ends or slows,both civilians and combatants return to their homecommunities, sometimes carrying the virus.unsafe drinking water and inadequatematernal and child healthcare.Violence against women contributesdirectly and indirectly to women’svulnerability to HIV and their ability tocope with it. In population-basedstudies world wide, 10 per cent to morethan 50 per cent of women reportphysical assault by an intimate partner.Physical violence, the threat of violence,and the fear of abandonment act assignificant barriers for women innegotiating the use of a condom,discussing fidelity with their partners, orleaving relationships that they perceiveto be unsafe. Those who are especiallyvulnerable to violence are women knownor suspected to be HIV positive, youngwomen and girls, sex workers, traffickedwomen, street children and orphanswhose parents have died of an AIDSrelatedillness.Women play several roles in armedconflict situations: as armed activists, asrelatives of armed activists, as relatives ofstate armed forces, as shelter providers,54Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

The HIV/AIDS Epidemics of South Asiaas victims of sexual and physical abuseand as peace-builders. 34 While thepowerlessness of women in conflictsituations is to be emphasised, their abilityto cope with adverse situations shouldalso be highlighted. Often, the formationof self-help groups, supportivecounselling groups and other trainingallow women avenues to negotiatesafety in their relationships. Thesevectors of change need to be consideredwhile addressing issues of violence,gender inequalities, trafficking andHIV/AIDS. 35Throughout South Asia, men, women,boys and girls are trafficked within theirown countries and across internationalborders in a clandestine trade. Conflictsituations are found to aggravate theunderlying factors leading to trafficking,including the heightening of existing socioeconomicdisparities, class and genderbias, lack of transparency in regulationsgoverning labour migration and poorenforcement of human rights standards. 36In the conflict-affected areas in South Asia,many issues arise in relation to womenaffected by armed conflict. These includethe lack of protection of reproductiveand sexual health rights of refugeeand displaced women; the nonrepresentationof women in conflictresolution activities; and the failure of stateand non-state actors to adhere tohumanitarian norms in regard to thetreatment of women and children inconflict. However, some post factomeasures for women affected by conflictare in evidence. In Pakistan, a pilotproject, Women in Crisis Home,coordinates inputs for women affected byconflict. In Bangladesh, a project for poorwomen who suffered due to the unrest inthe Chittagong Hill tracts was developed.In India, financial compensation for warwidows was offered. In Sri Lanka, womenhave been participating in conflictresolution activities. 37Box 3.10The Indian Army addresses HIVTen years ago, soldiers with HIV had to contend withdiscriminatory treatment from their colleagues andsuperiors. Although they were not always dismissed,the results of their test were frequently openly displayed.Today there is considerably more understanding aboutthe nature of HIV infection and sensitivity about issuesof confidentiality, and regular awareness programmeshave been instituted. Voluntary Counselling and TestingCentres are being opened, an AIDS educationprogramme has been instituted in 200 Armed orcesschools and the military system of blood banks is beingmodernised. unding for these activities comes fromNACO, with a budget in 2001 of over Rs 15 million($ 306,000).In conjunction with these activities, commanding officersare expected to be aware of, and respond to, any personalSource: Extract from Healthlink Worldwide, 2002problems that a soldier might have, as a means of headingoff potential high-risk behaviour. urthermore, regularSainik Sammelans (soldiers’conclaves) are planned toget Commanding Officers (COs) of units to talk withsoldiers freely about HIV, while the CO’s wife reachesout to the wives of the soldiers. However, suchdiscussions are not always open and frank. Officerssay that if they talk about sex with the soldiers theylose the authority to enforce strict discipline. On thesoldiers’ part, there is a lot of hesitation on their part toask questions freely. “It’s like a class-room lecture. Youcan just sit there and listen.” Partly as a result of thebroader prevention programme in the 1.1 million-strongArmy, the number of soldiers living with HIV remainslow. The most recent figures (1999) show 1,400 armypersonnel have contracted the virus, with a far smallernumber in the Navy and the Air orce. Soldiersdiscovered to be HIV-positive are not dismissed, butare given easier work.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 55

The HIV/AIDS Epidemics of South AsiaBox 3.11Sex education for Sri Lankan soldiersThe Institute for Development of Community Strengths(INDECOS) contacted senior officers in the Sri Lankanarmy to seek their approval and co-operation to conductsex education programmes among their soldiers. Theofficers were supportive and, wherever necessary,organised leave for the soldiers. They also provided thevenue and meals.One-and-a-half day programmes were conducted withgroups of 30 to 40 participants from both sexes rangingfrom new recruits to senior officers. The methodologyused included group work, discussions, and role-play, apractical session on condom use and grouppresentations rather than lectures. Communicationtechniques were taught to encourage participants toinform friends and family about sexual health issues.Soldiers were also asked to contribute experiences ofSTIs and HIV/AIDS; these were compiled into a bookof case studies. The soldiers who shared theirexperiences were ensured anonymity.Around 900 soldiers attended the programmes. Theywere each encouraged to speak to approximately fiveothers. A syllabus was created to be shared with otherNGOs. After the completion of the programme,requests have been made to continue to educate newrecruits.During the course of the programme, it became apparentthat soldiers had little knowledge of sexual health issues.However, they were very keen on learning and suggestedmore topics, such as family planning.The ‘communication’ sessions–teaching participantsto pass on information they learned–were an integralpart of the programme. It was also found importantto involve senior officers so they could understandthe principles and integrate concepts into theirregiments. Any problems or feelings of discomfortcaused by discussing sexual issues was overcomeby allowing participants to work in small groups andencouraging them to introduce their own ideas and toask questions.On subsequent visits to the army camps, soldiers werefound to be carrying condoms, signifying theirunderstanding and willingness to protect themselvesfrom STIs and HIV.Source: Extract from UNAIDS, 2000c3.2.3 Armed forces in conflictsituations and their vulnerabilityWithout strengthened HIV preventionefforts, the presence of internationalpeacekeeping forces and other mobilepersonnel in post-conflict settings mayprovide a focus for a new local epidemic.The impact of peacekeeping operationson the HIV/AIDS epidemic is of suchconcern that in July 2000 the UNSecurity Council addressed the issueand adopted resolution 1308 with specialrecommendations for states onprevention measures to be taken. InBangladesh, authorities believe that theHIV/AIDS education programmesorganised by the Army prior to overseasdeployment were successful in alertingthe personnel to the vital need to avoidbehavours that put people at risk. 38Boxes 3.10 and 3.11 illustrate the SouthAsian success stories in addressing HIVamong soldiers, through a compassionateand caring approach, as distinct from oneof discipline and punishment.3.3 Current Response toHIV/AIDS in South AsiaThere is frequent debate about whether theHIV response should be focused especiallyon vulnerable groups in the hope ofcontaining the epidemic at an early stage,or whether all citizens must be involvedearly on to reduce the potential for rapidspread of the epidemic. The issue here,however, is that of scale rather than focus,considering that both approaches entailthe delivery of HIV preventive informationand services, the active inclusion of56Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

The HIV/AIDS Epidemics of South Asiastigmatised people and an honestdiscussion of issues pertaining to sociallystigmatised behaviours. Governmentsmust intelligently apportion scarceresources and efforts between theespecially vulnerable groups and thegeneral population because the reality isthat HIV prevention must be available toeverybody regardless of their degree ofvulnerability. The extent and intensity ofsuch efforts, however, must be judiciouslytailored to each group’s scale of need.The stigmatisation of people living withHIV may hasten the spread of the virusdue to denial of medical attention or theunavailability or unaffordability oftreatment. Social stigma can also increasevulnerability to HIV by deterring peopleat risk from accessing education,information, counseling and testing.With support from the WHO, UNAIDS,World Bank, UN agencies and other bi/multilateral agencies, most of theSouth Asian countries have establishednational AIDS policies 39 and coordinatingbodies through their Ministries of Health(Tables 3.3, 3.4). The national policieshave helped set programme priorities andprovided justification for unconventionalmeasures such as sex education in schoolsor condom promotion. However,prevailing HIV/AIDS-related policies andstrategies focus on those considered tobe most marginalised and thoseconsidered likely to ‘spread the infection’and largely pertain to injecting drugusers, sex workers and truckers.The advantages of early prevention,where many lives can be saved andhealthcare and other costs can be averted,have yet to be fully agreed upon. Thepredominantly health-focused context ofthe epidemic and prevailing social normsand political imperatives have, in fact,resulted in the HIV/AIDS epidemic beinglabelled as someone else’s concern or aforeign-driven agenda. Governmentshave yet to take the full responsibility toprotect disempowered people from thestigma related to HIV/AIDS and to preventits spread by including HIV-relatedstrategies and budgets in the NationalPlans or enforcing legislation aimed atprotecting the rights of PLWHA.3.3.1 Range of responsesWithin South Asia, there is considerablevariation in the national policy responsesto HIV/AIDS, mirroring the diverse natureof the multiple epidemics. Lessons canbe drawn from countries such as Thailand,which have achieved notable successes inmitigating the spread and impact of HIVby expanding their responses beyond theconfines of a health approach to one thatembraces a broad spectrum of humanrights and development needs. Theconceptual shift reflected the new globalrecognition that HIV took root andflourished wherever human rights wereviolated and wherever communities weredisadvantaged by poor development.During the initial years of the epidemic,the health sector took the lead role,instituting epidemiological monitoringand surveillance systems, introducingsystems for blood screening and the useof sterile equipment and providing careand treatment facilities. As the epidemicprogressed and a more comprehensiveresponse evolved, other sectors suchas education, industry and transportcame to the forefront. An inclusive,comprehensive response to HIV/AIDS isstill not readily discernible in thecountries of South Asia, for variousreasons. These include:Over-identification of National AIDSProgrammes with SexuallyTransmitted Infections ControlProgrammesThe relationship between national STIGovernmentsmust intelligentlyapportion scarceresources andefforts betweenthe especiallyvulnerable groupsand the generalpopulationbecause thereality is that HIVprevention mustbe available toeverybodyregardless of theirdegree ofvulnerability.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 57

The HIV/AIDS Epidemics of South AsiaBox 3.12Policy response to HIV in South AsiaThe policy-related responses to HIV in South Asia arecharacterised by the following:n Elaborate composition of several of the nationalpolicies.nLack of sincere support from governmentdepartments other than health and developmentpractitioners, including organisations of civil societyworking on poverty, gender and governance issues.nnnReliance on public information and communicationas methods for containing the HIV/AIDS epidemicrather than addressing the structural factors thatdrive the epidemic.Rhetorical support for multi-sectoral responseswithout adequate explanation of what these entailand how they can be achieved.Absence of adequate and timely resources to followup and implement policies.Governments in South Asia can collectively play animportant role in containing the spread of HIV/AIDSwithin countries and in the region. Since most countries,except India, are considered to be in the early phase ofthe epidemic, the gravity of the HIV/AIDS challenge isoften overshadowed by other health and developmentrelated needs. HIV thus spreads quietly and rapidlyamidst malnutrition, TB, lack of access to safe drinkingwater, transport, adequate housing, illiteracy, childlabour, conflict, etc.programmes and national AIDSprogrammes took time to be defined andarticulated in national AIDS policies andvaries between countries. In Sri Lanka, forinstance, the STI programme became thefocus for national AIDS control andprevention activities. In India, however,while the implementation component ofthe STI programme was merged with theNational AIDS Programme, thecomponents of teaching, training,research and epidemiology have remainedindependent. 40 In Nepal, the NationalSTI Programme is a special division underthe National AIDS Programme. In somecountries, STI programmes wereestablished many years before the adventof the HIV epidemic. The integration ofefforts against HIV with established STIprogrammes, thus, enabled speedy accessto an already existing, albeit not yet fullydeveloped, network of health personneland institutions.Health ‘heavy’ programme prioritiesIt was long assumed that a ‘miracle’ drugor vaccine would be found and thatHIV/AIDS would not assume intractabledimensions. Ministries of Health thusadopted a traditional public healthapproach. Monitoring the epidemicthrough HIV sero-surveillance assumedhigh priority. HIV testing with pre-andpost-counselling was followed by adviceto use condoms, clean needles andsyringes etc. Screening blood for HIV wasidentified as an important means ofpreventing its further transmission. Apoor grasp of the scale of the HIV/AIDScrisis made medical and otherestablishments reluctant to broaden thefocus of the AIDS programme to includethe participation of agencies outside thehealth sector.Welfare-based, instrumentalistapproachesThe bulk of responses embody narrowbio-medical and instrumentalistapproaches centred on epidemiology,‘target’ populations and strategies tochange individual behaviours. It was soonclear that much more is needed to meetthe challenges of the epidemic in SouthAsia as most vulnerable people are unableto protect themselves in the absence ofthe power to influence their sexual, socialor healthcare circumstances. The low58Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

The HIV/AIDS Epidemics of South Asiasocio-economic status of women, younggirls and boys, rampant child labour andsocially sanctioned norms that violatehuman rights and promote subservienceand stratification (whether in terms ofclass or caste) facilitate the spread of HIV.Those working to contain HIV/AIDS havemostly supported welfare-based,isolationist and vertical responses thatfocus on ferrying HIV-related services tothose perceived as needing them. Thedearth of appropriate attention to theinterfacing issues of poverty, livelihoods,empowerment, gender and human rightsguarantees that such responses have littleimpact. Successful HIV prevention andcare challenges human and societal valuesand norms, intimate human behaviourand relationships and demands changesin norms relating to class, gender,sexuality and power. It cannot but involveall of society. Besides continueddependence on rational behaviour,incentives and subsidies to arrest thespread of HIV are increasingly beingchallenged by growing poverty andinequality, mismanagement andtransaction costs and growingfundamentalism in South Asia.Lack of operational tools forimplementing the developmentagendaReducing poverty, improving genderrelations and preventing human rightsviolations as well as initiating an overallimprovement in the quality of humanlife formed the thrust of the newdevelopmental approach to tackleHIV/AIDS. The agenda gained importanceas prospects of a vaccine or cure for HIVinfection receded. However, such a broadagenda does not fall within the scope ormandate of a single ministry or agency butcuts across several of them, none beingindividually equipped to take on thedaunting task of developing an overallresponse. Yet, it was the ministries of healthalone that were burdened with theresponsibility of developing planswithout help from other ministries andagencies.The predominant responses supportedby countries in South Asia to addressHIV/AIDS fall into two broad categories–individual and community-levelinitiatives.Individual-level initiativesl Mass and small group education: Asinformation was initially thought to bethe key to behavioural change, HIVprevention programmes began witha focus on transmission andprevention. Several mass educationefforts successfully raised publicawareness of AIDS. Some educationprogrammes even helped initiatebehavioural change as evidencedby a rise in condom sales. Suchprogrammes have fetched appreciableresults in India and Nepal, amongpopulations perceived as beingvulnerable.l Peer education: Trained peer educatorsrecruit leaders from communities toeducate their peers. This approachhas helped increase communityparticipation and engage diversegroups in the HIV/AIDS preventionefforts. Peer educators help developand discuss safer sex, distributecondoms as well as IEC materials suchas video clips and pamphlets andencourage meaningful engagement toimprove community empowerment,health and human rights. The peerprogrammes carried out by sex workersin India and Bangladesh arenoteworthy examples of the success ofsuch initiatives.l Voluntary Counselling and Testing(VCT): VCT has gained value as aservice that can potentially helpchange negative attitudes about HIVSuccessful HIVprevention andcare challengeshuman and societalvalues and norms,intimate humanbehaviour andrelationships anddemands changesin norms relating toclass, gender,sexuality andpower.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 59

The HIV/AIDS Epidemics of South AsiaPromotingconstructiveattitudes amonghealthcareproviders andimproving thequality ofcounselling arepublic healthimperatives.and AIDS. However, testing is oftengiven precedence over counselling inmost South Asian countries.Promoting constructive attitudesamong healthcare providers andimproving the quality of counsellingare public health imperatives. A FamilyHealth International (FHI) sponsoredevaluation of counselling initiatives inthe South Asian countries in 2001found that the quality of counselling,including counselling skills, werecause for concern.Community-level initiativesl Outreach initiatives: Outreachprogrammes enable individuals tocirculate HIV-related informationwithin existing social networks.Outreach workers help stimulatebehavioural change in marginalisedgroups such as drug users, sex workersand their sexual partners. Outreachwork is characterised by harmreduction strategies such as providingcondoms to sex workers and does notnecessarily consider the vulnerabilityfactors associated with sex work.Outreach workers in South Asiaface difficulties in working withmarginalised and excludedcommunities given the environmentof stigma and discrimination.l School-based programmes: AIDSeducation has yet to find legitimacy inmany schools in the countries of theregion. Existing programmes providebasic AIDS information in theclassroom, and discussions ofsexuality and peer pressure arelimited. Some educators may sufferinhibitions during such discussionswhile others may consider sucheducation unnecessary and aspolluting young minds. Besides, thevast majority of children vulnerable toHIV/AIDS are outside the formalsystem of education.llCondom promotion and socialmarketing: Several studies fromvarious South Asian countriesidentify lack of access and poorcommunication with sexual partnersas major barriers to condom use. As aresult, most HIV preventionprogrammes include the distributionof free condoms with the aim ofimproving their availability. The poorsustainability and reliability of freecondom distribution programmesprompted the introduction of socialmarketing as a more viablealternative. In an effort to increasetheir social acceptability, condomswere made available at nontraditionaloutlets such as truck stops,bars and hotels. Social marketing hasalso helped promote voluntarycounselling and testing. Bangladeshand India have reported that thesimultaneous empowerment of sexworkers has helped expand the scopeof traditional condom distribution.SHAKTI, a HIV project of CAREBangladesh working with streetbasedfemale sex workers, helpedorganise sex workers into the DurjoyNari Shanga (Undefeatable Women’sCommittee) in 1988. 41 The groupassumed the responsibility ofmarketing condoms to sex workers.Though sales declined during periodsof police harassment, the group wasable to increase the overall sales withina short period. In December 1998, only39 per cent of all vaginal and anal sexualintercourse episodes had entailedcondom use, but the figure rose to 52.4per cent and 65.6 per cent over thesubsequent two years.Blood safety: Unsafe blood and bloodproducts have been major challengesto the containment of HIV sincethe beginning of the epidemic.Governmental efforts to prevent thespread of HIV through this route60Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

The HIV/AIDS Epidemics of South Asiainclude the provision of guidelines forthe treatment of blood disorders andthe rational use of blood, and thescreening of blood for HIV. Blooddonation is promoted to help reducedependency on professional bloodsellers. Despite monitoring, however,poor compliance to uniformstandards of blood safety is commonin South Asia.3.3.2 National responsesAfghanistanAfghanistan has yet to formulate itsNational AIDS policy or national plan onHIV/AIDS. 42 The government has neithermade attempts to confirm or rule out thepresence of HIV/AIDS nor has it initiatedsteps to lower vulnerability to HIV amongits peoples. The number of HIV/AIDScases in Afghanistan is not known but isprobably less than 100. 43BangladeshBangladesh established a National AIDSCommittee (NAC) in 1985, with aTechnical and Coordination Committeeat the central level and other committeesat various peripheral levels. The Ministryof Health and Family Welfare formulated aNational Policy Document on HIV/AIDSand STI that received cabinet approvalin 1997 and a framework for itsimplementation was developed between1997 and 2002. Bangladesh’s HIV/AIDSpolicy documents pay special attention toinjecting drug use and approve harmreduction as an appropriate strategy.However, the Ministry of Home Affairs,which is concerned with implementationof the Act, does not approve of harmreduction as it conflicts with existingdrug laws. Under the StrategicImplementation Plan (SIP) for HIV/AIDSPrevention and Control under the Ministryof Health and Family Welfare, Bangladeshinitiated HIV prevention efforts among itsprisoners. Acknowledging that militaryand police personnel also buy sex, the SIPgave near-equal importance to HIVprevention among the police, the militaryand sex workers. The SIP aims to achieveabout 80 per cent condom usage amongbrothel-based sex workers.In Bangladesh, there is no specificlegislation to protect the rights ofPLWHA. The Constitution of Bangladeshhowever, confers fundamental rightssuch as the right to equality, nondiscrimination,life, liberty and privacy 44to all its citizens. The National Policy onHIV/AIDS and STD related issuesendorses the Universal Declaration ofHuman Rights (UDHR) as a standard forpolicy making and action at all levels inthe response to HIV/AIDS and STDs inBangladesh. In the context of access tohealthcare, the policy states that “healthprofessionals must treat all personsseeking medical attention withoutdiscrimination and prejudice”.BhutanThe National STD/AIDS ControlProgramme in Bhutan, begun in 1988, hasadopted a multi-sectoral initiativeinvolving all sections of society. Theprogramme is integrated into thecountry's decentralised national healthsystem. HIV education has been taken torural communities and integrated with theeducation curriculum. The momentum ofthese efforts has been sustained by theHealth Ministry's information educationactivities. 45 According to UNAIDS, morethan 25 per cent of the government’s totalbudget is allocated to healthcare andeducation, both of which are provided freein Bhutan. 46IndiaThe Indian Government formed aNational AIDS Committee in 1986 andlaunched its National AIDS ControlDespitemonitoring,however, poorcompliance touniform standardsof blood safety iscommon inSouth Asia.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 61

The HIV/AIDS Epidemics of South AsiaProgramme in 1987. In 1992, the NationalAIDS Control Organisation (NACO) wasestablished to implement the strategicplan for prevention and control of AIDSin India for 1992-97. State AIDS Cells wereset up in each State for the expeditiousimplementation of the programme.Currently, Government of India isimplementing a comprehensive NationalAIDS Control Programme – Phase IIthrough autonomous State AIDS ControlSociety (SACS) in all States and UnionTerritories. A multi-sectoral response hasbeen launched involving variousministries. In addition an innovativestrategy through Family Health AwarenessCampaign has been initiative tomainstream HIV/AIDS into the country’shealth care system.In the absence of an anti-discriminationlegislation, courts in India havefollowed the principles enshrined inthe Constitution, which guaranteefundamental rights including the right toequality, the right against discriminationand the right to protection of life andliberty. 47 While these provisions havebeen interpreted to protect againstdiscrimination by the State 48 on the basisof HIV status, 49 the juridical interpretationnow also needs to provide protection fromdiscrimination in the private sector. Afterall, fundamental rights are enforceable notonly against the State but also applicableto all citizens and non-State actors.Although the right to health is afundamental right, PLWHAs do facediscrimination in healthcare settings. Thisis particularly true for injecting drug users,who are easily identified by needle marksand abscesses. Discrimination takesmany forms including outright denial oftreatment, physical isolation in wards,early and inappropriate discharges,delays in treatment, higher treatmentcharges and prejudicial comments andbehaviour. Confidentiality about HIVstatus is often breached. 50Box 3.13The right to confidentiality for PLWHA in IndiaIn 1998, in a defining judgment in Mr. X V. Hospital Z,the Supreme Court of India held that although doctorpatientconfidentiality was part of the code of medicalethics, a patient’s right to confidentiality was notenforceable if he or she was HIV positive and posed arisk of transmitting the infection to the prospectivespouse. Mr. X's case concerned the issue of breach ofconfidentiality of the petitioner's HIV-positive statusby a hospital blood bank to the petitioner's relatives.Since HIV-related infection endangers the life of thespouse, the Court held that the right to privacy of thepatient is not absolute in this situation and may berestricted. The court also ruled that since Indianmatrimonial laws allow venereal infection to besufficient grounds for divorce, a person suffering froma venereal disease has no right to get married till s/heis fully cured and such right must be treated as a‘suspended right’. It further observed that since actslikely to spread communicable diseases are a crimeunder the Indian Penal Code, the failure of the hospitalto inform the spouse of the disease would make itparticipant criminis.Later, the Lawyers’ Collective’s HIV/AIDS Unit filed acase on behalf of Mr. X, seeking clarifications andchallenging the 1998 judgment. On 10 December 2002,the Supreme Court held that all observations relatingto marriage in the earlier judgement were not warrantedas they were not issues before the Court. The SupremeCourt did, however, state that its pronouncementsregarding the role of hospitals to make disclosure ofHIV positive status in that judgment remain as theywere made. In effect, therefore, the 1998 judgment,to the extent that it suspended the right of PLWHA tomarry is no longer good law and the right is restored.However, his does not take away from the duty ofthose who know their HIV-positive status to obtaininformed consent from their prospective spouse priorto marriage.62Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

The HIV/AIDS Epidemics of South AsiaIranThe National Committee to CombatHIV/AIDS, chaired by the Minister ofHealth, was established in 1987. TheCommittee provides policy guidance tothe National AIDS Programme. TheNational Strategic Plan, though basedon multi-sectoral collaboration andcoordination, largely focuses onprevention. 51NepalNepal’s National AIDS Prevention andControl Programme was established in1995. The same year, the Ministry ofHealth adopted a National Policy onHIV/AIDS/STDs, establishing amulti-sectoral approach involving 12government ministries.The Constitution guarantees citizenscertain fundamental rights. These includethe right to equality, which prohibits thestate from discriminating on the basis ofreligion, race, sex, caste, tribe, ideologicalconviction or any of these. 52 Although thisprinciple has not been tested in courts asyet in the context of HIV/AIDS, thisprovision would oblige State-runhealthcare institutions to provide nondiscriminatorytreatment to PLWHA.Further, there is a provision that enablesthe State to take affirmative legislative orpolicy action to protect and advance theinterests of special groups, includingthose who are physically or mentallyincapacitated. 53 Whether HIV/AIDSwould qualify for such a provision issubject to judicial interpretation. TheConstitution allows restrictions to beimposed on the right to freedom andpersonal liberty on the grounds of publichealth and morality 54 and proponents ofisolationist public health strategies mayseek to apply this principle to PLWHA.The right to privacy is consideredinviolable except as provided by law 55 and,as in India, assumes special significancein the context of doctor-patientconfidentiality about HIV status.Notwithstanding constitutionalguarantees, healthcare professionalsroutinely discriminate against PLWHA,often refusing to treat people with HIV.Moreover, Nepal's healthcare system isinadequately equipped to handleHIV/AIDS cases 56 . The Infectious DiseaseAct, 1963, the Prisons Act, 1963, and theHotel Management and Sales andDistribution of Liquor (Control) Act, 1966all discriminate against PLWHA,segregating them on the basis of theirsero-status. PLWHA are forced to carrytheir burden alone to avoid beingalienated by their families and in order toretain their jobs. 57PakistanPakistan’s Federal Ministry of Healthinitiated a National AIDS Prevention andControl Programme (NACP) in 1987. Inearly 2001, NACP developed a NationalHIV/AIDS Strategic Framework to guidethe activities of the HIV/AIDSstakeholders in Pakistan. This frameworkencompasses nine priority areas,including coordinated, multi-sectoralresponses, reduction of risk amongvulnerable groups, reduction ofvulnerability among youth and improvedquality of care for PLWHA. 58The Constitution of Pakistan prohibits theState from discriminating on grounds ofsex, caste, race, religion, residence andplace of birth in matters pertaining toaccess to public spaces andemployment. 59 In principle, this wouldapply to discrimination on the basis ofHIV status in State-run medicalinstitutions. There is, however, nolegislation to cover discriminatorypractices in private healthcare settings.Increased knowledge and compliancewith universal precautions within theRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 63

The HIV/AIDS Epidemics of South Asiahealthcare setting and improved qualityof care for PLWHA 60 are among the priorityareas identified in the National HIV/AIDSStrategic Framework. In spite of this,there are reports that PLWHA in Pakistannot only suffer the physical anguish of thedisease but also experience isolation,discrimination, and abuse. 61 Clearly, thelegal principles and fundamental rightsenshrined in the Constitution do notalways ensure access to healthcareservices for PLWHA and othermarginalised communities. This onlyunderscores the need for the involvementof other agencies in the HIV/AIDSprevention efforts. An ILO project onHIV/AIDS education for workers aims toimprove their understanding of the socialand labour implications of HIV/AIDS atthe workplace.Pakistan also has a Disabled Persons'(Employment and Rehabilitation)Ordinance 1981, 62 which provides forrehabilitation and employment ofpersons who are disabled due to disease.It remains to be seen, however, if PLWHAqualify to be covered under its provisions.Moreover, the ordinance does not dealwith discrimination.Sri LankaThe Constitution of Sri Lanka guaranteesthe fundamental right to accesshealthcare services to all its citizens. 63 Italso ensures the fundamental right toequality and prohibits discrimination onthe grounds of ethnicity, religion,language, caste, gender, sex, maritalstatus etc. 64 There has been at least onecase of termination of employment onthe basis of HIV status in Sri Lanka. 65There have been efforts to urgeemployers not to fire employees solelyon the basis of their HIV positive status. 66Tables 3.3 and 3.4 indicate that the SouthAsian nations, with the notable exceptionof Afghanistan, have taken steps to tackleHIV/AIDS. An evaluation needs to bedone of the coverage and effectiveness ofgovernmental and non-governmentalprogrammes in prevention and theirimpact on poor and marginalisedpopulations. Data on patterns of HIVinfection and sexual behaviour continuesto be scarce and most countries withnascent epidemics need to expand datacollection and analysis. Crafting costeffectiveprogrammes and identifyingpolicy and programme needs isalso essential.Box 3.14The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM)“The purpose of the und is to attract, manage anddisburse additional resources through a new publicprivatepartnership that will make a sustainable andsignificant contribution to the reduction of infections,illness and death, thereby mitigating the impact causedby HIV/AIDS, tuberculosis and malaria in countries inneed, and contributing to poverty reduction as part ofthe Millennium Development Goals.”—GATMMore than $3 billion has been pledged to the Globalund, although less than a third has reached theund as of 2003. In January 2003, the Global undapproved the second round of grants to the tune of$866,000,000 over two years, to be given to countriesaround the globe. It has been estimated that aneffective global response to the three diseases wouldcost $10 billion a year. While the Global und will be akey player in funding such responses, the resourcesso far pledged and released to the und will only covera fraction of the total need. rom South Asia,proposals of a total value of $72,215,420 from India,Pakistan, Nepal, Bangladesh, Iran, and Afghanistanwere approved in January 2003. India got the largestshare of the funds and Afghanistan the least. Theproposals from Bhutan, Maldives and Sri Lanka didnot receive funds in the second round but might getfunded in the coming rounds to approve grants fromthe GATM.64Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

The HIV/AIDS Epidemics of South AsiaThis chapter analysed policy responsesthat directly relate to HIV/AIDS and thosethat influence the socio-economic contextof the epidemic. Clearly, the latter willdetermine the course of the epidemic inSouth Asia. While countries wage acontinual struggle to upgrade the socialand economic status of their peoples andagree that vulnerability to HIV/AIDS islinked to poverty, these linkages have neverbeen clearly analysed or articulated. Povertyis viewed as a static condition rather thanas an outcome of the various pressures thatimpinge on people’s capacity to achieveeconomic and social security. The term‘impoverishment’ is preferable, as it issuggestive of the dynamic processesleading to poverty. Impoverishment canresult from long-term or suddenunemployment, loss of assets (such asland), lack of access to basic social services(e.g., education, health, security, andtransportation), or lack of control overeveryday decisions. Impoverishment isoften characterised by inequalitiesbetween socio-economic groups.In almost all the countries, ministriesTable 3.3Policy responses to HIV/AIDS in South Asia, 2001Afghanistan* Bangladesh Bhutan 67 India 68 Iran (I.R.) 69 Nepal Pakistan 70 Sri Lanka 71National N.A. Yes Yes, as an Yes Yes, as a Yes Yes, but YesHIV/AIDS unit within committee, limitedProgramme Ministry of not a resourcesHealth programme and impactNational N.A. Yes, Limited Yes, Yes Yes, N.A. YesPolicy elaborate policy elaborate focus onpolicy adopted to policy humanprovide AZTrights(Zidovudine)to pregnantwomen withHIVNational N.A. Yes, A medium- Yes Yes Yes In 2001, YesStrategic including term plan but requiresor Action specifics for prioritisationPlanseveralissuesResources N.A. Government Donors Yes, with Donors, Yes Yes, but Yes,available has taken a two large government only one- donors,(government World Bank World resources third of Worldand other) loan; reliance Bank loans and what was Bankon donors and Global Global originally loanund und budgetedProgramme N.A. Occurring Yes, as a Yes, but N.A. Noted in Yes, to Noted inDecentr- part of the some strategy the four strategyalised national states provinces,health are much of whichstructure stronger two arethanfunctioningothers* There is little official or unofficial data for Afghanistan. urthermore, events since October 2001 make anycomments about “government” policy problematic, if not irrelevant.Note: N.A. indicates not available, not necessarily the absence of a policy response.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 65

The HIV/AIDS Epidemics of South AsiaThe mechanism todeliver ‘publicgoods’ for nationalHIV/AIDSpreventionprogrammes canmove no fasterthan any other andNGOs that adopt afast track oftenfind themselves inconflict with thelaw or with theauthoritiesconcerned.other than health have seldom beeninvolved in the HIV-related policymakingprocess. Some countries haveinvolved the ministries of education andwomen’s affairs. The organisationalstructure of ministries and departmentsvaries from country to country and sodoes the relative influence wielded by oneministry vis-à-vis another. Sri Lanka, forinstance, had, at one time, a combinedMinistry of Health and Women’s Affairsand the issue of HIV and women wasapproached with a health bias. On theother hand, India and Pakistan, eachwith a separate ministry for women, wereable to bring to the problem a sharperfocus on developmental concerns ofwomen.A multi-sectoral approach has also beenslow to emerge in budgetary allocationand programme development withinministries other than health, as theseministries have been reluctant to prisefunds away from tightly controlled orlimited budgets and competing demands.Yet, countries like Bangladesh wererelatively pro-active in attempting todevelop multi-pronged programmes evenat a time when the infection rates werelow. UNAIDS estimated that at the end of2001, there were 13,000 persons withHIV/AIDS, and that 1,000 deaths due toAIDS-related infections had occurred inthat year. 72 The rates are higher in specificgroups such as injecting drug users(2.5 per cent) and commercial sex workers(0.6 per cent). 73HIV/AIDS came to be accorded highnational priority only in recent times inSouth Asia, whereas in Africa, theDeclaration on the AIDS Epidemic wasendorsed by the Heads of State andGovernment of the Organisation of AfricanUnity (OAU) in June/July 1992 itself. TheDeclaration adopted the target that: “Bythe end of 1992, each one of us will bepublicly recognised as the leader of thefight against AIDS in our country.”3.4 Challenges andImperativesSouth Asian countries face variouschallenges in the implementation of theirnational plans of action to tackleHIV/AIDS. These challenges areheightened by the persistence of thefactors that constrain development ingeneral. The mechanism to deliver‘public goods’ for national HIV/AIDSprevention programmes can move nofaster than any other and NGOs thatadopt a fast track often find themselvesin conflict with the law or with theauthorities concerned.People living with HIV/AIDS continue tofeel isolated, neglected and deprived ofthe benefits intended for them.Urbanisation and post-liberalisationpublic culture – consumerism fuelled bygreater media exposure and a tendencytowards increased commodification ofwomen – have prompted changes in thelifestyles of the younger generation. Theseonly make them more vulnerable toinfection, underscoring the need forurgent preventive measures. Even the bestplanned programmes face formidableproblems in the South Asian region. Thesheer magnitude of the geographical anddemographic challenges in some of thecountries, the staggering numbers ofpeople below the poverty line, low levelsof literacy, large migrant populations,inadequate health infrastructures andcompeting demands for scarce resourcesmay all conspire to relegate HIV/AIDS tothe backburner.The South Asian Association for RegionalCooperation (SAARC) Secretariat has yetto accord HIV/AIDS priority status. SouthAsian countries can benefit through66Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Table 3.4Policies and practices on selected HIV/AIDS-related issuesAfghanistan Bangladesh Bhutan India Iran (I.R.) Nepal Pakistan Sri LankaAdolescent Not recognised; Not a high No policy Major concern: Services HIV education Minimal WithinReproductive female access priority; age of action, but increase in for married in secondary policy nationalHealth Policy/ to services legal marriage some age for marriage/ adolescents; schools, but concern and reproductiveProgrammes 74 severely limited has been discussion some Information, minimal for policy not services health policy/raised; efforts Education and unmarried; ratified in schoolto have sex Communication HIV/AIDS in curriculaeducation insecondaryschools resistedschoolcurriculumHarm reduction Drug production N.A. N.A. Harm minimisation Drug use N.A. N.A. N.A.drug efforts and trade programmes are illegal; largefacilitated by encouraged through percentage ofunwritten targeted inter- IDUs whonational policy ventions for IDUs are jailed areor become HIVpositive 75Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 67Trafficking N.A. Laws exist to Prohibited Prohibited, but Prohibited Policy and Illegal, but Illegalprevent trafficked action plan occurstrafficking women/girls exist toenter theprohibitcountrytrafficking forthe sex trade;practicecontinuesProtection for N.A. N.A. N.A. Upheld by courts, Health N.A. N.A. Very limitedHIV positive but discrimination ministryemployees occurs in practice 76 prohibitssome company firms frompolicies emerging dismissingHIV positiveemployees 77Note: N.A. indicates not availableThe HIV/AIDS Epidemics of South Asia

The HIV/AIDS Epidemics of South AsiaBox 3.15Critical role of political leadership in the response toHIV/AIDS in South AsiaSeveral activists have pointed out the need for greaterurgency on the part of political leaders in South Asia torecognise the existence of the problem and raise theresources required to deal with it. In India, for instance,it was only at the Global AIDS Law Conference in 1995that the President, Prime Minister and the Minister ofHealth shared a platform to speak on HIV/AIDS. In 2000,the Prime Minister of India chose to refer to this problemin his address to the nation. Thereafter, the issue ofcombating the epidemic has gained prominence. India’sPrime Minister has since met with the Chief Ministersof the six states with high prevalence rates to discussthe pace of implementation of state policies andinterventions.This initiative received wide publicity, thus adding asense of urgency and accountability for acceleratedstate-level action. The Prime Minister also met withbusiness leaders and supported the idea of establishinga Business Coalition Trust for HIV/AIDS in September2001. In December 1998, the Prime Minister Atal BihariVajpayee addressing a meeting on the National Programfor Prevention and Control of HIV/AIDS declared that“HIV/AIDS is the most serious public health problemfacing India”. Chandrababu Naidu, the Chief Minister ofthe state of Andhra Pradesh, stated in 2002 that: “Iconsider AIDS the biggest enemy for society. If weignore it now, we will have problems. That is why wehave to break the silence”. The Indian delegation to theUN General Assembly Special Session on HIV/AIDS inJune 2001 was led by the Union Health Minister andincluded the leader of the opposition. A NationalConference on Human Rights and HIV/AIDS wasorganised in November 2000 by NACO in collaborationwith UNAIDS and specialised agencies of the UNsystem.In Pakistan, the Prime Minister’s address to the nationin 1998 contained details of the National Plan of Actionon Women developed by the Ministry of Women’sDevelopment. The Plan addressed not only HIV/AIDS,but also the broader issues of women and poverty, theimpact of economic policies on women, sexual violence,discriminatory laws and practices and human rights.In Nepal, on 5 December 2000, HRH the late CrownPrince had remarked that: “HIV/AIDS has now becomea problem that no one can afford to ignore”. 78 TheHealth Minister also stated, in 2002, that theimportance of regional responses and action remainsimperative to containing the epidemic in Nepal. TheQueen of Bhutan, HRH Ashi Sangay Wangchuk has alsobeen a powerful advocate for the rights of PLWHAand has spoken at various international platforms suchas the fifth and sixth International Congress on AIDSin the Asia Pacific (ICAAP).In Maldives, at the National Conference on the MaldivianChild held in July, 1991, the President Maumoon AbdulGayoom stated that: “…I would like to emphasise thefact that Islam does not prohibit the effective planningof family size or the use of contraceptives for thatpurpose. There should, therefore, be no hesitancy onany religious grounds to use contraceptive methods incarrying out our child spacing and family planningprogrammes”. 79 This statement became particularlyuseful when the Ministry of Health began to encouragethe use of condoms as a means of HIV prevention.technical exchange with developingcountries that have much to offer.With concerns that India might emergeas the global epicentre of the secondwave of HIV infections, HIV/AIDSbecomes a matter of serious concern forthe entire region.The South Asian countries must nowaddress the implications of the WorldTrade Organization (WTO) regimesregarding Intellectual Property Rightsand patent systems on ARV drug pricingand the growing demand for such drugs.The impact of growing conflictsituations and the limited availability ofresources in the countries of the regionmay well be compounded by imminentglobal recession. Health ministries andNGOs that are dependent on donorsmay find funding for HIV/AIDS dryingup as wealthy nations re-adjustdevelopmental aid programmes andpriorities.68Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

The HIV/AIDS Epidemics of South AsiaCountries in South Asia, being in the earlyphase of the HIV epidemic, still haveample opportunity to avert large-scalefuture infections. An environmentsupportive of broad-based governmentalinitiatives is emerging, albeit slowly. Themultiplier effect of efforts against AIDSthrough developmental responses such asliteracy programmes, income generationschemes and reproductive healthinitiatives is gaining ground. NGOparticipation is being increasinglyrecognised as being critical to the successof such efforts. In the first decade of thisnew century, there is more hope than everbefore that countries in South Asia will bebetter placed to come to grips with theepidemic.“The ‘low prevalence’ label may misguide policymakers into downplaying thesignificance of the epidemic. There is the additional danger of people failingto protect themselves in situations of high risk in ‘low prevalence’ countries,as they do not perceive HIV as being present at a degree serious enough forconcern.This global epidemic, which has no boundaries, has become the number onehealth threat and a major impediment to development for many countries ofthe world. The Maldives, a small island developing country, situated in themiddle of the vast Indian Ocean with a population of less than 300,000 people,is no exception.”Address by Mr. Hussain Shihab, Permanent Representative of the Maldives to theUnited Nations at the United Nations General Assembly Special Session onHIV/AIDS (UNGASS), 2000Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 69

The HIV/AIDS Epidemics of South Asia70Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDS72Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDS“An important aspectof HIV/AIDS policy isto ensure theprotection of the humanrights of those who arevulnerable and alsothose who are infected.Appropriate workplacepolicies that ensureawareness, access tohealth services, nondiscriminationat theworkplace and care andsupport for thoseinfected go a long wayin mitigating the impactof HIV/AIDS”.Atal Bihari Vajpayee,Indian Prime Minister, atthe launch of the IndianBusiness Trust forHIV/AIDS, New Delhi,September 2001Chapter 4Human Rights and HIV/AIDS4.1 IntroductionThis chapter looks at the necessity of usinga human rights approach in the fightagainst HIV/AIDS. It argues that theepidemic can be combated effectively onthe one hand only with an enabling legalenvironment, and on the other, societalacceptance through sustained sensitisationand the elimination of stigma anddiscrimination.Many of the key strategies against HIV—especially those dealing with behaviourchange among vulnerable groups—require a set of legal and statutory changesthat make it feasible for PLWHA to have agreater voice in decisions affecting theirown lives, without fear of beingstigmatised and discriminated against.Treating HIV prevention as a corecomponent of the policy frameworkof human development can helpaccomplish this task, since the objectiveof a ‘caring society’ is common tothe concerns of human rights andAIDS activists.4.1.1 Understanding humanrights within a humandevelopment frameworkHuman rights are now widely acceptedas being central to any community ornation’s effective response to HIV/AIDS.This has been acknowledged both ininternational documents and nationalresponses. 1 It is important, then, to assessthe role and importance of a human rightsframework in responding to HIV/AIDS.Human rights are inherent in andinalienable to every individual. They renderthe government and the larger societyaccountable to the citizen. Every individualhas a right to live with freedom and dignityand ‘citizens’ are the ‘duty holders’obligated to respect, protect and addressthis fundamental need. Human rights arenot given or bestowed upon people byindividual governments or society butare earned by virtue of being born `human’.As Justice J.S. Verma, former chairpersonof India’s National Human RightsCommission so aptly put it, “dignity is theentitlement of all as long as life exists.” 2HDR 2000 defines human rights as “therights possessed by all persons, by virtueof their common humanity, to live a life offreedom and dignity. They give peoplemoral claims on the behaviour ofindividuals and in the design of socialarrangements–and are universal,inalienable and indivisible.” The value of ahuman rights approach lies not only inprinciples such as state accountability andpopular participation, but also in thenormative potential of rights to alleviateinjustice, inequality and poverty. 3Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 73

Human Rights and HIV/AIDSThe internationalresponse toHIV/AIDS has beencharacterised bytwo diametricallyopposed publichealth approaches:the isolationistapproach and theintegrationistapproach.The conceptual framework of humandevelopment places people at the centreas empowered beings. It embodies arights-based approach to developmentthat could serve as the appropriate frameof reference for integrating the humanrights concerns in the struggle against HIV.Principles of GIPA are, therefore, intrinsicto the human development approach.“The protection of human rights isessential to safeguard human dignity inthe context of HIV/AIDS and to ensurean effective, rights-based response toHIV/AIDS. An effective response requiresthe implementation of all human rights,civil and political, economic, social andcultural, and fundamental freedoms of allpeople, in accordance with existinginternational human rights standards…”. 4Addressing the epidemic within a humanrights framework involves a strongemphasis on acceptance and nondiscriminationof populations perceivedto be more vulnerable to HIV. The lastdecade has witnessed the increasingconcentration of the epidemic in thedeveloping world where the responseneeds to not only protect individual rightsand privacy, but must also deal with widerdevelopmental concerns like poverty,gender and inequality. Such an approachwill encompass the InternationalCovenant on Economic and Social Rights,the Convention on the Elimination of AllForms of Discrimination Against Women(CEDAW) and the Convention on Rightsof the Child (CRC). In sum, it will capturethe spirit of the Universal Declaration ofHuman Rights, which talks about povertybeing the greatest denial of human rights.4.1.2 Relevance and importanceof human rights to HIV/AIDSIt has been argued that protecting therights of those affected and at risk is thebest public health strategy to cope withan epidemic. A rights-based approachrecognises vulnerability to the epidemicnot just in terms of individual behaviourbut also the social, cultural and economicconditions that lead to this vulnerability.It also recognises that the vulnerability ofwomen, children, migrant workers, menwho have sex with men, injecting drugusers and sex workers can be reducedthrough the protection of their humanrights. It is only when the stigma anddiscrimination faced by PLWHA iseliminated, that they can be empoweredto take control of their lives. Protection ofhuman rights helps to create a supportiveenvironment, encouraging PLWHA toaccess the various health and HIV/AIDSrelatedsocial services and, consequently,stimulating behaviour change. Thisposition has been vindicated by theexperiences of several countries. 5The international response to HIV/AIDShas been characterised by twodiametrically opposed public healthapproaches-the isolationist approachand the integrationist approach. Theisolationist response proposes three basicstrategies for HIV/AIDS prevention:compulsory and universal HIV screening,the disclosure of the HIV status of thosetesting positive and their isolation fromlarger society through discriminatorypractices. The integrationist strategy, onthe other hand, proposes voluntarytesting following informed consent, thenon-disclosure of a person’s HIV-positivestatus and the equitable treatment ofPLWHA in healthcare, employment andall other facets of life.Integrationist policies were based on thefundamental human rights of individualsto self-autonomy, privacy and equality.The basis of this philosophy was that,in the long term, voluntary testing,confidentiality and non-discriminationwould encourage people to come out andaccess health services. This, in turn, would74Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSincrease the possibility of bringing aboutbehaviour change and instilling a sense ofpersonal responsibility through counselling,thus helping retard the spread of thevirus. The integrationist approach,therefore, sought to battle and reducestigma whereas the isolationist approachsought to increase it, thus pushing theepidemic further underground.Initially, the isolationist response,requiring as it did the disclosure of thepositive status of persons in order toprotect the rest of society from the spreadof the epidemic, 6 was felt to be mostappropriate in South Asia. However, thisapproach was given up when it was seento be violating people’s human rights andfuelling stigmatisation. 7 HIV-relateddiscrimination first attracted attention inthe region when India announced thetesting of foreign students, mainly thoseof African origin. 8 This was followed by anannouncement that certain categories oflong-term residents also had to be testedfor HIV. Concerns that foreigners mighttransmit the infection to the localpopulation prompted the preparation ofa draft bill prohibiting marriage betweenforeigners and Indian nationals.Fortunately, the proposed legislation didnot see the light of day.The realisation gradually dawned that theisolation versus integration debate couldnot be perceived as an issue of publicinterest versus individual rights. It cameto be acknowledged that the protectionof the individual was itself in the publicinterest as it increased accessibility toservices and brought the epidemic intothe open. This enabled concerted andeffective public health interventions thatwere ultimately beneficial to societyat large.An outstanding example of a successful,integrationist rights-based approach isthat of the STD/HIV Intervention Project(SHIP) in the red-light area of Sonagachiin the Indian city of Kolkata (See Box 4.1).The empowerment of sex workers in SHIPbrought about significant improvementsin their health as evidenced by a drasticdecline in STD rates and the marginal risein HIV infection.Certain key legal issues arose in the contextof HIV/AIDS, which the human rightsframework had to consider. The threeissues at the core of any response to HIV—consent to testing, non-disclosure of HIVstatus and anti-discrimination–requiredthat policies be informed by threefundamental human rights— those of selfautonomy,confidentiality/privacy andequality.The issue of consent to testing addressedthe question of whether testing should bevoluntary or mandatory. Consent,therefore, dealt with the right to selfautonomy,to decide for oneself what canbe done to one’s own body.The issue of non-disclosure was based onthe right to privacy/confidentiality. It wasalso based on the very pragmaticconsideration that disclosure (since thatmight lead to stigma and discrimination)would make people distrust healthcareand shy away from it, thereby driving theepidemic underground.Anti-discrimination was based on thefundamental right to equality – that HIVpositive status should not preventpersons from accessing services(healthcare, education, employment,insurance, travel etc.) and lead to theirbeing treated unequally from others.These issues also exemplified the famousparadox—that the best way to controlHIV/AIDS is to protect those mostvulnerable and those affected. 9 Help,The isolationistapproach wasgiven up when itwas seen to beviolating people’shuman rights andfuellingstigmatisation.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 75

Human Rights and HIV/AIDSBox 4.1Sexual negotiation as empowerment: the Sonagachi approachor most Indian women, it is almost impossible to evencontemplate assertiveness in a sexual relationship witha man and negotiate safer sex. However, a group ofsex workers in Sonagachi in Kolkata are successfullynegotiating safer sex relationships with clients as wellas better treatment from society, including from thepolice. In 1992, the STD/HIV Intervention Project (SHIP)set up a STD clinic for sex workers to promote diseasecontrol and condom distribution. However, the focusof the programme soon broadened to address structuralissues of gender, class and sexuality.SHIP aims to build sex workers’ capability to questionthe cultural stereotypes of their society, and buildawareness of power and who possess it. The sexworkers themselves decide the programme’s strategies.Twenty-five per cent of managerial positions in theproject are reserved for sex workers and they hold manykey positions. rom the initial stages itself, they wereinvited to act as peer educators, clinic assistants andclinic attendants in the project STD clinics.The project was built around the following ideas andstrategies:n The peer educators were provided with a uniformof green coats, and staff identity cards, which gavethem social recognition. A series of trainingactivities were organised, with the aim of promotingself-reliance and confidence among the sex workers,and earning respect from the community rather thanperpetuating the attitude that they were ‘fallen’womenn Sixty-five peer educators went from house to housein the red-light areas, equipped with information onSTD/HIV prevention, AIDS, how to access medicalcare and ways of questioning power structures thatpromoted violencen Peer educators conducted a survey with babus (longtermregular clients). Only 51.5 per cent of theclients had heard of HIV/AIDS and 72.7 per centhad never used a condom. As a result, allianceswere formed between the sex workers and theclients to promote safer sexual practices, includingthe elimination of sexual violence in the arean A training session for police personnel wasorganised by the All India Institute of Health andSource: Extract from Nath, 2000nnnnnnnHygiene. By the end of April 1996, about 180 policeofficers had attended these training programmesIn 1995, the Durbar Mahila Samanvaya Committee(DMSC), a union for sex workers, was formed topromote and enforce their rights. The stategovernment formally recognises the regulatoryboard that DMSC members set up with some statedepartments. This board ensures that allstakeholders in the red light area adhere to amutually agreed code of conduct, such as returningchildren trafficked to the area to their homesStories from history concerning how sex workershad fought for their rights are told, enabling SHIPto engage people’s emotions and rally them rounda common objectiveThe project responded to the needs of the sexworkers as they arose. or example, SHIP providednon- formal education when the demand for literacyarose, as well as vocational training programmesfor sex workers concerned about security in oldage. A credit and savings scheme was alsoestablished to help sex workers set up selfemploymentschemesThe Komal Gandhar theatre group set up by sexworkers has enabled them to communicatemethods of negotiating safer sex with clients,pimps, the police and brothel owners in a nonthreateningenvironmentSHIP has negotiated with groups of (mainly) men,including pimps, brothel owners, clients and thepolice, to convince them of the importance of theircampaign and even enlisted their support forimproved rights for sex workers. This representsa direct challenge to oppressive patriarchalstructuresSuccessful implementation of the project is not justabout changing behaviour but also attitudes likethe way that society views sexuality, the lack ofsocial acceptance of sex work and the legalambiguities relating to itThe sex workers have met with a range of partners,and have developed the view that their struggle assex workers is not very different from the strugglesof poor women in the informal sector. The strugglesare against patriarchy and domination76Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSsupport and protection for the infectedand their carers has been identified as akey strand of the campaign againstHIV/AIDS. “Protecting the groups andindividuals at risk is a moral obligation, apriority strategy owed to brothers andsisters because, like us, they are human.They feel. They suffer. They and theirfamilies are cruelly burdened when thisinfection takes hold, and nowhere moreso than in poorer, developing countrieswhere palliative drugs are generallyunavailable, social support outsidethe family, is negligible and wherestigmatisation based on ignorance andprejudice is rife. Prevention is not theonly strategy.” 10There are certain ethical issues that areimportant considerations in the humanrights-based approach to HIV/AIDS(See Box 4.2).With the realisation that the denial offundamental human rights had to betackled for HIV/AIDS to be effectivelycontrolled, other key legal issuesaddressing the fundamental right to liferequired consideration. It was noticedthat those most susceptible to HIV/AIDSwere persons who were legally andsocially disempowered and whose basicrights were denied to them. These groupsdid not have the basic human rights tolead a wholesome life, which could guardthem against public health crises,particularly HIV/AIDS. These populationsincluded injecting drug users,prisoners, sex workers, women, womenexperiencing gender violence, children,migrant workers and men who have sexwith men.Therefore, it was understood thatenforcing positive rights (the entire rangeof socio-economic rights), law reform anddecriminalising behaviours would help incontrolling the spread of HIV/AIDSwithin these groups and, thereby, itsspread within the general population aswell. In order to achieve this, reviewingand amending laws that prejudice,criminalise and marginalise these groupsis essential, and this needs to be supportedby changes in underlying cultural andsocial attitudes.It is important to demonstrate the linkbetween globally recognised humanrights standards and the response toHIV/AIDS. Table 4.1 attempts to highlightthe practical aspects of human rights inthe context of HIV/AIDS.4.2 HIV/AIDS, Stigma andDiscrimination and HumanRights in South Asia“Research shows that discrimination ismost frequently associated with diseasesthat have severe (incurable andprogressive) outcomes and modes oftransmission that are perceived tobe under an individual’s personalbehavioural control. 11 UnfortunatelyHIV/AIDS fits the criteria perfectly.HIV/AIDS discrimination has led to theuse of such terms as ‘leper’ to label thosethat are infected with disease as well asto brand them as ‘others’ or ‘deviants’. 12Metaphors portraying AIDS asretribution or punishment for a sinful lifeor moral failure are a powerful indicationBox 4.2nnnnnnIt is important todemonstrate thelink betweenglobally recognisedhuman rightsstandards and theresponse toHIV/AIDS.Ethical issues related to HIV/AIDSScreening and testing policies, including screening of pregnantwomenConfidentiality and privacyDiscrimination at the workplaceBlood safety and related issuesAccess to and delivery of healthcareBio-medical research (e.g. development of vaccine and drugsand trials; implementation of public health policies in preventionand control)Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 77

Human Rights and HIV/AIDSSource: UNAIDS. 2002cTable 4.1Legal and human rights of those affected by HIV/AIDSSome key human rights principles HIV/AIDS-related action Relevant human rights instrumentsThe right to the highest attainable Ensure that HIV-prevention tools l Article 25 of the Universalstandard of physical and mental health and services (such as treatment Declaration of Human Rightsfor STIs, provision of male and l Article 12 of the Internationalfemale condoms, and voluntary Covenant of Economic, Socialcounselling and testing) areand Cultural Rightsavailable, together with drugs for l Article 12 of the Convention onopportunistic infections, pain and Elimination of All orms ofsuffering, and anti-retrovirals. Discrimination Against WomenEnsure provision of the necessary Articles 24 and 25 of thehealth infrastructure and personnel. Convention on the Rights ofthe ChildThe right to information and education Provide information and education l Article 19 of the Universalrelating to sexual health and HIV Declaration on Human Rightsprevention. l Article 17 of the InternationalCovenant on Civil and PoliticalRightsl Article 37 of the Convention onthe Rights of the ChildThe right to privacy Ensure that counselling and l Article 12 of the Universaltesting are voluntary, and that Declaration on Human RightsHIV test results are confidential; l Article 17 of the Internationalguarantee the right of non-Covenant on Civil and Politicaldisclosure to the third parties. Rightsl Article 37 of the Convention onthe Rights of the ChildThe right to livelihood and living acilitate safe mobility practices l Article 23 and 25 of thewith dignity and ensure access to reliable Universal Declaration of Humaninformation with regard toRightsvulnerability to HIV/AIDS and l ILO Convention 97, Article 1 oftrafficking, especially for women the Migration for Employmentand childrenConventionl Articles 36 and 39 of theConvention on the Rights ofthe Childof the stigma attached to HIV/AIDS.Through stigma, society often blamesinfected people for being ill and assertsthe innocence and health of thestigmatisers”. 13While many serious diseases attractstigma and discrimination, HIV/AIDS isparticularly open to generate responseswhich ‘discredit’ 14 those who are infected.This is both because the routes of HIVtransmission include sexual behaviourand the sharing of injecting equipmentby drugs users—behaviours that areconsidered shameful or illegal in manysocieties—and because many of thegroups that have been most affected arealready marginalised and stigmatisedwithin society. This stigma has beencompounded by fear due to lack ofknowledge within South Asian societiesabout the modes of HIV transmission.78Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSBox 4.3Stigma and discrimination in South Asia: an illustrative studyA UNDP study, in partnership with five NGOs, conducteda survey using a generic rapid research methodology, toidentify and measure the components that influence HIVrelatedstigma, discrimination and preparedness toadequately care for HIV positive patients within hospitalsin Bangladesh, India, Nepal, Pakistan and Sri Lanka.Research was undertaken in one private and two publichospitals in each of five cities (Colombo, Delhi, Dhaka,Karachi, and Kathmandu). The 1200 respondents weredrawn from four staff groups within each hospital:doctors, nurses, ward assistants and laboratorytechnicians. The results produced a number of scalesthat appear to be key components of stigma anddiscrimination and reveal great differences in the leveland make up of stigma and discrimination withindifferent hospital settings and among different levelsof hospital staff.The study highlighted the close relationship betweenstigmatising attitudes and discriminatory practices onthe one hand and levels of knowledge, awareness andprofessional experience of HIV among hospital staff onthe other. These attitudes and practices have profoundimplications for the quality of healthcare that HIVpositive patients receive. Most medical staff are boundby codes of ethics that are designed to ensure that allpatients are treated equally. Yet, in the face of aninfectious disease, the staff’s concern for their ownsafety can combine with limited knowledge andexperience of HIV to lead to stigmatising attitudes anddiscriminatory practices within hospitals. Suchstigmatising behaviour among hospital staff, especiallyin the beginning stages of an epidemic, mirrors theattitudes of society at large.This preliminary study shows that it is both possibleand necessary to measure and disaggregate HIV-relatedstigma and discrimination. The results indicate that themajor components of stigma and discrimination towardsPLWHA in hospital settings are ignorance about HIVtransmission and fear of the consequences of infection.urther research is needed to understand theimplications of stigma and discrimination in the SouthAsian context and design interventions to reducesuch attitudes.It needs to be noted, however, that the study does notimply an across-the-board, sweeping indictment of thehealth system in South Asia. It recognises that healthservice providers work under difficult conditions andtheir attitudes and behaviour would reflect that ofsociety in general. It is also true that stigmatisingbehaviour is not unique to the region.Source: Extract from Nath, 2000This lack of knowledge is evident evenamong policymakers and healthcareworkers who have often appliedunnecessary and restrictive measures toPLWHA, thereby fuelling the misconceptions,fear and stigma relating to thedisease as well as violating individualrights.HIV-related stigma is built upon, andserves to strengthen and legitimise,existing social inequalities. The powerimbalances and socio-economic andgender inequalities within South Asiansocieties combine with taboos aroundsexuality, fear and ignorance about HIVtransmission, and inappropriate mediareports, to create a powerful stigmaattached to HIV/AIDS. Marginalisedgroups are also stigmatised partly becausethere is little general understanding of thestructural factors that make themvulnerable to HIV. Therefore, betterunderstanding of the developmentaspects of HIV would help reduce stigmasurrounding them.Throughout the region, PLWHA haveexperienced violent attacks, refusal ofmedical treatment, rejection fromfamilies, communities and from theworkplace, denial of last rites and manyother rights violations. In Bangladesh,there have been cases of PLWHA beingheld in police custody, 15 while in India aSupreme Court judgement hadRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 79

Human Rights and HIV/AIDSBox 4.4The three phases of the AIDS epidemicThere are three phases to the AIDS epidemic in any society.The first is the epidemic of HIV infection (entering the communitysilently and unnoticed).Second is the epidemic of AIDS, which appears when HIV triggerslife-threatening infection.Third is the epidemic of stigma, discrimination, blame and collectivedenial, which makes it so difficult to effectively tackle the firsttwo.Jonathan Mann, the late director of the Global Programme onAIDS, 1987‘suspended’ HIV-positive people’s right tomarry in 1998, though that right has nowbeen restored. 16 This is happening despitethe UN Commission on Human Rightsclearly stating: “Discrimination on thebasis of HIV or AIDS status, actual orpresumed, is prohibited by existinginternational human rights standards,and the term, ‘or other status’ in nondiscriminationprovisions in internationalhuman rights texts should beinterpreted to cover health status,including HIV/AIDS”. 17A recent study of the attitudes andbehaviour of health service providersindicates that stigma and discriminationpervades the hospital system as well(See Box 4.3).The stigma and discrimination attachedto HIV/AIDS also hampers preventionefforts, as people are less willing to test forHIV or to admit to their positive status.Many PLWHA, therefore, do not receive thesupport needed for behaviour change andare not involved in HIV-related responses.This also results in a lack of accurateinformation about levels of HIVprevalence, making informed preparationand responses impossible. Such denial andsecrecy takes place not just at a personal,but also at a social level, with communitiesand nations across the region refusing toadmit the scale of the problem.4.3 Social Violence andHuman Rights ViolationsThe active role of civil society, includingthat of local decision-policy-makers, inprotecting the rights of individualcommunity members is crucial insustaining the socio-cultural fabric ofany community. Given the existingenvironment of intolerance, stigma anddiscrimination, societal acceptance isparticularly crucial for the effectiveimplementation of HIV-related legislation.There is evidence within SouthAsia that human rights violations andviolence against individuals (includingthose who have been traditionallymarginalised, especially the poor anddisempowered, women, those belongingto Scheduled Castes/Scheduled Tribes,religious minorities, migrants andstigmatised groups) are often aggravatedwithin existing community structures.Studies in South Asia reveal that morewomen die from violence-induced causesthan from maternal mortality (the regionhas one of the world’s highest rates ofmaternal mortality 18 ). The lives ofmillions of women in this region aredefined by traditions that enforcesubmission to men and endorse unequaltreatment. In some countries, forexample, it is reported that young girlsand women are sometimes killed by theirrelatives even if they are raped, as they areblamed for bringing dishonour to thefamily. 19 Women from Bangladesh whohave been in the sex trade also fear beingkilled by their families. Apart fromtraditional mindset, another reason forsuch manifestations of violations is thelack of access that women have over80Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSBox 4.5Badi communities in Nepal: surviving social ostracism and violenceBadis form a section of the ‘untouchable’ Hindu castein Nepal. Badi women have traditionally sold sex, and40 per cent of Badi households have at least one womanengaging in the sex trade, according to experts. An NGO,Social Awareness or Education (SAE), has just startedcondom awareness and distribution among sex workersand their clients.Over the past five years, registered local bodies of ‘moralpolice’ called Tol Sudhar Samiti (NeighbourhoodImprovement Committee), usually comprising high castemen, have taken on a campaign to ‘expel prostitution’,which, in their view, was synonymous with the Badicommunity. One member of the campaign told TheKathmandu Post in April 2001, “When we found menin Badi women’s houses, we beat them as wouldpolicemen, when arresting thieves.” Similar discipliningof sex workers was done only by women activists.Manju, a community mobiliser working for SAE,remembers the terrifying night the Samiti broke intoher house and beat her up because she had complainedagainst their activities. She took refuge at the localpolice station. The next day, she found her house hadbeen vandalised. Manju was forced to rent out herhouse and move to another neighbourhood. Nirmala,another Badi woman, recalls the time a group of Badiwomen were summoned to the police station for adiscussion. “There was no discussion,” she says.“They intended to blacken our faces and parade usaround town with placards reading, ‘I am a whore’.”Protesting such forms of socially sanctioned violations,Badi women from several districts took out a silentprocession in December 2000 to highlight the violencedirected at them.Source: Based on reports in Los Angeles Times, August 3, 1994, John-Thor Dahlburg, Times Staff Writer; Nepali Times,July 5-11, 2002, Number 101familial assets, exacerbating socioeconomicinsecurities. Since youngwomen and girls lack education, thereare limited livelihood opportunitiesavailable to them, especially since theexisting social support mechanismaround them is inadequate. Such skewedsocio-cultural realities and trendsseriously challenge the right todevelopment for many, besides infringingtheir basic human rights. Women livingin these insecure conditions arevulnerable to trafficking and sexualviolence and, therefore, to HIV.Gender inequities and stereotypes inSouth Asia increase the vulnerability ofyoung women, and to a lesser extentyoung men, to HIV and create anenvironment in which it is easy for HIV tospread. 20 The taboos around the opendiscussion of sex and the social value thatis placed on the ignorance of women andgirls with regards to sexuality, safer sex andrelationships creates a situation in whichwomen and girls engage in sexualrelationships without the basicinformation, resources, confidence andskills needed to protect themselvesfrom HIV.The strong pressure on women and mento conform to widely held gender idealscreates a situation in which it is oftensocially unacceptable for both women andmen to seek information on sex thatwould empower them to protectthemselves from HIV. For women,ignorance of sexual matters is valued asa sign of ‘purity’ and ‘innocence’, whileknowledge about sex is seen as a sign of‘immorality’, making it difficult for themto seek information on sexual matters.Men, on the other hand, are expected toconform to a masculine ideal whichvalues sexual knowledge and experiencewith a variety of partners, often makingit hard for them to admit ignoranceon sexual matters and seek informationand support.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 81

Human Rights and HIV/AIDSAlthough male sexworkers are oftenmore aware oftheir vulnerabilitiesto HIV and STIsthan their peers,the fact that theyare an extremelymarginalisedgroup... makes itextremely difficultfor them to protectthemselves.In addition to the existing cultural valueplaced on sexual inexperience in women,it has been seen that the HIV epidemiccan prompt older men to seek everyounger partners who they believe will beless sexually experienced and thereforeless likely to be infected by HIV. 21 Thismakes young women more vulnerable tobeing infected by older men with widersexual experience. 224.3.1 Sexuality andvulnerabilities: men who havesex with menSex between men is common withinSouth Asia, as it is in other societies.However, such sex is generally not viewedas ‘homosexual’ and those men engagingin it are rarely part of any ‘gay’community. 23 Moreover, such activitiesare taboo and not widely talked about, andare also officially outlawed in most SouthAsian countries, often by old Britishcolonial laws that have been left in place.Despite this, it appears that in manycountries young men have their earlysexual experiences with other young menand that many go on to continuedbisexual activity in later life. For example,50 per cent of male university studentsinterviewed in Sri Lanka reported thattheir first sexual experience had been withanother man. 24 While male bisexualitycannot be understood simply as aresponse to men’s lack of access towomen, it is likely that restrictions oncontact between men and women inmany South Asian cultures do play a partin the widespread nature of sex betweenmen as an alternative means of sexualexpression.A study conducted in the Bangladeshicapital of Dhaka 25 found that the rights ofmen who have sex with men, includingmale sex workers, were being violated withincreasing frequency. The study went onto establish that such violations affectedtheir self-esteem, negotiating power, andultimately increased their vulnerability toHIV/AIDS. For men, selling sex is bothhighly stigmatised and illegal in most ofSouth Asia. Although male sex workers areoften more aware of their vulnerabilitiesto HIV and STIs than their peers, the factthat they are an extremely marginalisedgroup, and are forced to operate incircumstances over which they have verylittle control, makes it extremely difficultfor them to protect themselves. It isparticularly difficult for young men tonegotiate safer sex with older and morepowerful male partners, and when analsex is practised, the unavailability ofcondoms and lubricants can exacerbatethe vulnerabilities that they face.4.3.2 Mobile populationsMigration is a survival strategy for manyindividuals in search of work within SouthAsia. The region is currently undergoingmajor macro economic changes as partof the process of globalisation, which hasopened up many avenues for large-scalelabour mobility. Poverty, absence ofadequate or appropriate livelihoodoptions, depleting rural employmentopportunities, caste and gender-basedexploitation and oppression, violenceand conflict, the hope of finding betteropportunities elsewhere and the searchfor a better life are among the key factorsthat make people move in search oflivelihoods. Migration patterns from theregion include internal and inter-countrymobility, as well as overseas migration.The migration trends depend upon socioeconomicand geographical factorsas well as tradition/past migrationexperiences in the source community,availability of local livelihood options andproximity to metropolitan cities.According to figures from the Bureau ofManpower and Employment andTraining of Bangladesh, the average82Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSnumber of documented migrant workers,both skilled and unskilled, is about 200,000per year. In India, according to theNational Sample Survey (1993), 24.68 percent of the population—approximately200 million people—were recorded ashaving migrated, either within India, toneighbouring countries or overseas.Recent studies have estimated the annualflow of workers overseas to be well over100,000, 80 per cent of them from theunskilled sector. Nepal’s Department ofLabour has registered 52,170 overseasmigrant workers, and this figure does notinclude the vast numbers crossing theopen border into India, for whichestimates are as high as one million.Figures provided by the Bureau ofEmigration and Overseas Employment ofPakistan for 1999 show 2,790,221 migrantworkers working abroad. Its major citieshouse vast migrant populations both fromwithin Pakistan and outside. Roughly20 per cent of the population of Karachiconsists of individuals who have comefrom other provinces or are migrants fromAfghanistan, Bangladesh, Myanmar,Philippines and the Central Asian states.The total number of Sri Lankans abroad isestimated to be around 788,000, of whom90 per cent are in West Asia, includingSaudi Arabia, Kuwait and the United ArabEmirates. In 1999 alone, almost 180,000people are recorded as having leftSri Lanka for employment abroad, out ofwhich 64.5 per cent were females. Besidesofficial data on number of departuresand arrivals at ports of entry, there issubstantial movement by peopleunofficially, by refugees, immigrants andtemporary residents.A factor that significantly influences thedecisions of potential migrants is thenarrative of returning migrants, who, intheir desire to create a favourableimpression, highlight monetary gains andunderplay or gloss over experiences ofexploitation and abuse. The decisionto migrate, therefore, is often based onlittle more than an ill-defined impressionthat life will offer more elsewhere,with very little information about theground realities.Migrants contribute to the developmentof local economies in both the source anddestination countries. Earnings fromwork abroad are a vital source of incomefor migrants’ families back home. In manycases, the remittances from foreignmigrant workers are one of the mainsources of foreign exchange for countriesin the region. In Sri Lanka, for example,such remittances form the bulk of foreignexchange earnings. 26 In Pakistan,remittances in 1993 were estimated to be44 per cent of the total earnings fromexports. In Bangladesh, foreign employmentis the second highest source offoreign exchange earnings after garmentexports. Migrant workers are a source ofcheap labour in destination countries,since many of them work for lower wagesthan the resident workers.It is, however, paradoxical that in spite ofthis, a majority of these migrants are poor,do not have access to health services andare exploited and neglected. They residein squatter settlements and urban slumsand are employed in the informal sector.Being ‘foreign workers’, they are often notcovered by the same legal protections astheir local counterparts, and are generallyunaware of their rights as workers. A largenumber among them have to cope withinsecurities in their jobs, unsteadyincomes, cultural alienation, lack ofaccess to social support systems andsocial capital and loneliness. It is thesevery challenges that make migrants morevulnerable to HIV infection.However, attempts to establish intuitivelinks between mobility and HIV/AIDSA large number(of migrants) haveto cope withinsecurities in theirjobs, unsteadyincomes, culturalalienation, lack ofaccess to socialsupport systemsand social capitaland loneliness.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 83

Human Rights and HIV/AIDSIt must be stressedthat migrants areneither ‘carriers’ ofthe virus nor arethey responsible forthe spread of theepidemic.have often resulted in stigmatisation ofmigrants as well as restrictions on them,including forced testing for HIV anddeportation of those found positive andlimitations on the rights of women tomove in some countries. The inhumaneand exploitative conditions that mostmigrants face in source areas, duringtransit and within host communities indestination countries need to be changedand a comprehensive response needs tobe developed to facilitate safe migration,thereby reducing HIV/AIDS relatedvulnerabilities.It must be stressed that migrants areneither ‘carriers’ of the virus nor are theyresponsible for the spread of theepidemic. They are often unaware ofwhether they have been exposed to HIVand of the potential harm this poses totheir spouse and unborn children. Mostof those returning home because of illnessarising from various opportunisticinfections are not aware that HIV is thecause of their poor health. Many,especially those in West Asia, are deportedwithout explanation if found to be HIVpositive. In the rare cases where they mayhave knowledge about their HIV status,the climate of stigma and discriminationmakes them reluctant to disclose theirstatus within their communities and evenfamilies. Importantly, the femalespouses/partners of male migrants arefurther disadvantaged because existingasymmetrical power and genderequations make it difficult for them toprotect themselves against HIV infection.Vulnerability of women migrantsThe gender dimension of migrationrelatedvulnerability presents a complexpicture. The number of women migratingis increasing within South Asia. Globally,the percentage share of female labour inthe total agricultural labour force isreported to have increased from 44 percent to 48 per cent within the last 50 years,in spite of the share of agricultural labourwithin the total labour force decliningby over 20 per cent within the sametime period. 27 Such gender-specific trendsalso give rise to particular migratorypatterns, leading to what may be termedthe ‘feminisation of migration’ acrossthe region.For many women, migration—inaddition to being a livelihood strategy—is also an escape route from limitationsimposed by traditional societies,oppressive laws and abuse or violence. Astudy in Bangladesh has shown thatfamilies tend to urge women to migratewhen they are perceived as being a burdento the family. 28 There are also higherexpectations from women to send backremittances, compared to young men.The circumstances of such migrationprocesses, coupled with the limitedpreparedness, may create conditions thatlead to women—especially young girls—being lured with false promises ofemployment and marriage and beingtrafficked into the sex trade, slavery andexploitation. Gender biases limit theaccess of women migrants to informationand services that could make theirmovement safer. These women also lacksupport mechanisms within their sourcecommunities,thus confining theirknowledge to hearsay. All these factorsexacerbate women’s vulnerability to HIV.Women migrants are often victims ofviolence and harassment. Reports of sexualassault by employers and others arecommon both within the region andoverseas, and legal redress is rarely availableor availed of. Further, pressure from thefamily to send more money may often leadwomen migrants to supplement theirearnings through sex work. In all of thesesituations, the ability of women to84Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSnegotiate safer sex remains low, even if theyare aware that they might be exposed toHIV. Contrary to popular belief, thevulnerability to HIV remains high for thosemigrating with families as well. When menmigrate in search of work, women leftbehind are often exploited includingsexually. As sole caretakers of the childrenand family they are especially vulnerableas the expected incomes from malemigrants are often unstable or inadequate.Apart from women who move, even thosewhose partners move, leaving thembehind, are vulnerable to HIV/AIDS to theextent that they are vulnerable toexploitation and denial of rights. Theirlower position in society and their limitedcontrol over their lives heighten theirvulnerability to sexual exploitation,particularly when debts have beenincurred for covering migration costsand remittances fail to come. Wherewomen move alone, leaving their spouseand children behind, the men are ofteninvolved in multi-partner sexualrelationships and girl children are knownto become exposed to situations of sexualexploitation, abuse, rape and incest.The region has several examples of effectiveresponses aimed at reducing thevulnerability of migrant populations.Formal pre-departure trainings in SriLanka, initiatives for interactionsbetween returnee migrants and out-goingmigrants in Bangladesh, multi-sectoralresponses to address the broad spectrumof needs of migrants in selected sourceareas in Nepal and India are someexamples. However, there is need forconcerted and more comprehensiveresponses. All efforts to reduce the HIVvulnerabilities associated with mobilityneed to address the broader issues ofpoverty, livelihoods, education, access toinformation and services and the need fora rights-sensitive legal environment.Effective responses would necessarilyreflect the voices of migrants and theirneeds and would involve returneemigrants, spouses, youth, key enforcementpersonnel, recruiting agencies andPLWHA, addressing vulnerabilities atsource, during transit and in destinationcountries. Most importantly, all efforts toreduce the vulnerability of migrantpopulations must be careful not tostigmatise the migrants or their familiesand communities.4.3.3 Trafficked women and girlsFor a large number of people in the region,migration has become a key survivalstrategy. However, the lack of safe, secureand legal channels for migration driveunsuspecting and uninformed womenand girls into the hands of unscrupulousagents and traffickers who promise them‘good jobs’ and ‘safe travel’ into sites ofwork. These are usually young men,themselves from poor families, who arelured into the trafficking networks in orderto support their own families.Because trafficking is an illegal andconcealed activity, it is difficult to beprecise about the exact numbers ofwomen and children involved. Estimatesare based on the reports of lawenforcement agencies, researchers andgroups working with survivors andcommunities, and indicate that hundredsof thousands of women and children havebeen or are vulnerable to being traffickedfrom South Asia. Sources estimate that10,000-20,000 women and children aretrafficked from Bangladesh every year. 29NGOs have estimated that 5,000-7,000girls from Nepal are annually traffickedinto Indian brothels. 30The factors contributing to an increase inthe trafficking of women are as follows:l increased demand and supply oftrafficked persons;When menmigrate in searchof work, womenleft behind areoften exploitedincluding sexually.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 85

Human Rights and HIV/AIDSIt is extremelydifficult for sexworkers who areHIV positive to getmedical treatment,and once found tobe HIV positive, ortoo sick to receivecustomers, they arethrown out of thebrothels.lllllllprofessionalisation of the traffickersand syndicates;modern transport, technology and theInternet;the growth of sex tourism;the feminisation of poverty;trading in human organs;the changing nature of sex work; andthe erosion of social capital.The all-pervasive neglect, discriminationand sexual abuse of women and girls in theregion are responsible for their increasedvulnerability to being trafficked, and toHIV/AIDS. Research shows that womenand girls often end up bearing the tripleburden of exploitation – they are poor, theyform a marginalised group and they arewomen. 31 HIV prevalence rates has beenestimated to be as high as 60 per cent inthe brothels of Mumbai, India, wherecondom usage is very low. 32 It is extremelydifficult for sex workers who are HIVpositive to get medical treatment, andonce found to be HIV positive, or too sickto receive customers, they are thrown outof the brothels. This often forces them intoinformal and unsafe sex work for survival.Significantly, the region is witnessing adangerous trend of younger girls beingtrafficked increasingly to satisfy consumerdemand. According to the CoalitionAgainst Trafficking in Women (CATW),the average age of girls trafficked fromNepal into India has fallen over the pastdecade from 14–16 years to 10–14 years.One common myth fuelling the demandfor young girls in South Asia and West Asiais that sex with a virgin girl can cure STIsand HIV/AIDS. This means that theyoungest girls, biologically the mostvulnerable to HIV infection, are especiallysought out for unprotected sex by the menmost likely to infect them.Women in Afghanistan have endured aparticularly difficult environment, havingbeen, until recently, denied even the mostbasic rights, including employment andeducation. The female literacy rate is oneof the world’s lowest—15 per cent in1995. 33 Decades of political and civil unrestand conflict had heightened theirvulnerability to violence. Emerginginformation, reported, for example, byAmnesty International, indicates thatAfghan women and girls had been treatedas the spoils of war, and were beingsystematically kidnapped and rapedby fighters.Orphans, women with disabilities, andwidows, who are often very young, havebeen noted as being particularlyvulnerable. Poor widowed women withlittle or no financial support or means ofearning a livelihood are forced to resort tobeggary to feed their children, thus gettingexposed to abuse, including sexual abuse.In an atmosphere of silence and taboosabout sex, this only heightens thevulnerability of women and girls toHIV/AIDS. Furthermore, there arereports of rising levels of drug use amongdisplaced Afghan men, unsafe sexualrelationships, and the migration of malerefugees to metropolitan centres, such asKarachi in Pakistan to find work. Many ofthese men are uninformed about safe sexpractices and are themselves vulnerableto HIV/AIDS. On their return, theyincrease the vulnerability of their wives/female partners to HIV/AIDS.Trafficking and HIV/AIDS are presentingserious threats to the health, dignity andlives of young women and girls across theregion. The nexus of poverty, HIV and themarketing of youth within and acrossborders is creating ever-widening circlesof desperate insecurity and disproportionatelythreatens the lives of young girls,making poor people poorer throughsickness, loss of livelihoods and rejectionby society. The epidemic is severely86Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSBox 4.6India addresses the problem of trafficking of womenIn the course of discussions on the advancement ofwomen at the 57 th UN General Assembly in October2002, the government of India affirmed its commitmenttowards the empowerment of women, referring to theNational Policy for the Empowerment of Women (2001).S.S. Ahluwalia, Member of Parliament and member ofthe Indian delegation said that the Immoral Traffic(Prevention) Act of 1956 (ITPA), supplemented by theIndian Penal Code, prohibits trafficking in human beings.He also said several other plans, programmes andmeasures are in place to deal with the serious issue oftrafficking. The National Commission for Women, astatutory body, has been performing crucial sensitisationfunctions in this and other areas. At the regional level,he pointed out, the SAARC states finalised theConvention on Trafficking recognising this as a priorityarea of action. The Protocol on Trafficking in Persons,especially women and children, of the UN Conventionagainst Transnational Organised Crime is expected toreinforce national efforts to address this problem.Source: Statement by Hon’ble Mr. S.S Ahluwalia, M.P and Member of the Indian Delegation, Third Committee, 57 th UNGeneral Assembly, New York, 10 October 2002undermining human security and humanrights, destroying the lives of individualsand families and posing a serious threatto the social capital and the overalldevelopment of the region.Trafficked persons in South Asia are oftendiscriminated against even by their owncommunities, once they return or arerepatriated from destination countries.The process of re-integration for traffickedsurvivors is an uphill task, since theircommunities ostracise them. This is evenmore pronounced in the case of traffickedsurvivors who are HIV-positive. Studies inNepal have documented that HIV positivesurvivors of trafficking are oftenstigmatised and find it impossible tore-integrate themselves into theircommunities. 34Urgent and integrated action at thenational and regional levels is required toaddress the multiple and complex waysin which the security and rights of younggirls are threatened. The integralconnection between HIV/AIDS, genderand trafficking through the nexus ofvulnerability and sexual violence, can besummed up as follows:l the factors, which determine thecontext of trafficking, are also thellfactors, which are associated with theincreased vulnerability of women andgirls to HIV/AIDS. Specifically, theserelate to gender-related social andeconomic disempowerment, lack ofsocial capital formation and unequalaccess to all the indicators ofdevelopment, including health,information and education. Suchcircumstances severely underminethe basic rights to social protectionand the right to the highest attainablestandard of living; 35trafficking is part of a pattern ofmigration within and acrosscountries, which removes personsfrom the protection of theircommunities and severs them fromtheir systems of social support. Thesevery factors are recognised as causesfuelling the continued spread of theHIV epidemic, and which, in turn,violate a person’s right to a standard ofliving adequate for the health andwellbeing of oneself and one’s family;those caught in the web of traffickingface an increased vulnerability toHIV/AIDS on account of their inabilityto control their working and livingconditions, including sexual relations,as well as their inability to come out ofit. Such situations grossly violate aRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 87

Human Rights and HIV/AIDSlperson’s right to freedom from slaveryor servitude and the right to physicalintegrity (security of person); andcommon societal responses to thoseaffected by HIV/AIDS as well astrafficking are strongly influenced bystigmatisation, discrimination andfurther marginalisation. Theseresponses, in turn, undermine thebasic rights and freedoms of theseaffected individuals, includingthe right to mobility and residence,the right to essential services, rightto confidentiality, right to freeassociation, and sexual andreproductive rights.Declaration of Human Rights) are boundby the standards laid down therein,depending on the binding nature of thedocument and the manner in which eachcountry codifies it within its national laws.Very few nations in the world—and nonein South Asia—have specific statutorylaws governing HIV/AIDS or ensuringprotections to PLWHA. Fundamentalrights guaranteed by national constitutionsare, therefore, the prime source oflaw in South Asia. However, there are alsocustomary and personal laws, particularlyin South Asia, that determine the rights ofindividuals, especially women.4.4 The Scope of HumanRightsIt is important to briefly explain the legalframeworks within which most PLWHAin South Asia live. As mentioned inChapter 3, some of the fundamentalhuman rights are covered under several ofSouth Asia’s national constitutions,although the scope of these rights variesfrom country to country, as does theirapplication in the context of PLWHA.Nations who are signatories tointernational documents/agreements/conventions (such as the UniversalApart from constitutional guarantees,policies and guidelines on HIV/AIDSdrawn up by national governments oftenbecome the prime basis on which therights of PLWHA are defined. However, inIndia, governmental policies/guidelinescannot be enforced by the courts, thoughmany rights of PLWHA are defined throughcourt judgments as India is governed bythe system of English common law. 36Recently, widely published cases of lawenforcement interventions involvingharassment of vulnerable group outreachworkers created an uproar within civilBox 4.7Mandatory testingIndia: Under India’s Immoral Traffic (Prevention) Act,1956 (ITPA), the sex trade itself is not considered anillegal activity, although brothel keeping and solicitingin public places are. Presently, there is a Bill pendingbefore the Parliament in India to amend ITPA. The Billprovides for the rehabilitation of sex workers. However,it also contains provisions for mandatory testing of sexworkers for STDs and HIV. In addition, Section 8stipulates that the government shall set up special cellsin the health administration to organise mandatory healthcheck ups on women in the sex trade. This is contraryto the testing policy of India’s NACO, which encouragesvoluntary and informed testing.Bangladesh: The 1995 National Policy on HIV/AIDS andSTD Related Issues espouses a rights-based approachand endorses the Universal Declaration of Human Rightsas a benchmark for policy making and action at all levelsin the response to HIV/AIDS and STDs. However, thepolicy makes it mandatory for private and public sectorhealthcare institutions, employment clinics and thearmed forces services to notify the Directorate GeneralHealth Services about all people living with HIV/AIDS(PLWHA) and provide case details. At the same time,the policy maintains that notification must beanonymous and confidentiality must be maintained atall points.88Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSTable 4.2Important human and legal rights and their implementationPopulation cohortsPeople Living with HIV/AIDS (PLWHA)l The right to life–treatment andhealthcare, employment, confidentialityand privacy, protectionfrom violence, form groups andassociationsl The right to equality and nondiscrimination–inhealthcare,employment, insurance, travel andmovement, services, marriage andfamilyl The right to information–ontreatment, safer sex options, harmreduction methodsl The right to privacy andconfidentiality–in healthcare,employment, legal/ judicial systemsl The right to bodily integrity andautonomy–consent in treatmentand testingl The right to health–access to thebest available medication ataffordable pricesl The right to reproductive choicesand decision making–continuing orterminating pregnancy, decisionabout fertility (in the context ofsterilisation that HIV-positivewomen are subjected to withoutconsent)Human rightsOverview of laws and their implementation in South AsiaThere are no specific legislation in the region either protecting orinfringing upon the rights of PLWHA. However, many constitutionsprovide certain fundamental rights including the right to equalityand non-discrimination, right to life and liberty as well as privacy, 37which are pertinent in the context of HIV/AIDS. Though there islack of protective legislation, many national strategies state thatPLWHA are entitled to fundamental human rights and freedom,including the right to confidentiality as part of the right to privacy.In Nepal this right is considered inviolable except as provided bylaw. 38 Public health institutions in some countries are obligated notto discriminate between patients on the basis of HIV status and toprovide treatment for opportunistic infections. Despite suchguarantees, discrimination of PLWHA in healthcare settings is notan uncommon experience. Breach of confidentiality about HIV statusis another significant issue in the context of healthcare settings.Inability to access services due to fear of stigma and discriminationis a significant concern for PLWHA in this regard. There are severalexamples in the region of people having lost their jobs because theytested HIV positive In Maldives, administrative measures sayingthat there should be no discrimination against PLWHA with regardto employment applies only to those in civil service and governmentownedcompanies. 39 PLWHA are also systematically deniedinsurance, as insurance schemes in general exclude liability for HIVrelatedexpenses.Injecting drug usersl The right to life–civil rights againstarbitrary arrest and harassment bylaw enforcement and others,reintegration/rehabilitationl The right to health–information,treatment, non-discrimination inhealthcare, access to harmreduction strategies (clean needles,syringes and paraphernalia)Overview of laws and their implementation in South AsiaVarious drugs such as opium and cannabis have traditionally beeneaten, drunk or smoked in most countries of the region. 40 ollowingthe introduction of heroin, however, injecting drug use is nowcommon. The prevalence of injecting drug use varies considerablywithin and between countries, from very low levels estimated inAfghanistan to up to 93 per cent in some places in Bangladesh.Most of the South Asian countries are signatories to the Conventionagainst Illicit Traffic in Narcotic Drugs and Psychotropic Substances,1988 and the Single Convention on Narcotic Drugs, 1961. There isalso a SAARC Convention on Narcotic Drugs and PsychotropicSubstancesRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 89

Human Rights and HIV/AIDSllDecriminalisation of drug use andreform of related laws used toexploit IDUsThe right to equality and nondiscrimination–toservices includinghealthcaresigned in 1998. The countries have implemented laws that criminalisedrug use, the cultivation of opium poppy and cannabis; production,processing, buying, selling, trading, keeping and trafficking of drugs.The penalty for violation of laws related to drugs can vary fromvarious lengths of imprisonment to death sentence in severalcounties, including Sri Lanka and India. Laws for the treatment andrehabilitation of drug users have mainly been adopted as part ofpunitive measures in Afghanistan 41 for policing the use andpossession of drugs. There are reports that due to lack of treatmentfacilities in Nepal, a large number of drug users have been roundedup and put in prison where the ‘cold turkey’ 42 method of treatmentis followed. Injecting drug users are being arrested throughout theregion for carrying needles and syringes 43 and most legislation doesnot provide space for the implementation of harm reductionprogrammes. Needle exchange programmes have been introducedand are funded by some governments, such as that of the state ofManipur in India, Iran and Nepal. However, legally, such initiativesmay amount to abetment of offences under the drug laws of thecountry. In most of the countries in the region, offenders of druglaws make up a very substantial part of prison populations.Sex workerslllllThe right to life–civil rights againstarbitrary arrest and harassment bylaw enforcement agencies andothers, right to form groups andassociations, right to assemblereedom of speech and expression–to publish educational andinformation materialsThe right to health–information,treatment, non-discrimination inhealthcare, access to harmreduction strategies (condomdistribution, safer sex, educativematerials)Decriminalisation of homosexualintercourse and reform in relatedlaws used to exploit men who havesex with menThe right to equality and nondiscriminationto services includinghealthcare, protection fromobscenity lawsOverview of laws and their implementation in South AsiaEven though the awareness of HIV/AIDS among sex workers isrelatively high in countries of the region, condom use remains low.Legal evictions of sex workers within many countries in South Asiahave intensified feelings of mistrust and harassment between sexworkers and law enforcement officials. While sex work is not acrime in itself in many of the countries, brothel and street-basedsex work is illegal. Iran is an exception, where execution (by firingsquad or stoning) is the maximum penalty for sex workers and suchexecutions are common. 4490Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSsociety in India. 45 Implementation ofinterventions gets delayed in such a nonenablingenvironment and lives are lost.The published cases reveal that nationalguidelines clash with legislation and lawenforcers’ instructions. For instance,criminal laws affecting vulnerablepopulations have impeded sexual healthinterventions among them. Harmreduction methods like condomdistribution and needle exchangeprogrammes could be, and have been,seen as abetting crimes (homosexual sex,sex work, drug use). As a result, theireffective implementation has beenimpossible in many countries.Clearly, clarification, understanding andsensitisation of the particularities of theHIV/AIDS response is needed within lawenforcement agencies at first, but also inthe judicial administration and thelegislature. There has been someinteresting development in this regard inIndia. (see Box 4.8)4.4.1 Judicial issuesApart from the United States and Australia,the highest number of HIV/AIDSrelatedlitigation has perhaps taken placein India. In 1997, the Lawyers’ Collectivechallenged the termination of the servicesof a worker on the ground of beingHIV-positive though the person wasotherwise functionally healthy. In alandmark judgement of the Mumbai HighCourt, the worker was reinstated and paidback wages. More importantly, theCollective was able to obtain an order ofsuppression of identity because of whichthe HIV-positive person could sue undera pseudonym.A study of 130 cases handled by theLawyers’ Collective between 1998 and2001 found that the most important legalissue for men related to employment. Inthe case of women, the major problemrelated to maintenance, custody ofchildren and property rights (such asmatrimonial or joint property rights). 48An increase in the number of divorcecases was also noted. It has beensuggested that women remain vulnerablewithin the institution of marriage due tothe unjust gender construction ofsexuality in various Indian laws. 49Many of the South Asian countries haveundertaken several measures to reform thelegal climate surrounding HIV/AIDS.Some of them are:l organising and training a nation-widenetwork of lawyers to handleindividual complaints;l providing free legal services;Box 4.8Indian courts exhibit sensitivity towards PLWHAThere are several cases related to HIV/AIDS pendingin Indian courts 46 and the courts are exhibiting a certainsensitivity to the need for PLWHA to maintainconfidentiality. In many cases, they have passed ordersof ‘suppression of identity’ so as to enable the concernedpersons to take recourse to the legal system withoutfear of being identified and stigmatised. In cases ofsuppression of identity, the petition or suit is filed inthe full name of the PLWHA. After the pseudonymorders are passed, the papers with the full name arekept in a sealed cover in the exclusive custody of theregistrar of the court while the court files aresubstituted by the pseudonym. Any interim order orthe final judgment of the court is issued under thepseudonym.In November 2002, the Delhi High Court issued noticesto both the Union government and the Delhi governmentseeking their replies on the refusal of several cityhospitals to treat an HIV-positive person. Notices werealso issued to several hospitals where the person hadgone for treatment, only to be turned away. 47Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 91

Human Rights and HIV/AIDSllorganising workshops to formulatepolicies for the protection of the rightsof PLWHA and their families; andcampaigning for the decriminalisationof homosexuality and sex work and forthe formulation of laws covering issuessuch as HIV testing, confidentiality ofHIV test results and discriminationagainst people with HIV. 50Sex workers have used legal redress andaccess to the justice system to addressrights violation, as happened inBangladesh (see Box 4.9).4.4.2 Legislative reformsThe need for legislative reforms has beenunderlined at regional workshops on HIVlaw, ethics and human rights organised inthe early and mid-1990s by the UNDPRegional Project on StrengtheningResponses to the HIV Epidemic in Asiaand the Pacific. 51 The issue still remainsto be adequately addressed by mostcountries.In most countries of the region, doctors whowish to prescribe ARVs to survivors of rapefind themselves torn between governmentpolicy and medical ethics. These drugs areused as ‘Post Exposure Prophylaxis’ (PEP)for occupational exposure 52 and to reducemother-to-child transmission of HIV. Ithas been contended that they should alsoprove effective for rape survivors. 53However, many countries limit the use ofPEP to occupational exposure and not torape. This violates the rights of personssurviving sexual violence, compromisestheir treatment and care and infringesupon doctors’ ethical duties. Moreover,even in countries that have policies forPEP provisions in occupationalexposure, there is limited knowledgeabout such provisions, reducing theiroperational efficacy.Box 4.9Sex workers in Bangladesh: human rights violations and legal redressTanbazar is a red-light area in the Bangladeshi river porttown of Narayanganj, 25 km south of the capital cityof Dhaka. Nearly 30 per cent of all the brothel-basedsex workers in Bangladesh live in this area and it ishome to more than 1,600 sex workers and theirchildren. It is said that the earnings from brothelssupport not only other commercial activities within thebrothel (shops, etc.) but also extended families of thesex workers. In July 1999, local officials evictednumerous sex workers from the brothels in Tanbazar.A brothel in the western town of Magura was home to400 women and 50 of their children until it was alsoclosed down.The sex workers sought compensation and took to thestreets of Dhaka in protest, carrying their children andplacards reading “Rehabilitate us or give back ourhouse”. The sex workers said that they had been forcedto live on the street or in parks. “We staged thisdemonstration after failing to get any help fromauthorities,” said Momtaz Begum, President of the SexWorkers’ Network of Bangladesh. She alleged that thesex workers were evicted even though they wereoperating legally and paid taxes on the brothel property.One of sex workers said that they were forced to payprotection money to the police and local thugs. “Theyused to get money from us on a regular basis besideshaving free sex. Now they are trying to throw us outand make our lives uncertain,” said Sathi, a sex worker.HIV prevalence rate in the brothel area is estimated tobe 15 per 1000 persons, and the syphilis prevalencerate is about 50 per cent. Experts, therefore, fearedthat the scattering of these workers would deprive themfrom accessing available social and health resourcesand would thus make them vulnerable to HIV.In a landmark judgement in March 2000, after a casewas filed by over 100 sex workers and human rightsorganisations, the Bangladesh High Court ruled thatthe eviction of sex workers was unlawful and theyhad the right to make a living in this trade.Source: Based on reports featured in the Daily Star, Bangladesh, July-August 1999 and BBC News, March-July 200092Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSReforms concerning gender equality andthe empowerment of women do notalways receive the much-needed supportin male-dominated legislative assemblies.Entrenched conservative attitudes inmost countries in the region renders theliberalisation of laws relating tohomosexuality difficult. Laws concerningsex work, the availability of condoms inprisons and needle exchange programmesare also treated as being far toocontroversial by legislators, who prefer tosupport only what are perceived as ‘safe’and conservative measures.One issue that has dominated the lawreform scene in India and Sri Lanka isthe proposed repeal of the provision inthe respective penal codes making it anoffence to engage in “carnal intercourseagainst the order of nature with any man,woman or animal”. This section appliesto homosexual as well as heterosexualoral and anal sex, with consent not seena valid excuse. 54 In 1995, Sri Lankaamended certain sections of the PenalCode and the repeal of the provisiondealing with homosexual acts wasrecommended. 55 In passing theamendment, however, the legislature notonly decided to retain the section makinghomosexuality an offence but widenedits scope to cover sexual relationsbetween females by replacing the word“males” with “persons”. Such incidenceshave led to greater harassment of sexualminorities.4.5 Access to Treatment,Care and SupportA crucial aspect of the human rights ofPLWHA is their access to treatment.Denial or lack of such access amounts toa violation of the basic human right to life.The last decade has witnessed a numberof significant advances in the understandingof the HIV infection and how itcan lead to AIDS. These advances haveled to the development of a range ofpotent drugs to control HIV infection (seeBox 4.10). Both these developments havesubstantially altered the way in whichHIV/AIDS is regarded and treated. Thefatal course of HIV infection can now bealtered to a chronic manageable conditionthat allows a person living with HIV tolead a relatively normal life.The drugs that control HIV infection,known as Anti-retroviral drugs (ARVs),are a recent phenomenon and haveradically changed the HIV care landscapewithin a short span of a few years. Acombination of three or more differentARVs in various regimens, that as a groupare known as Highly Active Anti-Retroviral Therapy (HAART), form thestaple of HIV treatment today indeveloped countries. 56HIV is one of the most rapidly mutatingviruses and its immense capacity forgenetic variation enables it to sometimesproduce forms that are unresponsive tothe drugs that interfere with viralreplication. Treating HIV infection with asingle ARV drug-monotherapy – quicklyleads to drug resistance. The chances ofdrug resistance are also present in the caseof dual therapy. The rule, therefore, is toprovide for triple therapy or HAART,where the chances of drug resistance aregreatly reduced. In the United States, thewidespread use of HAART since 1996 hasled to a 50 per cent decline in AIDSincidence, hospital admissions andrelated deaths.4.5.1 HAART: availability andaccessDeveloping countries are home to 95 percent of PLWHA 57 and WHO estimates that6 million people in these countries arein immediate need of HAART. However,The drugs thatcontrol HIVinfection, known asanti-retroviraldrugs, are a recentphenomenon andhave radicallychanged the HIVcare landscapewithin a short spanof a few years.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 93

Human Rights and HIV/AIDSBox 4.10Vaccine developmentTill May 2000, there had been over 60 Phase I/II clinicaltrials of at least 30 candidate HIV vaccines. Theseinitial trials were designed to test the safety andimmunogenicity of the candidate vaccines.The National Institutes of Health (NIH), International AIDSVaccine Initiative (IAVI) and the South African AIDSVaccine Initiative (SAAVI) are some of the world’s majorresearchers of the HIV vaccine. NACO, India, IndianCouncil of Medical Research and International AIDSVaccine Initiative have initiated work to develop anindigenous vaccine relevant to sub strain C of HIV-1.HIV vaccines present unique considerations for productand clinical development and careful planning is neededfor their timely development. The important areas inthis regard include product characterisation andmanufacturing, anticipating the needs of future trialsand accumulating sufficient safety, immunogenicity andefficacy data during clinical development.Despite the urgent public health need, HIV vaccineresearch is at best a questionable financial investment.The scientific challenges are daunting, and thedevelopment timeline is lengthy, expensive and unsure.In addition, the vast majority of people who need an HIVvaccine live in resource-poor developing countries. Thisconcern about the lack of a paying market in developingcountries discourages private companies that fund HIVvaccine research from investing in research on productsparticularly suitable for lower-income countries.It is likely that multiple large-scale trials of severalHIV vaccines will be necessary before a highlyeffective product is identified. These trials will involvethousands of volunteers around the world over severalyears. Clinical trials of HIV vaccines raise importantconcerns about participant protections and researchethics.Because HIV vaccines employing advanced technologymay be expensive, compared with current vaccines, theseverely limited healthcare resources in poorer countriesis a major issue of concern. In addition, the inadequatehealthcare infrastructures in many developing countrieswill render it difficult to distribute a vaccine. Besides,vaccination programmes will have to be adapted to reachthe risk groups that need an HIV vaccine most urgently.Current immunisation programmes in developingcountries focus on reaching children, but it is the sexuallyactive adolescents and adults that will most immediatelyneed a vaccine for HIV. Part of the challenge lies inaddressing the reluctance on the part of many countriesto acknowledge that young people are sexually active.The problem of reaching highly mobile or displacedpopulations will also have to be examined.AIDSVAX (produced by VaxGen) is the only HIV/AIDSvaccine that has reached phase III clinical trials designedto determine actual preventive efficacy in humanbeings. The vaccine was reportedly 78.3 per centeffective in people of African origin and 68 per centeffective in Asians.62 per cent or 500,000 of the 800,000people estimated to be receiving HAARTin 2001 live in developed countries. Only230,000 people from developingcountries were on HAART in 2002, withBrazil accounting for half this number.HAART reaches only 5 per cent of thosewho need it in the developing world (SeeTable 4.3). In December 2002, around43,000 people in Asia were receivingHAART, barely 4 per cent of theestimated 1,000,000 who neededtherapy. “These drugs have savedhundreds of thousands of lives in Europeand the United States. They could do thesame for millions more in developingcountries. If we can get cold Coca Colaand beer to every remote corner ofAfrica, it should not be impossible to dothe same with drugs.” 58The feasibility of HAART inresource-limited settingsThere are two perspectives on the issueof access to treatment–theinstrumentalist perspective of thehuman capital approach and the humanrights perspective of the humandevelopment approach. The humancapital approach, with its focus on ratesof return and affordability by individuals,is against public provisioning of HAART.94Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSSource: WHO/ITAC, 2002Table 4.3Coverage of anti-retroviral treatment in developing countries, December 2002(Adults by region)Region Number of people Estimated Coverageon ART need (%)Sub-Saharan Africa 50,000 4,100,000 1Asia 43,000 1,000,000 4North Africa, West Asia 3,000 7,000 29Eastern Europe, Central Asia 7,000 80,000 9Latin America, Caribbean 196,000 370,000 53All regions 300,000 5,500,000 5This school argues that the efforts to stepup access to treatment may dilute thefocus on HIV prevention while the highcosts of HAART may divert scarce resourcesaway from HIV prevention efforts andother competing require-ments within thehealth sector. In other words, HIVprevention and health priorities such asgastro-enteritis, tuberculosis, malaria,malnutrition, and population control maymerit greater consideration than themedication requirements of a smaller,albeit vocal, special ‘interest group’ ofPLWHA and their advocates.greatly strengthened by mainstreamingHIV/AIDS. Therefore, there is nounavoidable trade-off between theprovision of HAART and other healthpriorities.The second argument of the humancapital school is that HAART involvesrather complex regimens of expensivedrugs that have serious side effects.HAART, therefore, calls for additionalinvestments in training medicalpersonnel in the long term treatment,monitoring and care of PLWHA.However, if public health action on HIV—especially the care and support regime—is perceived as being an example for otherhealth challenges, then it would no longerbe viable to see HIV/AIDS as a specialinterest of a few people. Instead, theapproaches and lessons of theHIV/AIDS strategy would help augmentthe capabilities of the existing publichealth system at all levels. Indeed, itwould be essential to strengthen theprimary health centres and local hospitalseven to meet the challenge of HIV at itspresent scale in South Asia, in addition toongoing work of the NGOs, voluntarycounselling and testing centres etc.In other words, the agenda for healthsector reforms in South Asia would beBox 4.11International TreatmentAccess CoalitionOn 12 December 2002, an International Treatment AccessCoalition (ITAC) of more than 50 partners was formed to overcomethe challenges of expanding access to ARV drugs. The partnersincluded NGOs, donors and governments, PLWHAs and theiradvocates, the private sector, academic and research institutionsand international organisations. ITAC hopes to promote the efficientsharing of information and technical data about what works insuccessful programmes, assist the establishment of reliable drugprocurement systems, and training healthcare workers. The groupalso aims to galvanise and coordinate donor action and providemuch-needed technical assistance to national HIV treatmentprogrammes. It will be served by a small secretariat at WHO’sHeadquarters in Geneva.Source: ITAC(http://www.itacoalition.org/content.html)Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 95

Human Rights and HIV/AIDSThe majority ofthe population,advocates of thehuman capitalschool argue, isnot literate, andgood health is notan immediatepreoccupation ofpoor households.Moreover, HAART has to be taken on afairly regular basis, life-long, implyingregular treatment expenditures for severalyears. In addition, a person living withHIV has to spend on regular medicalevaluation to monitor disease progressionas well as on treatment for themanagement of the side effects of HAART.In all the countries of South Asia, the costof HAART is significantly higher than theaverage per capita income. Access totreatment is, thus, a luxury that most SouthAsian governments and the large majorityof their PLWHA cannot afford. The highcost often results in frequent interruptionof treatment, especially among the poorerpatients and this could lead to drugresistance. Presently, the private sector isthe only provider of anti-HIV treatmentsthat include ARV drugs and, in certaincases, even little understood indigenouspreparations. The haphazard provision ofARVs further underscores the urgency forgovernmental initiatives to standardiseHAART, train the health sector—bothpublic and private—and provide affordabletreatment.With South Asia bearing more than onethirdof the world’s TB burden,comprehensive national programmesbased on the free distribution of anti-TBdrugs have been in operation for severalyears. In recent times, TB controlprogrammes have also absorbed theadded cost of Directly ObservedTreatment (DOT). The TB programmesin Bangladesh, Indonesia, Nepal andMyanmar have made considerable stridesin achieving high rates of cure throughDOT, thus providing the rationale forconsidering a similar approach in the caseof HAART. Though there are few studies todemonstrate the feasibility of DOT forHAART, the approach can work amongsome groups such as sex workers orinjecting drug users.The human capital school also focuses onthe difficulties in implementing initiativesthat promote the use of HAART in aresource limited setting. The majority ofthe population, its advocates argue, is notliterate, and good health is not animmediate pre-occupation of poorhouseholds. The problem is compoundedwhen the intervention calls for complexpatterns of healthcare, in terms of thetimings and dosage of drugs, the need forancillary services such as periodic medicalreview, counselling and the managementof side-effects. The discrimination againstPLWHA even by healthcare providers andthe healthcare system in general cangreatly complicate access to HAART.This line of thinking can be countered,first, by the public obligation argument.PLWHA may be a small fraction of thetotal population in the region but, at4.2 million, their numbers are still largeand it would be a dereliction of dutynot to address the treatment, careand support of such a large number ofpeople. This argument could also bestrengthened if the morbidity and thefatality associated with HIV/AIDS is takeninto consideration. Approximately 1,000people are estimated to die every day inthe South and South East Asian region, anumber that could be compared to twofully loaded jumbo jets crashing everyday.At 400,000 deaths in a year, the death tollfrom HIV/AIDS is nearly 400 times thecombined annual death toll from railwayaccidents. Ignoring the requirements fortreatment would involve accepting adeath toll that would be unacceptable inother contexts. Clearly, then, the ‘silentemergency’ of HIV/AIDS in South Asiarequires urgent attention in ensuringaffordable and universal access totreatment, care and support.It would also be erroneous to look atprevention, care and support as mutually96Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSBox 4.12Meeting the challenge of drug pricingUntil 2001, drug pricing was a formidable deterrent forgovernments to consider the public provisioning of lifeextendingtherapy to people with HIV. HAART costpatients about $10,000 to $12,000 a year in early 2000.In a bid to make ARVs affordable to the poor, UNAIDSundertook the Accelerated Access Initiative in mid-2000. The initiative began as a partnership betweenfive pharmaceutical companies–GlaxoSmithKline,Boehringer Ingelheim, Bristol-Myers Squibb, Merck andHoffman-La Roche—and the United Nations agencies.The initiative involved negotiations between thesecompanies and developing country governments tosupply HIV/AIDS medicines at reduced prices. Of thefive companies, only GlaxoSmithKline announced a 90per cent reduction in ARV prices. urther requests tolower prices met with little success until late 2000,when the first ARV generic drugs from the Indianpharmaceutical company, Cipla, entered the market.Within weeks, the prices of branded anti-HIV drugsplummeted to $500 to $800 for low-and middle-incomecountries.In ebruary 2001, Cipla offered to supply AIDS drugsfor less than $1 a day, “a humanitarian price” forAfrica, considering that nearly the entire population thatneeds ART there dies because drugs manufactured bymultinational companies are priced beyond their reach.Among Cipla’s earliest customers was Medecins Sansrontieres, a global charitable organisation of doctors,which began buying the generic ARVs for $350 a patienta year, which was a thirtieth of the previous Americanprice. or the Indian market, however, Cipla’scombination therapy is priced higher. Even after areduction in prices in late ebruary 2001, Cipla’s tripledrug cocktail of Lamivudine, Stavudine and Nevirapinecosts a patient in India Rs. 4,230 ($90.64) a month,which is more than the African price.In August 2001, Cipla launched Triomune, a cocktailof Stavudine, Lamivudine and Nevirapine in a singlebi-layered formulation. Triomune costs patients lessthan $40 a month. The patents for these drugs arepresently controlled by different companies.GlaxoSmithKline holds the patent on Lamivudine,Boehringer Ingelheim on Nevirapine and Bristol-MyersSquibb on Stavudine. Cipla also released Nevimunesuspension, a formulation of Nevirapine withZidovudine and Lamivudine for children. Three ofCipla’s generic ARVs were added to WHO’s list ofsafe drugs in March 2002.The fact that a generic drug manufacturer in SouthAsia could successfully and substantially bring downthe costs of ARVs in sub-Saharan Africa holds outpromise for a similar successful lowering of drug pricesin the region. Moreover, the significant differentials inthe cost of HAART in the countries of the region, asalso the fact that the capacity to manufacture ARVsis available only in a few countries, offers anopportunity for regional trade and cooperation. This mayalso bring about a universal standard of treatment, careand support across the region.exclusive responses to HIV/AIDS. Thereis enough evidence from variousinitiatives to show that the availability ofcare and support has enhanced thesuccess of prevention. The experience ofBrazil shows that a policy of providing freeor subsidised HAART to PLWHA hashelped de-stigmatise AIDS and facilitatedthe mainstreaming of HIV-related care(see Box 4.13). As a result, PLWHA had theopportunity to access counselling on notonly treatment but also on preventionand protection for themselves and theirfamilies. This inclusive approachembodies the principle of GIPA, byaccepting them as partners withhealthcare providers in mitigating theimpact of HIV and slowing its spread.The humane approach of providinghealthcare and prevention services ensuresgreater credibility, acceptance, sustainabilityand involvement on the part of bothprovider and recipient of care. In the caseof SHIP in Sonagachi in the Indian city ofKolkata, sex workers were not approachedwith isolated messages on HIV prevention,but were simply offered free treatment forSTIs. Similarly, the Community HealthEducation Society (CHES) in the Indiancity of Chennai provided STI treatment tosex workers with no mention of HIV unlessRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 97

Human Rights and HIV/AIDSthe women brought it up themselves.Once sex workers found that they couldreceive care in a non-judgmental andnon-discriminatory manner, theydeveloped enough trust in the providersto share their intimate concerns aboutunsafe sexual practices and HIV.Condoms, made available at this point,were more likely to be accepted with adegree of understanding of why and howthey needed to be used. Providing HAARTto those in need, along similar lines, is likelyto enhance HIV prevention besidesproviding care. HAART may alsocontribute to lowering the efficacy of HIVtransmission by greatly reducing thenumbers of viral particles in the semen andvaginal fluids.The argument that HAART is beyond thereach of people in South Asia also has itslimitations. It is true that the cost of thetherapy, multiplied by the total numberof PLWHA in the region, appear daunting,more so because these are recurringlifetime costs. However, a carefulexamination of global experiencesindicates that affordable treatment neednot be an unrealisable dream fordeveloping countries (see Box 4.12).The WHO has also made efforts to dealwith the issue of access. In 2002, it issuedguidelines for scaling up ART in resourcelimitedsettings, as part of a commitmentfor expanding the coverage of ART to 3million people by 2005. The guidelineswere developed through a consensualprocess of consultations with healthcareproviders from developed and developingcountries and propose a public healthapproach to the issue. Such an approachincorporates the following elements:l the scaling up of treatmentprogrammes to meet the needs ofPLWHA in resource limited settings;l the standardisation and simplificationof ARV regimens to support theefficient implementation of treatmentprogrammes; andl ensuring that ARV treatmentprogrammes are based on the bestscientific evidence in order to avoidthe use of substandard treatmentprotocols which compromise thetreatment outcome of individualBox 4.13Lessons from the Brazil experienceIn 1992, the World Bank had projected that there wouldbe 1.2 million people living with HIV in Brazil by 2002.Brazil’s programme of universal access links preventionprogrammes with treatment. The programme ofcompulsory licensing, under which most of the ARVswere manufactured locally and provided either free orat subsidised rates to those in need of treatment, isestimated to have prevented 600,000 new infections.Health authorities estimated that from 1994 to 2002,58,273 AIDS cases and 3,371 cases of verticaltransmission of HIV were prevented and that 90,962deaths from AIDS-related illnesses were avoided.Equally impressive are a 60–80 per cent reduction indeaths and a seven-fold reduction in hospital admissions.The authorities estimated savings of $1 billion sincethe late 1990s.The Brazilian experience is unique not only for itsuniversal access but also for its use of generic drugsmanufactured in Brazil. Use of generic drugs decreasedindividual drug costs by 72 per cent and by 64 percent for two-drug- and three-drug-treated patientsrespectively, between 1997 and 2000. Despite theincreasing number of patients, the total annual cost oftherapy decreased 8 per cent from 1999 to 2000 anddid not exceed the programme budget of $300 million.As a result of the national production of generics, thecost of ARV treatment has not escalated in recentyears, making it possible to maintain universal accessto ARV therapy. The Brazilian model offers importantlessons for developing countries, because it shows thatuniversal anti-AIDS therapy is an achievable goal, evenin a low-income country.Source: Valenti, 200298Regional Human Development ReportHIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSclients and create the potential for theemergence of drug resistant virus.There are also examples of successfulgovernment action to ensure affordableor free treatment from developingcountries, notably Brazil (See Box 4.13).Though Brazil’s per capita income issignificantly higher than that of the SouthAsian countries, it is still instructive to seehow governments can make treatmentavailable to even those from the lowerincome groups by according the rightpriority to treatment. The provision ofHAART and care, consistent with theframeworks of human development andhuman rights, help establish the necessityof ensuring affordable and universalaccess to treatment, care and support forPLWHA in South Asia.A study by British medical journal, Lancet,comparing the costs of HIV preventionversus treatment reported that for everylife-year purchased with treatment drugs,28 life-years could have been purchasedwith prevention. The study 59 used Cipla’sARV costing of $350 a patient a year anddid not include drug distribution costs. Theimplication is that the scarce resourcesavailable to fight AIDS should go toprevention programmes rather thantreatment. Similar arguments that thepotential savings of investments inprevention far outweigh the monies savedeven with low cost ARV treatmentintervention in developing countries, raiseserious questions regarding the principlesthat are needed to guide policy makers inadopting public health strategies. Theglobal debate on whether to accord equalfunding priority to treatment andprevention continues, even as there isemerging consensus that a judicious mixof both are needed to achieve any measureof success in dealing with HIV/AIDS.Meanwhile, a number of field-based studiesfrom developing countries are demonstratingthe feasibility and benefits ofHAART. They show that treatment andprevention can both be achieved in asimple and low cost manner.A study of a model employer-fundedprogramme for South Africa concludedthat a programme that focused only onthe prevention and treatment ofopportunistic infections would be costeffectivefor all companies and all gradesof workers. If it was to prove profitable,HAART would have to be provided at$500 to $750 per patient per year. WithCipla making ARVs available in Africafor less than $370 a year, the potentialviability of such a model is greatlyenhanced.The widespread introduction of HAARTin low-income countries is dependent onthe provision of generic ARV drugs thatare either free or heavily subsidised.Meanwhile, HAART, accompanied by lowcost options with regard to the routinelaboratory monitoring of CD4 cell countsand viral loads, is already beingattempted in some resource-limitedsettings. In the last two years, smallgroups of people living with HIV arereceiving HAART because of the modestefforts of the few small-scale initiativesthat exist in the Caribbean, India andAfrica. They serve as beacons of hope forthe millions in need of ART in thedeveloping world.4.5.2 Ways of reducing the costsof ARV drugs in South AsiaThe access to ARV treatment is severelylimited in developing countries in generaland South Asia in particular because ofseveral reasons: lack of proper guidelineson the correct selection and use of drugs,lack of adequate and competent healthservices, lack of affordable drugs on asustainable basis, high price of patenteddrugs and low purchasing power.The widespreadintroduction ofHAART in lowincomecountries isdependent on theprovision ofgeneric ARV drugsthat are either freeor heavilysubsidised.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 99

Human Rights and HIV/AIDSBox 4.14The role of equitable pricing in ensuring accessEquitable pricing—or differential or tiered pricing—refersto the concept of pricing products in different marketsaccording to the consumers’ ability to pay as measuredby their income levels. By pricing ARV drugs at differentprices for different consumers, companies can hopeto partially recover costs while, at the same time,making these drugs available to as many patients aspossible. Segmentation of markets for the purpose ofequitable pricing can be done using the HumanDevelopment Indices (HDI) in a coordinated andtransparent manner, since this measure would factorin public provision of health along with individual abilityto pay. Differential pricing has clear benefits and risks.However, the risks can be mitigated through carefulpolicy planning.BENEITSIncreased access: This can be ensured through greateraffordability. Since affordability is a graded, and not azero-one, concept, differential pricing ensures accessto far more patients than would otherwise be possible.In other words, every additional dollar reduced inprices makes the drug more affordable for a newpatient.Increased revenues: A single, universal price will keeppharmaceutical companies out of low-income countries,which are potential markets. By using equitable pricing,companies can increase revenues in absolute terms.The financial impact of pricing to market, therefore,should be seen in terms of revenue gained from enteringmarkets as opposed to revenue lost from charging lowerprices.RISKSParallel re-importation: The most obvious risk is thatof leakages. Pharmaceutical companies have voicedthe dangers of low-priced drugs being illegallytransported back to developed country markets,thereby lowering prices in the high-priced markets.Clearly, if markets are not segmented, prices can fallin both markets to the lower level.However, this risk can be countered by nationalgovernments through carefully designed policies thatprevent re-importation 60 of these drugs to developedmarkets. The experience from other differentially priceddrugs and products has been encouraging and therehas been little evidence of large-scale re-entry ofcheaper products back to developed markets.Sustainability concerns: Since differential pricing isprimarily a producer-driven initiative, there are concernsover whether it can be seen as a stand-alone solution.There is also no guarantee that prices will be the lowestpossible, since it depends essentially on the discretionof the firms. It also faces the danger of being used asa bargaining tool to extract reciprocal concessions onintellectual property rights (IPR) law design, and othercritical issues.Some of these shortcomings could be mitigated ifdifferential pricing is part of a global initiative with clear,transparent rules. The private, not-for profit andgovernment sectors will need to work together to ensurethat pricing is based on marginal cost for the poorestcountries, that all essential drugs are covered and thatequitable pricing is just one, and not the only, strategyto ensure access to drugs. 61There have been several attempts bypublic-private collaborations to offer ARTdrugs at decreased prices, the mostimportant of these being the AcceleratingAccess Initiative. Till March 2002, 78countries had expressed interest inparticipating in the Initiative. Each ofthese countries has committed itself to,and is in the process of, developingnational care and treatment plans. So far,18 countries (12 from Africa, five fromLatin America and the Caribbeancountries and one from Europe) haveactually reached an agreement with thedrug companies. While the initiative is auseful attempt to lower the price of drugs,it clearly needs to be supplemented byother measures as well.4.5.3 The role of patentsPatents are a major factor in restrictingaccess to ARV drugs. Pharmaceuticalcompanies in high-income countriesdevelop these drugs after years of researchRegional Human Development Report100 HIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSand development at high costs. 62 Patentson these drugs preserve monopoly rightson producing them for a minimumnumber of years and the selling priceincludes a premium that helps recoup theresearch costs. Generic versions of thesedrugs are much cheaper to produce.The cost of these drugs in a particularcountry depends on several factors. Someof these are related to patents: whetherthe pharmaceutical companies haveapplied for patents in that country(which, in turn, depends on the size andvalue of the potential market); whetherthe country permits product patents onpharmaceuticals; and whether it has thetechnical capacity, market size and thelegal framework to produce genericversions of these drugs. Pricing policieswithin these countries also determine thecost. India, for example, has beenimposing price controls on bulk drugsthrough the Drug Price Control Order(DPCO), 1995. However, the number ofdrugs under this order have been steadilydecreasing after complaints by theindustry over loss in profitability.Combined with the change in the patentregime, this has adverse implications foraccess to affordable drugs.Till 1995, individual country patent lawswere determined by domestic policy.However, the global system of intellectualproperty rights (IPR) is today much morestructured than before. With theestablishment of the World TradeOrganisation (WTO) Agreement onTrade-Related Intellectual Property Rights(TRIPS), most countries are required tostrengthen their intellectual propertylaws. TRIPS has profound implications forthe availability of and access to medicinesfor the South Asian countries, especiallyin the context of HIV/AIDS since most ofthese medicines are the products ofongoing research, and their supply willbe immediately affected by changes inpatent laws.The TRIPS Agreement and accessto drugsThe TRIPS Agreement, which came intoeffect in 1995, requires all membercountriesto extend intellectual propertyrights to all technologies, covering bothproducts and processes. 63 TRIPS requirescountries to recognise product andprocess patent rights in the pharmaceuticalsector and offer patents for aminimum of 20 years in order to protectthe rights of innovators and balance themwith the rights of consumers.India, Pakistan, Maldives, Bangladesh andSri Lanka together account for 98.7 percent of all HIV/AIDS cases in the region.All five of them are members of the WTO.Nepal and Bhutan currently haveobserver status at the WTO. Nepal hasbegun negotiations for accession andBhutan needs to begin accessionnegotiations within the next five years.Iran’s application for accession has notbeen unanimously approved by the WTOGeneral Council, and Afghanistan has notyet applied for membership.Despite their varying official WTO status,all countries in the region are affected bythe TRIPS Agreement, since (barringIndia) all of them lack the capacity tomanufacture drugs locally and aredependent on imports from countriesthat are signatories to TRIPS.The single-most important implicationof TRIPS for access to treatment is theimpact of patent protection on drugprices. In the case of India, several studieshave shown that the introduction ofpatents once TRIPS is implemented canraise the prices of drugs by as much as 200per cent. 64Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 101

Human Rights and HIV/AIDSTRIPS has seriousimplications forpublic healthoutcomes in poorcountries since itnot only affectsmedicines forHIV/AIDS but alsoresearch in otherdiseases.TRIPS also affects the production ofgeneric versions of drugs. Countries inSouth Asia have different levels ofproduction capacity. India has innovativecapabilities and the technical capacity toproduce generic versions of drugs.Pakistan, Nepal, Sri Lanka, Afghanistan,Bangladesh and Iran have reproductivecapabilities to differing degrees, since thepharmaceutical industry in thesecountries can manufacture finishedproducts from imported ingredientsonly. Bhutan and the Maldives dependentirely on imports to fulfil their drugrequirements. 65TRIPS restricts ‘reverse engineering’ ofpatented products and increases thewaiting time to market generic versionsof these products to the 20-year period ofpatent protection. The generic drugsindustry in India owes its existence to theabsence of product patents in thepharmaceutical sector and comprises,along with indigenous research-basedfirms, up to 74 per cent of the totalpharmaceutical market. With the adventof TRIPS, the industry will be unable toproduce generic versions of new drugs tillthe patent term expires or a compulsorylicense is issued. 66Apart from TRIPS, several bilateralagreements between developed anddeveloping countries on intellectualproperty rights have restrictive clausesthat sometimes negate the advantagesnegotiated under the multilateralframework. The United States and SriLanka signed a bilateral agreement in1991, under which the terms for issuing acompulsory license are significantly morestringent than under TRIPS. For examplethe government is required to negotiatecompensation to the companies in allcases of compulsory licenses except whenthose licenses are granted to remedyviolations of competition laws. Also, alldecisions regarding compulsory licensesare subject to judicial review. Such termsmake many of the flexibilities negotiatedunder TRIPS redundant.TRIPS has serious implications for publichealth outcomes in poor countries sinceit not only affects medicines for HIV/AIDSbut also research in other diseases.Recognising this problem, the TRIPSAgreement provided for exceptions tothese rights under certain specificconditions. However, it becameincreasingly clear that this was notenough. The exceptions could bechallenged under the WTO DisputeSettlement Procedures, and developingcountries lacked the legal expertise andthe resources to fight these often lengthyand expensive battles.As the implications of TRIPS for HIV/AIDSmedicines became clearer in the yearssince the Agreement was signed, civilsociety groups and HIV/AIDS activistsacross the world launched aninternational campaign against therestrictive provisions of the agreement.Developing country governments also feltincreasingly constrained by the TRIPSprovisions and demanded more flexibilityto address their public health concerns.In response to these concerns, the DohaDeclaration on TRIPS and Public Healthwas adopted at the Fourth WTOMinisterial Conference in 2001.The Doha DeclarationThe Declaration reaffirmed thecommitment of the WTO members topublic health goals. Specifically, membersagreed “that the TRIPS Agreement does notand should not prevent Members fromtaking measures to protect publichealth…that the Agreement can andshould be interpreted and implementedin a manner supportive of WTO Members’right to protect public health and, inRegional Human Development Report102 HIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSparticular, to promote access to medicinesfor all.”While the Doha Declaration was primarilya political statement, it lays down clearlegal guidelines for dealing with cases inthe dispute settlement process, and is animportant and necessary reaffirmation ofthe precedence of public health concernsover patents. Since the Declaration,however, WTO members have found itdifficult to reach an agreement on ways ofoperationalising it. Following thediscussions at the mini-ministerial inSydney, Australia, in 2002, the chairmanof the WTO TRIPS Council released a drafton 19 November 2002 for a decision bythe General Council. Most countriesagreed with the chair’s proposal of amoratorium on disputes regarding TRIPStill the Agreement is amended. However,disagreements remain over certainelements of the solution such as coverage,scope of eligible countries, etc.The Doha Declaration was particularlyimportant for the South Asian region,because most countries are dependent onimported HIV/AIDS drugs, and, giventhe low purchasing power in thesecountries, the cost of drugs is an importantconcern in the provision of treatment.However, the Declaration and theflexibilities in TRIPS at the internationallevel will only partially help in ensuringaccess. Eventually, implementation ofthese provisions will be done throughnational legislation and appropriatedomestic policy.Most WTO members in the South Asianregion have already altered their patentlaws to make them TRIPS-compliant.India, Pakistan and Sri Lanka have timeuntil 1 January 2005 before bringing thepharmaceutical sector under TRIPS.However, it is not clear if all theamendments carried out fully takeadvantage of the flexibilities under theBox 4.15Clarifications under the Doha DeclarationArticle 31: The TRIPS Agreement, under Article 31,allows for compulsory licensing under a set of conditions.The Doha Declaration increases the flexibility availableto member-countries to define the circumstances underwhich compulsory licenses are necessary. Under TRIPS,governments are expected to negotiate with patentholders for voluntary licenses on reasonable terms beforeissuing compulsory licenses, except in the case ofnational emergencies. The Doha Declaration leaves thedefinition and scope of national emergencies to thegovernments, giving them the discretion to categorisepublic health crises as national emergencies if necessary.Article 31(f) of the TRIPS Agreement states thatcompulsory licenses should be issued primarily forsupply in the domestic market. The Doha Declarationrecognises that this does not address the problem ofcountries with little or no manufacturing capacity, orwith insufficient domestic demand that are completelydependent on imports. Several proposals are currentlyunder discussion at the WTO to identify potentialoptions for imports of generic drugs.Article 30: This section provides for limited exceptionsto exclusive rights 67 provided under patents. Severalcountries and experts have proposed an authoritativeinterpretation under Article 30 as a solution to theproblem of allowing generic drugs for exports 68 thatis more streamlined and administratively simpler toexecute than Article 31.Article 6: The TRIPS Agreement leaves countries freeto decide the principle of exhaustion of IP rights thatthey wish to follow, subject to national treatment andmost favoured nations principles. The principle ofexhaustion defines the point of sale at which theproducer’s right over the product expires. The DohaDeclaration reaffirmed the right of countries topractise the principle of international exhaustion ofIP laws, allowing for private purchase and resale ofpatented products across countries through parallelimports. While this is an important provision for privatesuppliers of drugs, it does not resolve the problem oflarge-scale purchase of drugs at affordable rates.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 103

Human Rights and HIV/AIDSTable 4.4Comparative analysis of patent lawsCountryIndiaPakistanSri LankaPatent LawIndian Patents Act, Second Amendment 2002: Provides patent protection for all processes andproducts involving an “inventive step” and capable of “industrial application”. The Act exemptspharmaceutical products till December 2004, and clarifies rules for issuing compulsory licenses.However, the Bill has several clauses, which remain ambiguous and will need clarification beforeIndia accedes to TRIPS in 2005.Patents Ordinance, 2000: Promulgated to bring the country’s patent laws in line with TRIPS, thenew law recognises patents on all products and processes which are new, involve an inventivestep and are capable of industrial application, along with provisions for compulsory licensing andparallel imports.Code of Intellectual Property, Act No. 52 of 1979 The Act provides protection for patents for aperiod of 15 years. It does not comply with TRIPS and new legislation will be enacted beforeJanuary 2005. Sri Lanka does, however, have bilateral IP agreements (e.g. with the UnitedStates) under which it accords higher protection to patents from those countries.TRIPS Agreement and the DohaDeclaration. Maldives and Bangladesh,along with other least developedcountries have time until 2016 toimplement the patent provisions ofTRIPS for pharmaceutical products.The challenge of providing access to goodquality drugs to PLWHA is, indeed, adaunting one, dealing as it does withissues of medical research, pricing andintellectual property rights. However,facing the challenge is an integral part ofdealing with HIV/AIDS in a rights-basedframework.4.6 International HumanRights rameworkThe Universal Declaration of HumanRights has been recognised as the MagnaCarta of human rights all over the world.The basic tenets of this declaration are theright to liberty, security and freedom ofmovement, the right to work, the right toeducation, the right to social security andservices, the right to equality-equalprotection before the law, the right tomarriage and family and the right to health.International human rights have beenfurther codified in a number of legallybinding international covenants anddeclarations such as the following:l International Convention on theElimination of All Forms of RacialDiscrimination (CERD-1965)l International Covenant on Civil andPolitical Rights (ICCPR-1966)l International Covenant onEconomic, Social and Cultural Rights(ICESCR-1966)l Convention on the Elimination of Allforms of Discrimination AgainstWomen (CEDAW-1979)l Convention Against Torture andother Cruel, Inhuman or DegradingTreatment or Punishment (CAT –1984)l Convention on the Rights of the Child(CRC-1989)International human rights instrumentsplay an important role in respect ofHIV/AIDS and human rights, since theirnorms may guide the establishment ofprocedural, institutional and socialmechanisms to counter the HIV/AIDSepidemic. In addition to the legallyRegional Human Development Report104 HIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSTable 4.5Status of ratifications of main international human rights instruments 69Country International International Convention on Convention on Convention Convention onCovenant on Covenant on the Elimination the Elimination Against the Rights ofEconomic, Civil and of All orms of of All orms of Torture and the ChildSocial and Political Rights Racial Discrimination other Cruel,Cultural Discrimination Against Women Inhuman orRightsDegradingTreatment orPunishmentAfghanistan X X X — X XBangladesh X X X X X XBhutan — — — X — XIndia X X X X X XIran (I.R.) X X X — — XMaldives — — X X — XNepal X X X X X XPakistan — — X X — XSri Lanka X X X X X XNote:—indicates country has not ratifiedSource: Office of the United Nations High Commissioner for Human Rights(http://www.unhchr.ch/pdf/report.pdf)binding instruments listed above, theinternational community, through itsestablished mechanisms, like the UNGeneral Assembly and the Commissionon Human Rights, has issued morallybinding declarations and resolutions onemerging issues and interpretations of thecodified human rights standards.State parties to most of the human rightsinstruments need to submit reports totreaty monitoring bodies to receiveguidance on more effective implementation.This also serves the purpose ofenabling the international community topressurise state parties to speed up theimplementation, by publishing therespective implementation statuses andscenarios. The treaty monitoring bodies,such as the Human Rights Committee, theCommittee on the Rights of the Child, theCEDAW Committee etc. issue commentsand concluding observations on thereports submitted by the state parties(See Annex I). These bodies also take intoconsideration information submittedby non-governmental sources in therespective countries.Two prominent HIV/AIDS-specificinternational agreements are theDeclaration of Commitment passed atthe United Nations General AssemblySpecial Session on HIV/AIDS(UNGASS), June 2001 and the InternationalGuidelines of HIV/AIDS, 1996(See Annex II). There are other importantdocuments as well. 70As member states of the United Nations,South Asian nations are obliged topromote respect for human rightswithout discrimination. Moreover,international human rights law andcovenants are binding on state partiesthat have signed and ratified them.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 105

Human Rights and HIV/AIDSIn addition, theGuidelines stressthe duty of theStates to engage inlaw reform andidentify legalobstacles to aneffective HIV/AIDSstrategy ofprevention andcare.Despite South Asian nations beingsignatories to all of these agreements, thesituation on the human rights front isnot satisfactory.4.6.1 International guidelineson HIV/AIDSIn September 1996, the SecondInternational Consultation on HIV/AIDSand Human Rights, convened byUNAIDS and the Office of the UN HighCommissioner for Human Rights, led tothe formulation of the InternationalGuidelines on HIV/AIDS and HumanRights. 71 The Guidelines address multisectoralresponsibilities and accountability,including improving the roles of thegovernment and private sector. Inaddition, they stress the duty of the Statesto engage in law reform and identify legalobstacles to an effective HIV/AIDSstrategy of prevention and care. Theattendant difficulties in the actualimplementation of the Guidelines mustnow be addressed.United Nations Declaration ofCommitmentThe UN Declaration of Commitment isof particular interest since all countries ofthe region, barring Afghanistan, aresignatories to it. The UNGASS was the firstevent of its kind organised by the UnitedNations to address HIV/AIDS andincluded participation by civil society(See Box 4.16).The Declaration addresses issues ofprevention, care, support and treatment;leadership at the national, regional andsub-regional level; reducing vulnerability;alleviating social and economic impact;research and development; respectingimplementation of multi-sectoralstrategies; conflict and disaster-affectedregions; resources; and follow-up at thenational, regional and global levels.However, the need for a human rightsbasedapproach to deal with HIV/AIDSfinds only brief mention in theDeclaration.Thus, it is not surprising that thedocument fails to comprehensivelyaddress the needs of vulnerablepopulations such as men who have sexwith men, sex workers and injecting drugusers. This oversight is of concern to thecountries where the promotion of rightsof vulnerable populations is largelyabsent. Empowerment through humanrights initiatives has been difficult toinitiate due to social stigma and culturalpressures. It is evident that greaterinternational initiatives are required todraw attention to these deficiencies andadvocate for human rights protections aspart of HIV/AIDS strategies.4.6.2 Regional agreementsThe SAARC Convention on Preventingand Combating Trafficking in Women andChildren for Prostitution, held in January2002 marked an important step towardsaddressing the concerns of gender, sexwork and human rights. The SAARCmember states—Bangladesh, Bhutan,India, Maldives, Nepal, Pakistan and SriLanka—were signatories to theConvention, which requires all stateparties to enact legislation that providespunishment for the offence of trafficking,including for keeping, maintaining,managing, knowingly financing, orknowingly renting a place used fortrafficking. A major drawback of theConvention is that it considers traffickingsolely for the purpose of ‘prostitution’thereby limiting the scope of thelegislation. Further, the Conventionadopts a predominantly welfare-basedapproach in dealing with trafficking, asopposed to one based on protectinghuman rights.Regional Human Development Report106 HIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSBox 4.16The United Nations General Assembly Special Session (UNGASS) onHIV/AIDS and the UNGASS Declaration of CommitmentIn June 2001, Heads of State and Representatives ofGovernments of 189 nations met at the United NationsGeneral Assembly Special Session ON HIV/AIDS(UNGASS). This meeting was a historic landmark, inwhich member states recognised that the world facedan unprecedented and accelerating crisis, which wasseriously undermining development achievements andthreatening peace and security, and which requiredglobal action.A Declaration of Commitment was adopted by thedelegates, which the UN Secretary-General Kofi Annandescribed as “a blueprint for future efforts by the UnitedNations system and Member States to reduce the spreadof HIV/AIDS and alleviate its impact” (24 July 2001,letter to UN Resident Coordinators). This UNGASSDeclaration of Commitment provides a framework foran expanded response to the global HIV/AIDS epidemic.Its goals and targets are designed to address alldimensions of the epidemic and it represents an agendafor change and a benchmark for global action.The Declaration of Commitment recognises thatHIV/AIDS is a development challenge and addressessome issues that have been overlooked in traditionalpublic health approaches to the epidemic, including theneed to empower women, the importance of humanrights issues and the interaction between preventionand care. In particular, the Declaration states that“strong leadership at all levels of society is essentialfor an effective response to the epidemic” and callsfor a new type of leadership that has governments atits centre, with the full involvement of civil society,the private sector and PLWHA.The emphasis of the Declaration of Commitment is ona multi-sectoral approach. Within the Declaration,specific commitments are made in the areas ofenhanced leadership; prevention, care, support andtreatment; protecting human rights, particularly thoseof PLWHA; reducing vulnerability, especially of women;assisting children who have been orphaned and madevulnerable by HIV/AIDS; alleviating the social andeconomic impact of HIV/AIDS; further research anddevelopment; addressing HIV/AIDS in conflict zonesand disaster-affected regions; ensuring new andsustained resources; and maintaining the momentumand monitoring the progress of responses.The Asia Pacific Forum (APF) of NationalHuman Rights Institutions, a regionalnetwork comprising the Human RightsCommissions of Australia, Fiji, India,Indonesia, Mongolia, Nepal, NewZealand, Philippines and Sri Lanka, has acrucial role to play in ensuring respect forhuman rights in the context of HIV/AIDS.The APF members can ensure theprotection of the human rights of PLWHAand consequently the creation of anenabling environment throughcooperation; information sharing;training and development for institutionmembers and staff; developing andsharing technical expertise; andbenefiting from the ‘best practice’experiences of other institutions. 72 At thesixth annual meeting of the APF held inMelbourne in September 2001, themembers “committed themselves tocombat discrimination and human rightsviolations on the basis of HIV/AIDS andcalled upon the assistance of the UnitedNations, governments and NGOs in theperformance of this task”.4.6.3 HIV outreach workersamong vulnerable ormarginalised groups: humanrights defendersSex workers, men who have sex with men,injecting drug users, peer educators andoutreach workers make essential partnerswithin national HIV prevention efforts. Ifthey possess accurate information, themeans of protection and a supportiveenvironment amongst their peers, familyand the surrounding community(including administration of justiceand law enforcement agencies), theycan contribute effectively to the reductionRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 107

Human Rights and HIV/AIDSThe lack of anenabling Statestructure, alongwith activediscrimination andharassment byofficials acts as afurtherdisincentive forpeople to disclosetheir HIV status,making it harder tocontain theepidemic.of transmission of HIV to the generalpopulation.The mobilisation and empowerment ofwomen and men working in the sexindustry, the MSM community and drugusers to access basic services andinformation has strengthened efforts forthe management of the HIV/AIDSepidemic. Such empowerment andmobilisation should be seen as anessential ingredient to an effectiveHIV/AIDS response, as it contributes tosaving lives. Those within the vulnerableand marginalised groups who are workingto this end are actively defending humanrights and principles.The international community has, inrecent years, established that humanrights defenders deserve recognition andprotection by the state. 73 This responsibilityis outlined in the General Assemblyresolution, ‘Declaration on the Right andResponsibility of Individuals, Groups andOrgans of Society to Promote and ProtectUniversally Recognised Human Rightsand Fundamental Freedoms’. 74 It is,therefore, critical that all governmentsembrace this responsibility and protectthose key partners in the response toHIV/AIDS.4.7 The Role of the StateThe legislatures and judiciaries in SouthAsia have had an uneven record inprotecting human rights of PLWHA. Thispartially reflects the lack of understandingof the epidemic within these branches ofthe government themselves. It alsohighlights the additional challenges thatface PLWHA in countries where the Stateis insensitive to their needs. Even moreworrying are the well-documentedincidents of systemic harassment ofPLWHAs and designated human rightsdefenders. 75 The lack of an enabling Statestructure, along with active discriminationand harassment by officials acts as afurther disincentive for people to disclosetheir HIV status, making it harder tocontain the epidemic.4.8 RecommendationsAn overview of the legal frameworks in theSouth Asian countries clearly brings outseveral lacunae in the law and humanrights guarantees that have an adverseimpact on PLWHA and those mostvulnerable to the epidemic. Certainunequivocal measures, therefore, needto be taken at the policy and legislativelevel to effectively control the spread ofthe epidemic.The decriminalisation of livesand the guarantee of positiverightsIt is clear that all South Asian legal regimescriminalise those most vulnerable to theepidemic. It is because of the legalsanctions and social marginalisation andstigma that these groups face that they findthemselves vulnerable to public healthcrises such as HIV/AIDS. Removing theselegal sanctions will go a long way inaddressing the problem of vulnerabilityand stigma faced by these groups and willcheck the spread of HIV/AIDS not only intheir communities but in the generalpopulation as well. The empowerment ofindividuals is the best way to reducevulnerabilities to HIV/AIDS and this canbe done not just through the provision ofinformation and education but alsothrough the guarantee of legal protection.Protecting the human rights of those mostvulnerable to HIV/AIDS—a centralcomponent of an effective controlstrategy—will firstly require thedecriminalisation of vulnerable groupsthrough a serious and committed attemptat law reform and sensitisation of lawRegional Human Development Report108 HIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSBox 4.17Human rights violations and systemic harassmentBangladesh: The Bengal Vagrancy Act, 1943 definesa ‘vagrant’ as “a person found asking for alms in anypublic place or wandering about or remaining in apublic place in such condition or manner that makes itlikely that such a person exists by asking for alms”(Section 7). The Special Magistrate has the power tomake a summary inquiry and, after hearing the person,can declare him/her to be a vagrant. The person isthen handed over to the custody of the officer in chargeof the nearest receiving centre. The medical officerat the centre is empowered to examine the vagrantand give a medical report which must, among otherthings, state whether the vagrant is a mentallydeficient, a leper or suffers from any othercommunicable disease. Lepers, insane or mentallydeficient persons and those suffering fromcommunicable diseases and children are segregatedfrom each other. The Act is grossly misused and thepolice often arrest people who are wage earners suchas commercial sex workers, vendors, domestichelpers, day labourers, minor children on the streetsand detain them in the vagrant homes in inhumanconditions. According to a study 76 a majority of theinmates in the vagrant homes are women and most ofthem are commercial sex workers.Iran: In Iran, sex workers face a maximum penalty ofexecution by firing squad or stoning and such executionsare common. There have been cases of employmentbeing terminated on the grounds of HIV status.However, it has also been reported that the healthministry has, since October 2001, banned the expulsionof PLWHA from work. The exact extent and implicationsof this statement have not been verified.India: Sodomy is an “unnatural offence” under Section377 of the Indian Penal Code, the wording of which isidentical to that of the Penal Code of Bangladesh.Unnatural offences include carnal intercourse committedagainst the order of nature by a person with a man orwoman or by a man or woman in any manner with ananimal. Section 377 has been held to prohibit oralintercourse as well. However, through the 1990s, theuse of the section has been specific to the context ofchild sexual assault, for which there is no separate penalprovision. The provision has also been used to harassand victimise homosexuals, including men who have sexwith men. Section 294 of the Indian Penal Code, whichpenalises any kind of “obscene behaviour in public”, aswell as local Police Acts have also been used againstmen who have sex with men. Activists and NGOworkers often face harassment by police authorities,as happened in the town of Lucknow in July 2001, whenthe police raided the offices of two NGOs working withthe MSM community. our activists were arrested underSection 377 and charged with criminal conspiracy,abetment and possession/sale of obscene materials.They were denied bail by the magistrate’s court on theground that they were a “curse to society”. The HighCourt later granted bail after 45 days of imprisonment.The actions of the local police in this case expose thegaps between government policy and State action. Inits report pursuant to a National Conference on HumanRights and HIV/AIDS in November 2000, the NationalHuman Rights Commission has recommended the reviewand revision of Section 377 in order to empower MSMand give effect to HIV/AIDS interventions. The reportalso recommended the legalisation of sexual activitiesbetween consenting adults.enforcement, healthcare and otherauthorities. However, this should only bea first step. In addition, it will be necessaryto endow these communities with therange of positive rights that allow for thefull realisation of human potential. Theseinclude rights that guarantee life andliberty in all its varied forms (includingthe rights to sexual orientation, foundingof family, marriage and other civil rights),equality and non-discrimination, employment,access to services (includinghealthcare, social security, education,civic amenities, housing, transport etc.)and freedoms of speech, expression,movement and organisation.However, any attempt at decriminalisationmust be sensitive to the differencesamong the various groups vulnerable toHIV/AIDS, as a universally applicableapproach is not possible. Additionally,there is debate within these communitiesand groups on the appropriate legalresponse to their situation. Any effectivelegal response, then, must be undertakenRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 109

Human Rights and HIV/AIDSIt is important tonote, however, thatdecriminalisation ofthese groups doesnot mean ignoringthe root causeswhich put people inpositions ofvulnerability.after consultation with the stakeholdersfrom within these communities.The exercise of collective power by sexworkers can be one strategy that cansuccessfully minimise HIV/AIDS vulnerabilitiesand human rights violations, as canbe seen in the case of the SHIP projectand Durbar Mahila Samanvay Committee(DMSC) in Kolkata, India.The argument that sex work should bedecriminalised stems from rights-basedand public health perspectives. Fear ofprosecution has been seen to inhibit sexworkers from accessing information andservices including healthcare andHIV/AIDS information. Further, the illegalstatus of sex work makes negotiation withclients difficult. It also makes sex workersvulnerable to abuse both within the sexwork setting (madams, pimps, brotheloperators and owners) and outside(clients, law enforcers, lawyers, themagistracy etc.). Decriminalisationimplies that sex work, including solicitingand earnings from sex work, must not beconsidered criminal in so far as theypertain to consenting adults. There havebeen growing demands for this from sexworkers’ collectives, organisationsworking with sex workers, HIV/AIDSintervention groups, public healthspecialists and rights activists. Suchdemands have come in contexts wheresex workers have been able to presenttheir perspectives and where the adversepublic health implications of criminalisationof sex work have been recognised.There are other perspectives on thequestion of decriminalisation of sexwork, including the view that sex work,but not the sex worker, should becriminalised. These ideas largely arise outof the view that sex work itself amountsto exploitation of women. It is not clearhow sex work can be criminalisedwithout having an adverse impact on thelives of sex workers. The primary issue inadvocacy around these issues is theinvolvement of sex workers in thedecision-making processes. This itself isbound to be a difficult task, consideringthat there are a wide range of contexts inwhich sex work is carried out in theregion and even within countries.Decriminalisation, however, seems tobe a prerequisite for the participationof sex workers in such decisionmakingprocesses.It is important to note, however, thatdecriminalisation of these groups doesnot mean ignoring the root causeswhich put people in positions ofvulnerability (such as the mafia behindthe trafficking of humans or smugglingof narcotics). It only means that lawsmust begin to target those who are, inreality, behind the crimes.Protection for harm reductionprogrammesUntil the time that a human rightsfriendlylegal regime is put into place, itwill be necessary to introduce legalprovisions that will allow harm reductionprogrammes (providing clean needles toinjecting drug users and condoms to sexworkers and men who have sex with men)to be carried out among vulnerablegroups. In the absence of legal provisions,such programmes could easily beinterpreted as abetting crimes, as theyalready have been in India, despitegovernment support of such interventions.Even here, law reform must go handin hand with the sensitisation of statemachinery. Such law reform will requirethat NGO and community-basedorganisations working on harm reductionthrough advocacy, education andcounselling be allowed to functionoutside the purview of criminal laws suchas those relating to obscenity and publicRegional Human Development Report110 HIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSnuisance. Such harm reductionprogrammes must, however, lead tothe ultimate goal of law reform todecriminalise the behaviour of variousvulnerable groups.The introduction of antidiscriminationlegislationAs has been observed earlier, legal regimesin South Asia that guarantee equalityapply only to the public sector. As a result,private healthcare or employment fallsoutside the scope of the nondiscriminationlegislation and they are,therefore, free to refuse treatment or jobsto PLWHA. PLWHA, therefore, have nolegal recourse when they face suchdiscrimination in the private sector. Thisis a huge lacuna in the law that requires tobe filled urgently.Legal remedies for PLWHAApart from specifically protecting therights of PLWHA and those mostvulnerable to HIV/AIDS, it is alsonecessary to ensure that appropriate andaccessible legal remedies are available tothem. This can be done by insertingrelevant provisions in the respectiveconstitutions and the civil and criminallaws, where such safeguards and remediesdo not already exist.The remainder of this section will look atlegal remedies available to PLWHA in thecontext of the Indian legal system.To ensure that the rights of PLWHA areprotected and they are able to takerecourse to legal remedies, it is necessary(a) to ensure that the rule of law exists;and (b) to build an enabling environmentso that fear, discrimination and stigma donot hinder access to the judicial system.Constitutional remediesArticle 32 of the Indian Constitution has aremedial provision for the violation offundamental rights by the State and forthe enforcement of fundamental rightsagainst the State. The Supreme Court ofIndia has the power to issue directions,orders, writs or any appropriatedirections for the enforcement offundamental rights. Similar powers havealso been conferred by the Constitutionon the High Courts of each state. The rightto move the courts for the enforcementand/or protection of fundamental rightsrelates only to violation by the State orState-run organisations or agencies.Therefore, if discriminatory treatment ismeted out to PLWHA working in thepublic sector or accessing publichospitals, they can approach the courtsfor the enforcement of their fundamentalright to equality guaranteed underArticle 14.It is important to note that certainfundamental rights under the IndianConstitution (Articles 17, 23 and 24dealing with untouchability, traffic inhumans and forced/ child labour) can alsobe enforced against private individuals ifthere are violations. However, there is nosimilar provision for HIV positive status.Civil remediesThere are certain other rights of peoplethat may not be fundamental rights, butare legal rights or civil rights conferred bya statute, e.g. custody rights, maintenanceetc. Such rights are enforceable throughthe civil courts in the country. Therefore,if a private employer discriminates againsta PLWHA, then, subject to the existinglaws, the employer can be taken to courtfor the violation of the rights of theemployee. Persons who have beenillegally and unlawfully dispossessed fromtheir homes can file a suit for repossession.Similarly, issues relating to land, propertyrights, tenancy, maintenance, custody,divorce, dues from the employer, etc. canfind legal recourse through the civil courts.Legal regimes inSouth Asia thatguarantee equalityapply only to thepublic sector.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 111

Human Rights and HIV/AIDSWhile commitmentat the internationaland regional levelis extremelycrucial in initiatingdebate and settingguidelines forbuilding a humanrightsframework,theirimplementationcan be ensuredonly when backedby effective legalmechanisms at thenational level.Criminal law remediesThe penal code and other penal statuteslay down acts or omissions thatconstitute an offence. Once a complaintis made and is recorded as cognizable ornon-cognizable depending on the gravityof the offence, investigation and trialsfollow. A person is considered innocentuntil proven guilty. Victims of violence,persons who have been thrown out oftheir house because of their HIV positivestatus, individuals from vulnerable groupswho are being extorted, exploited etc. canfile a complaint in the police station. Ifthe complaints are not registered at thepolice station, they can send writtencomplaints to the senior officials and alsomake a complaint to the magistrate.Other foraIn India, certain statutory fora likeconsumer courts, AdministrativeTribunals, Lok Adalats (people’s courts)etc. have been set up to facilitate speedydisposal of cases on issues ranging fromconsumer disputes to grievances withgovernment departments and administrativematters within the civil services.These have not yet been accessed byPLWHA and their networks. Theirusefulness for issues relating to PLWHAneeds to be explored.National human rightsinstitutionsWhile commitment at the internationaland regional level is extremely crucial ininitiating debate and setting guidelinesfor building a human rights framework,their implementation can be ensuredonly when backed by effective legalmechanisms at the national level.National human rights institutions areone such mechanism. These areindependent bodies established by theState for the effective promotion andprotection of human rights issues thatarise in the context of HIV/AIDS.In his address to the international meetingof human rights institutions in Geneva inApril 2001, the Executive Director ofUNAIDS identified five practical ways inwhich national human rights institutionscan strengthen their work regardingHIV/AIDS:l by investigating violations of humanrights that occur in the context ofHIV/AIDS;l by conducting public inquiriesfocusing on these violations;l by receiving and, where appropriate,redressing complaints of HIV/AIDSrelatedhuman rights violations;l by providing advice and assistance togovernments in the area of humanrights and HIV/AIDS; andl conducting human rights educationin the context of HIV/AIDS.These commitments require theintegration of HIV/AIDS-related humanrights into institutional strategies andprogrammes at the national level. 77In India, the National Human RightsCommission 78 and the State HumanRights Commissions are empowered toinquire into complaints of violation ofhuman rights either suo moto or on apetition by a victim or someone actingon his behalf. They can also inquire intoinstances of negligence in the preventionof such violation by a public servant. TheCommissions have powers to review thesafeguards provided under the Constitutionor any law for the protection ofhuman rights and recommend measuresfor their effective implementation. TheCommissions may undertake research inthe field of human rights and takemeasures to promote awareness ofhuman rights among all sections ofsociety.In Nepal, the Human Rights CommissionAct (1997) established an independentRegional Human Development Report112 HIV/AIDS and Development in South Asia 2003

Human Rights and HIV/AIDSand autonomous National Human RightsCommission for the effective enforcementas well as protection and promotion ofhuman rights conferred by the Constitutionand other prevailing laws.Bangladesh has also initiated moves toconstitute an independent Human RightsCommission. The law, justice andparliamentary affairs ministry is in theprocess of finalising a draft legislation,which will also fix the terms of referenceof the proposed commission. Accordingto the draft, the commission wouldinvestigate the allegations of human rightsviolation and take necessary actions asper the existing provisions of law.Since 1986, the Human RightsCommission of Pakistan (HRCP) hasplayed a leading role in providing a highlyinformed and independent voice in thestruggle for human rights and democraticdevelopment in the country. It is anindependent, voluntary, non-political,non-profit making, non-governmentalorganisation. One of the main functionsof HRPC is to work for the ratification andimplementation by Pakistan of theUniversal Declaration of Human Rightsand of other related charters, covenants,protocols, resolutions, recommendationsand internationally adopted norms.Strengthening of social capitalThe poor development of social capitalin South Asia has severely limitedthe progress with regard to dealingwith HIV/AIDS, as societies remainentrenched in gender inequities, casteand class-based violence, religiousfundamentalism, violations of the rightsof marginalised populations and anoverall environment of intolerance.Provisions for strengthening, for example,educational systems, infrastructuralfacilities and local governancemechanisms would contribute significantlyto enriching the social, cultural andeconomic environment of communities.This, in turn, would have a favourableimpact upon the indices for developmentat macro levels.Role of parliamentarians 79Parliamentarians can play a key role atthe local, national and regional levelsin initiating dialogue and legislativeaction on HIV/AIDS and human rightsissues, as well as mobilising financialresources to support HIV/AIDSprogrammes. They can work at severallevels.l As political leaders, they can influencepublic opinion, and can increasepublic knowledge of relevant issues.l As legislators, they vote on acts ofParliament and can ensure thatlegislation protects human rights, andadvances effective prevention andcare programmes.l As advocates, they can mobilise theinvolvement of government, privatesector and civil society to dischargetheir societal responsibilities inresponding appropriately to theepidemic.l As resource mobilisers, they canallocate financial resources to supportand enhance effective HIV/AIDSprogrammes that are consistent withhuman rights principles.An important regional initiative is thesetting up of the SAARC MedicalParliamentarians, which held a meetingon reproductive health, STDs andHIV/AIDS in Kathmandu, Nepal, in May1998. The meeting issued a Declarationon the Prevention and Control ofHIV/AIDS. The Declaration asked parliamentariansto take a stronger role inadvocacy at the regional, national,and community levels. The meetingalso recommended the establishmentof a regional forum of SAARCThe poordevelopment ofsocial capital inSouth Asia hasseverely limited theprogress withregard to dealingwith HIV/AIDS, associeties remainentrenched ingender inequities,caste and classbasedviolence,religiousfundamentalism,violations of therights ofmarginalisedpopulations and anoverall environmentof intolerance.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 113

Human Rights and HIV/AIDSParliamentarians and mechanisms toreview and reform national laws andpolicies.In Dhaka, a successful workshop onHIV/AIDS and STDs for parliamentarianswas held in September-October 1997by ACTIONAID, an NGO, and thegovernment AIDS Prevention and ControlProgramme. It included a presentation bypeer educators of sex workers at theTangail brothel. 80 The objectives were tocreate an environment where participantsfelt at ease to talk, to bridge the gapbetween lawmakers and activists, to shareprevention and management interventions,and to identify areas where lawmakerscould contribute at the policylevel, in Parliament and in the local areathey represent.Democratically elected parliamentariansare in a unique position to influencepublic opinion and lead theirconstituents towards attitudes that aresupportive of an effective national andregional response to the epidemic.Political commitment is an essentialingredient to a rights-based response toHIV/AIDS and to the allocation ofadequate resources to implement it.4.9 ConclusionThe impact of the epidemics of HIV/AIDSon individuals and communities hasthrown light on the complex intersectionsbetween human development, humanrights and health. While these domains areorganically intertwined, there has been atendency to lose sight of this interdependence.This has led to the evolutionof philosophies, vocabularies, researchand activism that have virtually excludedone domain from the other. The emergingglobal recognition that human rights area potent approach to defining andadvancing human development andwell being, calls for increasedcommunication and interaction betweenthe fields of human development, rightsand health.“Let us resolve to replace stigma with support, fear with hope, silence withsolidarity. Let us act on the understanding that this work begins with each andevery one of us.”Kofi Annan, UN Secretary-General, World AIDS Day,1 December 2002Regional Human Development Report114 HIV/AIDS and Development in South Asia 2003

The Way orwardRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 115

The Way orwardRegional Human Development Report116 HIV/AIDS and Development in South Asia 2003

The Way orward“The social andpolitical circumstancesnot only intensify therisk of exposure toHIV but bear on theoptions to respondadequately to theproblem”Her Majesty Queen AshiSangay ChodenWangchuk of Bhutan in akeynote address at theSatellite Symposium onRights, Gender and HIV:Lessons from South Asiaat the 6th InternationalCongress on AIDS in theAsia Pacific (ICAAP),October 2001“It is time for leadersin South Asia to speakout on HIV/AIDS. Oneof the most seriousobstacles is the silenceand stigma surroundingthe disease. HIV/AIDSconcerns the mostprivate and personalarea of our lives... You,as leaders at so manydifferent levels, mustlook at reality honestlyand openly and speakclearly in response” .Dr Nafis Sadik, SpecialEnvoy of the UNSecretary-General ofHIV/AIDS in Asia at theSouth Asia High LevelConference ‘Acceleratingthe Momentum in theight Against HIV/AIDSin South Asia’.Kathmandu, Nepal,ebruary 2003Chapter 5The Way orward5.1 The Context of HIV andHuman Development: PolicyChallenges for South AsiaThe foregoing chapters have highlightedthe gravity of the challenge of HIV/AIDSin South Asia and the urgency ofaddressing the epidemic within a humandevelopment framework and a rightsbasedapproach. It is, therefore,imperative that HIV be treated as amainstream issue rather than a purelyhealth issue. An effective responsetowards the epidemic must be based onthe realisation that South Asia is indeedon the threshold of an unparalleledAIDS epidemic.The epidemic is becoming generalised inmany parts of the region, and focusedpublic action that goes beyond a purelymedical or communicable diseaseapproach is needed to tackle it. HIV/AIDShas a major impact on humandevelopment attainments, especially ofthe poor and marginalised communities/groups, including women. At the microlevel,it has a significant impact onindividuals, households and firms. Tillnow, the macro-economic impact of theepidemic in South Asia has been relativelylow compared to the situation in sub-Saharan Africa. However, since thestructural determinants of HIV prevalencesuch as high levels of poverty, migration,illiteracy, ill-health, gender inequality andurbanisation are widely present in SouthAsia, the region can ill-afford to wait for afull-blown crisis. The mutually reinforcingrelationship between HIV and humandeprivation in South Asia needs to bebrought at the centre of all efforts tocombat the epidemic.The most important lesson for South Asiais about fighting the epidemic right nowto prevent it from reaching catastrophicproportions. National responses shouldnot wait for HIV/AIDS cases to soar.Commitment to checking the spread ofHIV has to be imbued with a sense ofurgency. The cost of trying to reverse theupward trend of the epidemic once itreaches the 1 per cent level will haveserious implications in terms of humanlives and resources. 1Given the early stage of the epidemic inSouth Asia, it is important to address thestructural factors such as poverty andlivelihood, gender and human rights, foreffective prevention, care and support. Inorder to do this, it is essential to get theepidemic out of the “public health”box and address it as a mainstreamdevelopment issue. The elements of sucha response would include:l provision of livelihood and socialsecurity for PLWHA and vulnerablegroups;Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 117

The Way orwardWhile there isgeneral agreementthat the HIV/AIDSepidemic calls forpolicy intervention,there isconsiderably lessclarity about theappropriatecontent of anysuch policyresponse.lllempowerment of women to ensuregreater control over their bodies, bettersexual negotiation and avoidance ofopportunistic infection;public education to reduce ‘fear andloathing’, which is at the heart ofstigma and discrimination and linkmobilisation of positive people withwider social movements; andimproved management of theeconomy to address issues stemmingfrom globalisation like vulnerability oflocal livelihoods, healthcare accessand affordability and drug pricingregimes in the age of TRIPS.The policy and regulatory frameworkmust be simultaneously widened, toensure that:l access to basic services for positivepeople is guaranteed;l AIDS strategies go beyond publiccommunication and media advocacy;andl human rights of PLWHA are respected,with changes in laws and penal codesto ensure their decriminalisation.5.2 Policy Action forHIV/AIDSWhile there is general agreement that theHIV/AIDS epidemic calls for policyintervention, there is considerably lessclarity about the appropriate content ofany such policy response. Should it be apurely technical intervention? Shouldother goals be pursued as well? Whoshould participate in “delivering” theintervention?Countries have experimented witha number of policy approaches,incorporating one or more of the abovecharacteristics, in the two decades sincethe onset of the epidemic. These haveranged from the screening of donatedblood, HIV testing of individuals(voluntary or forced), counselling,subsidised provision of ARV drugs, needleexchange programmes, removal ofPLWHA from proximity to populations atrisk, subsidised condom distribution,prevention messages (through the massmedia and peer groups), and social andeconomic empowerment schemes.Sometimes, the primary goal has been toreduce HIV infection, but at other times,additional goals—such as economicbetterment and protection of humanrights—appear to have been incorporatedas well. The government has played acentral role in executing someinterventions, whereas others have beenconducted under the auspices of theprivate for-profit and non-profit sectors.Still others have been undertaken aspartnerships between the private sector,the government and NGOs. Groupstargeted for intervention have beeninvolved in the design and execution ofpolicy in some cases, while that has notbeen the case in others.To the extent that HIV/AIDS has anadverse impact on economic indicatorsand other socially desirable goals, policyaction is necessary early in the epidemic,rather than later. The question ofappropriate policy is also relevant here.One objection to policy action is thatindividual (or private) actions act toneutralise government policy, so the netoutcome of the policy intervention endsup being rather small. For example, acountry may have a policy of subsidisingHIV testing of blood for transfusion.Assuming that, in the absence of anygovernment policy, individuals wouldactually have paid for testing of blood, theonly impact of the policy of subsidisingHIV tests is a transfer of public resourcesto individuals using transfused blood,with no influence on HIV. Therefore,unless there is a clear assessment that sucha transfer is beneficial to society, the policyRegional Human Development Report118 HIV/AIDS and Development in South Asia 2003

The Way orwardis not a desirable one. Sometimes theeffects of a policy can even be the oppositeof the intended effects as, for examplepolicies that seek to identify and imprisonPLWHA. 2 In this case, individuals whomight otherwise have visited formal healthfacilities avail of HIV counselling andlearn methods to reduce the risk ofinfection to others, may choose not to doso. This may, therefore, enhance HIVtransmission, instead of the intendedpolicy effect of reducing it. 3Even if concrete evidence on someaspects of the economic impact ofHIV/AIDS is not readily available, thereare enough reasons for makinginvestments in an HIV/AIDS policy. Thefirst is, simply, the human developmentcosts of the epidemic, as indicated by thenegative effects of stigma and the lossof key adult members of individualhouseholds at the micro-level, and overalldeclines in life expectancy at birth inthe worst-affected countries at themacro level. There are also measurableeconomic impacts such as large medicalexpenditures on treating PLWHA that useup resources that could have been usedelsewhere in the absence of AIDS.However, to justify spending more onpolicies to address HIV/AIDS, it isimportant that investments in AIDSprevention and treatment be comparedto investments in other (health and nonhealth)sectors.5.3 Emerging Policy Issuesfor HIV/AIDS and HumanDevelopment in South AsiaThe future of public policy on HIV/AIDSand efforts to combat the epidemic inSouth Asia will increasingly be influencedby a number of emerging critical issues,three of which are highlighted in thissection. The first is the role of stigma anddiscrimination in affecting care andprevention strategies. The second is thespecial requirements of policy initiativesin regions of conflict, and the ways inwhich conflict affects the spread ofHIV/AIDS. The third issue is the questionof access to ARV drugs as the regionbattles the disease.5.3.1 Stigma and discrimination:rationale for actionThe stigma and taboos surrounding HIVin most South Asian societies haveprevented open discussion of HIV/AIDS,making the epidemic socially invisibleand leaving individuals ignorant aboutthe causes and how they can protectthemselves and others. It has also madelarge sections of society considerthemselves behaviourally immune to HIV,a disease they perceive as only attackingstigmatised ‘others’ like sex workers, menwho have sex with men, injecting drugusers etc.In the light of these damagingconsequences, it is clear that stigma anddiscrimination need to be urgentlyaddressed both in order to ensure effectiveresponses to the epidemic, as well as toguarantee the human rights of PLWHA.Challenging stigma and discrimination isthus increasingly becoming a priority forgovernments, civil society and intergovernmentalorganisations. 4Effective responses: the need formeasurement and disaggregationThere have been relatively few sustainedor effective responses aimed atchallenging stigma and discriminationwithin the region. This is partly because ithas been difficult to measure and proveresults in this area and also because thefactors that influence stigma anddiscrimination, and the interplaybetween them, are rarely explored. As aresult, responses have not addressed theTo justify spendingmore on policies toaddress HIV/AIDS,it is important thatinvestments inAIDS preventionand treatment becompared toinvestments inother (health andnon-health)sectors.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 119

The Way orwardResponses havenot addressed theroot causes ofstigmatisingattitudes ordiscriminatorypractices and,therefore, havelimitedeffectiveness.root causes of stigmatising attitudes ordiscriminatory practices and, therefore,have limited effectiveness.The gap in useful data on stigma anddiscrimination is now being recognisedas a serious problem. A UNAIDS researchstudy on HIV-related stigma anddiscrimination in India and Uganda notedthat “relatively little systematic researchhas taken place on the forms thatHIV/AIDS related stigmatisation anddiscrimination take, the different contextsin which they occur and their varyingdeterminants”. 5 Current interventions,initiated largely by NGOs, tackle stigmaand discrimination by applying thehuman rights standards as outlined byvarious human rights mechanisms. They,however, require benchmarks for actionso that progress can be monitored moresystematically. 6Besides, by focusing on the humanrights approach, many stigma anddiscrimination-related initiatives lose thepriority of the two main public healtheffects:l stigma results in denial, leading toinaccurate disease surveillance,severely restricting the ability toassess and plan health needsappropriately; andl stigma and discrimination decreasethe access to treatment andcounselling services. 7In order to effectively tackle the problem,simple research methods are needed thatwill provide precise and measurable dataabout the levels of stigma anddiscrimination and the underlyingcomponents (e.g. fear, moral judgementetc.) that inform them, as well as thecorrelations and linkages between thesecomponents. Such a disaggregated anddetailed understanding of both thelevels and operation of stigma anddiscrimination would allow thedevelopment of tailored, effectivesensitisation programmes.The key elements of successfulprogrammes tackling stigma anddiscrimination are 8l analysing of the causes and effects ofstigma and discrimination;l communication and education aimedat changing attitudes and behaviour,not just imparting knowledge;l establishing a more equitable policycontext;l giving top priority to tackling legalchallenges;l safeguarding the dignity and rights ofindividuals and marginalised groups;l addressing the issue from a humanrights framework;l empowering communities through aparticipatory process;l social marketing;l social mobilisation;l sensitising and involving leaders(government, religious andcommunity) to create a more opensociety;l involving marginalised groups andPLWHA networks in forming policy,designing and implementingprogrammes and allowing themto build ‘new identities’ withinsociety; andl identifying both prevention and care/support.5.3.2 Conflict and developmentin South AsiaThe South Asian region is torn by civil andmilitary conflict, both within countriesand across borders, and has large refugeepopulations. Though there have been fewstudies that establish a direct link betweenconflict situations and the spread of HIV,civil and military strife do aggravate thevarious factors that fuel the epidemic. Ata general level, conflict situations disruptRegional Human Development Report120 HIV/AIDS and Development in South Asia 2003

The Way orwarddevelopment, divert scarce resourcesaway from social and developmentalspending to military expenditure, displacepeople, throw normal administrativestructures and processes out of gear, andviolate human rights. All these factorsaggravate the conditions that contributedirectly to the spread of HIV. Women andgirls become more vulnerable to genderviolence and sexual exploitation and theyare less able to negotiate safer sex. Multipartnersex is common, as sexualrelationships become more transitory.Such sexual activity is often withoutcondoms, the easy availability of whichbecomes a problem. The breakdown ofhealth infrastructure results in STIs notbeing treated, testing of blood not beingdone and drugs not being available. Thepresence of international peacekeepingforces can also be the source of a newlocal epidemic. Conflict also placesinnumerable hurdles in existingHIV/AIDS prevention efforts.Effective responses: addressing theunderlying causesThe spread of HIV/AIDS in conflictsituations cannot be addressed inisolation. As in the case of other responsesto the epidemic, this too has to be locatedwithin a larger developmental framework.Thus, any response will have to firstaddress the underlying causes of conflict.It must also deal with providing care andsupport to PLWHA in conflict situations.The key elements of such a strategywould be:l undertake research to analyse the linkbetween conflict situations and thespread of HIV;l Address the underlying causes ofconflict and social tension by:n dealing with issues relating tolivelihoods, ethnic, religious andlinguistic minorities;n promoting developmentalpolicies that do not lead toldisplacement, ensure balancedregional development and donot harm the environment; andn ensuring a more meaningfuland participatory democracyby strengthening grassrootspolitical institutions.Undertake focused action using acompassionate and caring approachto HIV/AIDS in actual conflictsituations. Such programmes mustdeal with:n educating women about theirreproductive and sexual healthrights;n ensuring representation forwomen in conflict resolutionactivities;n designing awareness programmesregarding HIV/AIDSand sexual health for both sexes;n ensuring humanitarian normsin regard to treatment of womenand children in conflictsituations; andn enhancing awareness in thearmed forces about HIV/AIDS5.3.3 Treatment, care andsupportThe mainstay of efforts to respond to theepidemic in the South Asian region at thepresent time consists of public education,voluntary counselling and testing,condom promotion and the treatment ofSTIs and opportunistic infections.However, in the absence of a vaccine or acure for HIV infection, the need for takingup access to treatment as an integral partof the common agenda for humandevelopment and HIV prevention isincreasingly being recognised. Access totreatment comprises several elements,including the quality and scope ofhealthcare infrastructure and equipment,the availability of trained medicalpersonnel and the availability of highquality affordable medicines.The breakdown ofhealthinfrastructureresults in SexuallyTransmittedInfectons not beingtreated, testing ofblood not beingdone and drugs notbeing madeavailable.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 121

The Way orwardImproving accessto Anti-retroviralTherapy and carefor HIV infectionand AIDS needs tobe logicallyintegrated withHIV preventionprogrammes.Significant strides have been made overthe last decade in developing a range ofARV drugs to control HIV infection andthis has made an enormous difference tothe way HIV/AIDS is treated. However,the high cost of these drugs makes accessto them a major problem in developingcountries, including those in the SouthAsian region. Till December 2002, only4 per cent of the 1 million people whoneeded therapy had access to HAART. Thesituation is likely to get exacerbatedwith the coming into effect of theTRIPS Agreement. The Agreementwill require countries to legislate strictpatent laws, which will only furtherrestrict the availability of drugs and makethem more expensive.There is also concern over theeffectiveness of ARV treatment withoutadequate supervision or health infrastructure.Fears of drug resistance fuelledthese concerns and led to questionsregarding whether ARV treatment wasan appropriate policy response inpoor countries.Effective responses: attemptingsynergies and building capacitiesThe UN Declaration of Commitmentendorses HIV prevention and care asbeing at the core of the larger responseto the epidemic. This suggests that thedetection and treatment of HIV infectionand associated opportunistic diseases isimportant. The increasing availability ofARV drugs also makes it clear that itwould be unethical to withhold lifesavingtherapy. Most importantly, theDeclaration endorses the commitmentof countries to come to terms with theissue of providing HIV treatment.ARV drugs are not a cure for HIV infection.Improving access to ART and care forHIV infection and AIDS needs to belogically integrated with HIV preventionprogrammes. Offering a mix of voluntarycounselling and testing, ART andtreatment for opportunistic illnesses willbe a stepping stone to expandingprevention efforts, as this larger gamut ofservices will cover a larger number of thoseinfected and those at risk.Developing countries standing on thethreshold of ART need to ensure that theirprevention programmes do not getisolated from care programmes. In somedeveloped countries, the gains of ART interms of reduced morbidity and mortalityis being neutralised by stable or evenincreasing rates of HIV transmission.In addition, treatment for HIV needs tobe utilised as an additional impetus forupgrading sustainable health delivery intoto, rather than being seen as an extraburden on the health budget.The WHO Commission on Macroeconomicsand Health calculated that anoutlay of $66 billion per year onhealthcare and services in developingcountries would save about eight millionlives a year by preventing or treatingdiseases such as HIV/AIDS, malaria andTB. The resultant economic benefits ofsustaining the health of the workingpopulation and lowering future medicalcosts were estimated to touch $360billion a year by 2020.There is a mounting body of evidenceregarding the positive associationbetween investments in health andeconomic growth, indicating that ahealthy population is as much aprecondition for growth as a product ofit. The response to HIV/AIDS, includingHIV treatments, needs to be at the core ofpublic policy, poverty reductionstrategies, action for sustainabledevelopment and the preservation ofhuman security.Regional Human Development Report122 HIV/AIDS and Development in South Asia 2003

The Way orwardProviding ARV treatment in resourcelimited settings is possible, once theright capacities are built up. A stronggenerics drug industry provides muchneededcompetition to brandedproducts and is a key element in ensuringaffordable access to medicines. There isscope for technical cooperationamong countries within and outside theregion. In 2001, one such attempt wasmade with discussions between thePakistani and Indian pharmaceuticalindustry on transfer of technology,machinery and plant equipment fromIndia to Pakistan for bulk production ofgeneric drugs.Countries like Bhutan and the Maldives,which do not provide the economies ofscale for mass production and dependentirely on imports, must collaborate withgeneric drug producers in the region tosource their requirements. Compatiblelegislation in both producing andimporting countries is essential to allowfor such collaborations. Countries thatrequire import of ingredients also need toensure that their laws are in compliancewith international agreements and, at thesame time, allow imports from genericproducers without violating theseagreements.Issues of quality control also need to beaddressed. The WHO, together withUNAIDS and UNICEF, took an importantstep in this direction in March 2002, whenit released the first list of safe HIV/AIDSdrugs and suppliers. The list, which isbeing regularly updated, includes bothgeneric and research-based companies,ARVs and drugs for opportunisticinfections. Two Indian generic producerswere included, reducing concerns over thequality of locally produced HIV/AIDSdrugs. The WHO list highlighted theimportance of quality control being anintegral part of the technical capacitybuilding exercise to set up a competitivegeneric industry.Issues relating to drug quality andeffectiveness of ARV in resource-limitedsettings have been addressed in severalstudies by the WHO and independentmedical researchers. The WHO, whichestimates that ART can be extended to3 million people by 2005, hasdocumented treatment regimens that aredesigned specifically for resource-poorsettings and set out guidelines for suchtreatment. These guidelines outline whento start ART and describe recommendedfirst-line and second-line ARV regimensfor specific subgroups of patients. Theguidelines also recommend the setting upof a parallel HIV drug resistance sentinelsurveillance system and “innovativestrategies for enhancing adherenceto ART”.There are lessons to be drawn fromthe success of DOT in TB controlprogrammes. While there are few studiesto show that adopting a DOT approachwill work in HIV/AIDS programmes, itcould be attempted for some subgroupsof PLWHA.UNAIDS has documented a number ofcase studies that show that theeffectiveness of ART in reducingmorbidity and mortality in developingcountries such as Thailand, Uganda, Braziland Senegal is comparable to that in highincome countries. Managing ARVtreatments at district-level hospitals inSouth Africa, Kenya, Uganda and Senegalhas proven to be feasible, though notsimple. 9 Further, research on ARVregimens in resource-poor settings iscontinuously evolving. Though thesample sizes in pilot projects have beensmall, the evidence so far has beenencouraging and needs further work. Forthe South Asian region, this is particularlyA strong genericsdrug industryprovides muchneededcompetition tobranded productsand is a keyelement inensuring affordableaccess tomedicines.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 123

The Way orwardThe implications ofinternational tradetreaties such asTRIPS andtechnologicalcapabilitiesunderscore theneed for a multiprongedapproachto tackle thedisease.important since evidence from otherregions, though useful, is not adequate todevise appropriate ART strategies.Along with care and prevention, access totreatment is an essential part of the battleagainst HIV/AIDS. The implications ofinternational trade treaties such as TRIPSand technological capabilities underscorethe need for a multi-pronged approach totackle the disease. The elements of such anapproach are:l ensuring prevention programmes andcare programmes work in tandem andnot in an isolated manner;l studying the feasibility of providingHAART through DOT and applying itwhere it is found to be successful;l encouraging technical cooperationamong countries in the region to makeARV drugs available;l encouraging public-private partnershipsto offer ARV drugs at reasonableprices;l encouraging pharmaceuticalcompanies to take up differentialpricing for developing countries tomake the drugs more affordable;l adopting a larger public healthapproach and strengthening thegeneral health infrastructure; andl placing HIV/AIDS at the centre ofdevelopment strategies and publicpolicy.5.4 Addressing Drug UseThe expansion of injecting drug use inSouth Asia has been a factor in the spreadof HIV/AIDS in the region. The infectionspreads through the use of shared needlesand also through the sexual route to thewives and sexual partners of injectingdrug users.Much of the official response to injectingdrug use has been to de-emphasise its socialimportance and stigmatise users asmarginal members of society. Womeninjecting drug users are heavily stigmatised.As with other aspects of HIV/AIDS, the drugconnection has not yet become a part ofthe official dialogue and response in manycountries. Throughout the region, drug useis illegal and this leads to harassment bythe police. This only prevents injectingdrug users from availing of counselling andtreatment services.Most countries offer some detoxificationservices, but a wider set of harm-reductionprogrammes that focus on both drugabuse and HIV infection hardly exist, withjust one notable exception. Despite druguse being illegal in India, the northeasternstate of Manipur has undertaken harmreductionservices on an experimentalbasis in an attempt to reduce thevulnerability of injecting drug users. Theprogramme includes needle exchangeand education about sterilising drugequipment. This is the only needleexchange programme operating in thecountry. 10 The results have been positive,with a one-third decline in HIV infectionsamong injecting drug users between themid and late-1990s.Effective responses: focusing onharm reductionGiven this background, the potentialexists both for HIV to spread beyondinjecting drug users and for a range ofactions by policy makers and influentialauthorities. The policy response mustinvolve the following:l recognising that injecting drug use isa factor in national HIV epidemics;l ending the prevailing discriminationand marginalisation of injecting drugusers, with legal reforms, wherenecessary; andl taking up harm reduction strategies,including needle exchange programmesand education about sterilisinginjecting equipment.Regional Human Development Report124 HIV/AIDS and Development in South Asia 2003

The Way orward5.5 Adolescent SexualHealth NeedsThe fact that adolescents are sexuallyactive is a reality most South Asian societiestend to deny. Despite high levels of sexualactivity, adolescents were found to havelimited knowledge about STDs, RTIs andHIV. Ignorance about sexual health issuesmakes them less able to make informedchoices about safer sex and, hence,increases their vulnerability to HIV/AIDS.The problem is compounded by the factthat, across the region, policy makers andopinion leaders disapprove of efforts toincrease adolescents’ knowledge aboutsexual health and see it as polluting youngminds. Girls are especially vulnerable sincethey have little control in sexualrelationships and are not supposed to beaware of sexual matters. Some countrieslike India, Bangladesh, Sri Lanka and Nepalare making attempts to make youth awareof sexual health issues and improvereproductive health services but suchefforts are not systematic. Sri Lanka standsout as the only country whose Populationand Reproductive Health Policy hasspecific provisions about adolescents.Moreover, a large number of young peoplealso form part of mobile populations, withassociated vulnerabilities.Effective responses: acknowledgingthe problem and addressing itAny effort to check the spread of HIVamong the youth has to first acknowledgethe fact of adolescent sexuality. The otherelements of the strategy to reduce thevulnerability of youth should be:l Undertaking IEC programmes thatwill increase the awareness of youthabout matters relating to sexual health;andl addressing gender inequalities anddisempowering norms in life skillsprogrammes.5.6 Towards GenderJustice and EmpowermentOver the last two decades, responses toissues related to gender and HIV have beenintensified to address the problem multisectorallyand to take on more issues asthe epidemic continues to spread. Issuessuch as mother-to-child transmission,access to treatment, access to moreinformation and legal rights havebeen taken up at various levels bygovernments, civil society organisationsand international bodies. While gender isthe underlying issue inevitably addressedby most of these interventions, a specificanalysis of gender-centred responses isnecessary.The inequalities in societies in South Asiaare most manifest in the field of genderrelations. Policies and practices designedby or enforced by men curtail female accessto education and information, healthcare,decent work, proper nutrition, andsecurity. Though many South Asiancountries are making progress inpromoting women’s access to socialservices and involvement in decisionmaking,there is still strong socialresistance to such changes both withingovernments and major social institutionssuch as religious groups and businesses.One area in which limited progress hasbeen made is the violence againstwomen, especially by men. From publicbeatings and executions (Afghanistan), totrafficking in young women (seemingly,in all the countries of South Asia), todomestic violence (in all the countries),women are regularly sexually intimidatedand sexually abused. In Bangladesh, as inother countries, “male authority overwomen’s sexuality is socially accepted…and reflected in violent behaviour withinmarriage.” 11 In Pakistan, a 1987 study bythe Ministry of Women’s DevelopmentAny effort tocheck the spreadof HIV among theyouth has to firstacknowledge thefact of adolescentsexuality.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 125

The Way orwardocusing on thoseissues thatdisempowerwomen runs therisk of divertingattention awayfrom those areasof women’s liveswhere they arecapable of orderingthe worlddifferently.indicated that domestic violence takesplace in approximately 80 per cent of thehouseholds. 12 Violence also is expressedin less direct ways, such as denyingwomen and adolescent girls adequateand appropriate information about RTIsand STIs, about the female condom, orabout risks of HIV infection. Theassociation of commercial sex workerswith HIV transmission, without referenceto the reasons why women are involvedin sex work, contains built-in biases andcontributes to further discrimination inproviding them with various services.For women and girls from low-incomegroups, the violence of sexualexploitation is a real or potential outcomeof struggling to survive in difficulteconomic circumstances. Social andeconomic disruptions increase thelikelihood of what is sometimes called“survival sex”—exchanging sexual favorsfor food, small amounts of money, ortemporary security.The result of inequitable gender relationsis higher risk of HIV transmission, forwomen and men, and countries as awhole. Limited literacy and access to nonwrittenforms of information preventsboth men and women from becomingaware about HIV/AIDS and how it can beprevented. These factors also increasethe likelihood of misunderstandings,setting the stage for stigma anddiscrimination and the further spread ofHIV. If the pattern seen in Africa issubsequently replicated in South Asia,women are likely to suffer increaseddomestic violence and stigma if and whenthey reveal they are HIV positive.The prevention, care and support needsof men and women are different, not justbecause of their physiology but moreimportantly in the context of gender rolesand relations. Programmes that foster thedevelopment of women-controlledprevention technologies is one suchexample. Providing women with femalecondoms and micobicides are gendersensitive efforts which need moreencouragement in the region.On the other hand, there are alsoprogrammes that have recognised theunique vulnerabilities that men are facedwith. The Healthy Highways project inIndia was one such effort to reducethe vulnerability of truck drivers, crewmembers and their paid sexual partnersto STDs and HIV/AIDS. The response tothe programme was positive as menwelcomed the services and expressed aneagerness to get more information. Theproject is implemented through 30 NGOsand 18 transport companies.It is well accepted now that a multisectoralresponse is the need of the hour.This, in turn, demands that policies andprogrammes comprehensively addressissues that foster gender inequality andvulnerability. Coercive programmesand policies not only violate individualrights but invariably do not elicit thedesired results. There is need to providegreater access for women and girls toproductive resources such as education,employment, legal assistance, dispel theculture of silence and shame thatsurrounds sexuality, and protect girls andboys from adverse effects of genderstereotyping.Much of the analysis and description ofHIV and women is couched in thelanguage of “vulnerability”, which is notan operationally useful concept if thereality of women’s lives have to bechanged. 13 Focusing on those issues thatdisempower women runs the risk ofdiverting attention away from those areasof women’s lives where they are capableof ordering the world differently. It hasbeen argued that if the conditions ofRegional Human Development Report126 HIV/AIDS and Development in South Asia 2003

The Way orwardwomen’s lives are to be changed in waysthat will make a fundamental differenceto the global experience of HIV/AIDS, itwould be desirable to learn from policyareas where outcomes are clearlybeneficial and apply these to the globalresponse to HIV. 14 The population policyin parts of South Asia has been cited as agood example of this. However, theselessons cannot be directly applied todifferent situations. At best, they point theway forward and are evidence of what canbe achieved through policies andprogrammes that are relevant andeffective.There is general agreement that highfertility imposes unreasonable burdens onwomen and that reductions in family sizelead to improved standards of living forall members of the family. Moreover, thereare gains for society in general throughreductions in the level of poverty and abetter educated and more healthy youngergeneration who grow into moreproductive adults. There are also gains tothe State in the form of faster economicgrowth and lower rates of publicexpenditure (in areas such as educationand primary healthcare).As in policies for HIV/AIDS, the problemlay, in part, in putting in place thosepolicies that would be effective insupporting women—and to some extentmen—in limiting family size. This meantchanging a world in which women havetraditionally had little or no voice overmatters relating to fertility. The argument,quite simply, is that if women were givenmore voice and more power they wouldchoose lower rates of fertility, as a result ofwhich there would be profound outcomesfor women and children and substantialsocial benefits. Similar arguments couldbe made in the case of HIV/AIDSresponses as well.Effective responses: changing thedynamics of gender relationsAs long as gender inequality exists,women’s rights and opportunities to resistthe infection, to assert their reproductivechoices, to demand safer sex and tosupport their families will be threatenedand the epidemic will grow in scope andimpact. A range of policy-makers andservice providers need to take up strategicgender interests and power dynamics toseek effective solutions. Some of thesesteps would include:l creating gender-specific informationin simple language;l providing gender-sensitive individualand group counselling services;l providing widespread sex educationservices and programmes withadolescents;l sensitising and training healthcareprofessionals;l imparting more information to theaffected groups on women’s rights;l empowering women through capacitybuilding interventions;l involving men as partners; andl ensuring that programmesencompassing care take into accountthe fact that women have no supportand care facilities, and providingadequate care and support services5.7 StrengtheningPartnershipsThe challenge of HIV/AIDS, and the needto address the epidemic at multiple levelsin order to ensure a comprehensiveresponse, requires the development ofinnovative partnerships and dynamicnetworks that will work in a collaboratedmanner. This involves bringing togetherpartners from different sections ofsociety—government, media, civil societyorganisations, private sector, UNagencies, donors and PLWHA—andmoving beyond the focus on traditionalHigh fertilityimposesunreasonableburdens on womenand thatreductions infamily size lead toimprovedstandards of livingfor all members ofthe family.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 127

The Way orwardInnovativepartnerships canenhance outreachand effectivenessby poolingdifferent strengthsand reachingmultipleconstituenciesthroughcoordinatedaction.public–private partnerships. Such anapproach will, for example, explore howthe private sector and media can supportthe work of civil society organisationsor how PLWHA can play a role ingovernment initiatives.The field of HIV/AIDS has seen examplesof collaborative initiatives, although farmore needs to be done. These initiativeshave clearly demonstrated that innovativepartnerships can enhance outreach andeffectiveness by pooling differentstrengths and reaching multipleconstituencies through coordinatedaction. Such examples include the pathbreakingwork done by advocacy groups,PLWHA groups, research institutions,service providers, NGOs and the media.Social mobilisation is at the heart of anystrategy for reducing the spread andimpact of the epidemic. Lessonsemerging from implementation havedemonstrated the need to link theseefforts at the micro-level with broaderissues of poverty, gender equality andgovernance at the macro-level. This canonly be done through creative anddynamic partnerships within andbetween sectors that allow multipleactors to work together to produce results.Alliances within civil societyThe issue of access to treatment is a clearexample of civil society organisationscoming together to form strong andeffective alliances. In April 2001, 39pharmaceutical companies dropped theircase against the Government of SouthAfrica, 15 allowing the government toimport ARV drugs. This withdrawal cameafter unprecedented public pressure dueto the campaign for access launched byseveral national and international civilsociety organisations. Prominent amongthese were Medicins Sans Frontiereswhich won the Nobel Peace Prize in 2000,Treatment Action Campaign (TAC) andOxfam International. The work of civilsociety partnerships in this area alsoextended this pressure to policy makersand the sustained campaign world-wideto provide affordable drugs to poor peoplepaved the way for the Doha Declarationon TRIPS and Public Health in November2001. In December 2001, TAC won a courtcase against the Government of SouthAfrica, leading to a governmentcommitment to provide Nevrapine toprevent MTCT, another example of civilsociety collaborating across borders toinform public policy.South Asia has seen the development ofseveral innovative partnerships betweensex workers’ organisations and NGOs/community-based organisations workingon several gender-related issues, such asanti-trafficking. These partnerships haveresulted in the formation of regionallyreplicable models of ‘self regulatorymechanisms’ at destination sites, whichcurtail the trafficking of minors andpersons coerced into sex work and reducetheir vulnerability to HIV. The success ofthe Sonagachi project in Kolkata, India,and the various sex workers’ collectives inBangladesh in strengthening HIV/AIDSresponses have demonstrated thesignificant impact such partnershipshave on sustaining integrated and rightsbasedresponses.CSO–private sector partnershipsA non-profit organisation, Family HealthInternational’s (FHI) manual titled,Workplace HIV/AIDS Programs: AnAction Guide for Managers (2002)aims to develop and sustain effectivepartnerships between the privatesector, labour unions, managers andmedical personnel. The manual isdesigned for use by companies’ humanresources managers, medical officers andunion representatives. It providesRegional Human Development Report128 HIV/AIDS and Development in South Asia 2003

The Way orwardcomprehensive guidance in assessingthe real and potential impact ofHIV/AIDS on companies, in developingan HIV/AIDS policy to cover theworkplace and in designing andimplementing HIV/AIDS preventionand care programmes for the workplace.The guide also includes examples andcase studies of how other companieshave responded to the epidemic.The ILO has also undertaken initiativesto address the issue of HIV/AIDS at theworkplace. It formally launched apioneering Code of Practice on HIV/AIDSand the World of Work at the UNGASS.“This code focuses on the world of workbecause so many people with HIV can befound there,” the director-general JuanSomavia said on the occasion. “Of the 36million people infected with HIVworldwide, we estimate at least 23 million,or three-quarters, are working people aged15 to 49 years, often our most productivepeople, people in the prime of their lives.”The ILO Code of Practice is aimed atproviding workers, employers andgovernments with new globalguidelines—based on internationallabour standards—for addressingHIV/AIDS and its impact at theenterprise, community and nationallevels where most infections occur. It willalso help boost efforts to prevent thespread of HIV, manage its impact, providecare and support for those suffering fromits effects and reduce stigma anddiscrimination, which arise from it.The Code of Practice is part of newILO efforts to mitigate the impact ofHIV/AIDS in the workplace. Whileseeking to promote prevention incountries where the epidemic alreadyhas a strong grip, it is also designed tohelp prevent an increase in infectionrates in relatively unaffected countries.What is more, it also provides guidance onsuch issues as testing, screening andconfidentiality, non-discrimination inemployment, and gender issues.Governments and NGOs in South Asiahave not made major efforts to stimulatethe private corporate sector in HIV/AIDSprevention efforts. Nepal and Sri Lankahave initiated limited programmes to reachworkers within the private sector. Overall,however, there has not been an effectiveanalysis in the region of:l how business policies and practices(such as requiring employees to travelfor extended periods or operatingconstruction projects that attract singlemen and commercial sex workers) maycontribute to the risk of HIV/AIDS risk;l initiatives by government, businessesand labour to stimulate collectivedialogue about HIV/AIDS prevention;orl advocacy with businesses to stimulateeffective workplace responses.Although several efforts have been made inIndia to stimulate greater awareness andinvolvement of the private corporate sectorin HIV/AIDS prevention, most companiesremain without workplace policies orprogrammes. The Corporate sector in Indiahas established the Indian Business Trust forHIV/AIDS (IBT) in 2001 to address criticalissues related to HIV/AIDS through multilevelpartnerships. The Confederation ofIndian Industry (CII) and ILO in partnershipwith NACO, India, are implementingworkplace intervention. CII has alsoadopted workplace guidelines for membercompanies, but progress towardimplementation is limited. Trade unions,too, have been slow to respond; theirattention is instead focused on job securityissues in the context of economicliberalisation. 16 Nevertheless, national andstate governments and some internationaldonors, continue to urge the private sectorGovernments andNGOs in SouthAsia have notmade major effortsto stimulate theprivate corporatesector in HIV/AIDSprevention efforts.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 129

The Way orwardIn reality,governments andNGOs can offer awealth ofexperiences in thedesign andimplementation ofprevention and careprogrammes, assistin shaping policies,and monitoreffectiveness ofimplementation.and unions to adopt a more aggressiveresponse to the growing HIV/AIDSepidemic.There are limited examples within SouthAsia of company polices and practicesdesigned to reduce the risks of HIV amongemployees and to reinforce nondiscriminatorypractices toward HIVinfectedemployees. Some companies inIndia have begun formulating HIV/AIDSpolicies and, with assistance from NGOs,implementing prevention programmesfor workers. As a part of Sri Lanka’sreproductive health policy, interministerialcollaboration is beginning toprovide health information to femaleworkers in the Free Trade Zones. Workers’leaders, supervisors, and managers offactories all receive training in dealingwith a variety of risk reduction strategiesand potential problems on shop floors.Indian steel major, Tata Steel, took animportant initiative in corporate sectorinvolvement in HIV/AIDS programmes inthe town of Jamshedpur, Jharkhand. 17 Thecompany established a group of doctors,educationists and community workers todevelop and implement education andinformation programmes and undertakecounselling and medical guidance. Thecompany went beyond its workers and theirfamilies and developed an outreachprogramme to cater to the needs of migrantlabourers, truckers and army and policepersonnel. Condom vending machineswere installed at various places. Completemedical care is provided to all employees.Emphasis is also given to prevention ofopportunistic infections as well as nutritionfor good health. Counselling and socialsupport is also provided. The programmeis extended to the larger community and allother companies in the town.In general, governments have not madeworker health and safety a priority. Existinglaws and regulations are not enforced andnew collaborations with businesses are notpursued. Rather, NGOs have been theprimary initiators within India in terms ofengaging both urban and rural-basedbusinesses to address HIV/AIDS. Indeed,businesses themselves find limitedguidance or dialogue with governmentauthorities. For example, a study ofcorporate attitudes and practices inMumbai, India, found that businesses“rated support from community leadershigher than campaigns by government….”.18Thus, there is a basis for coordination andcollaboration. Businesses often feel theyare expected to initiate HIV/AIDS policiesand programmes on their own. In reality,governments and NGOs can offer a wealthof experiences in the design and implementationof prevention and care programmes,assist in shaping policies, and monitoreffectiveness of implementation.Leveraging private sector changes canexpand overall prevention and careresponses. This can take two forms:regulatory actions and financial incentives.Regulations are likely to be a result ofgovernment action to set standards andmechanisms to ensure adherence to thosestandards. Governments can requirecompanies not to test potential or existingemployees, to keep medical data onemployees confidential, or can levy a taxto help pay for HIV/AIDS programmes.Regulations relating to benefit coverageand workplace rights can also beformulated as a result of negotiations withunions or worker associations.Financial leveraging can result when onecompany encourages (or requires) acontractor to take action on HIV/AIDS inreturn for continued business or discounts.Insurance companies can offer premiumdiscounts to company policyholders thatmaintain effective HIV/AIDS preventionprogrammes for all or some employees.Regional Human Development Report130 HIV/AIDS and Development in South Asia 2003

The Way orwardInvolving religious leaders 19Involving religious leaders in campaignsrelating to HIV/AIDS can be quiteeffective. In the region there are examplesof Christian and Muslim religious leadersbeing involved in AIDS awarenesscampaigns. Both India and Bangladeshhave attempted to enlist imams in theHIV/AIDS campaign. The choice ofimams probably stems from the fact that,by virtue of leading prayers at a mosque,they carry authority, enjoy mass reach,possess the power to convince and theyhave a captive audience every Friday.Before prayers, they deliver the khutba,or sermon, during which, in addition toreligious topics, they may choose toeducate their congregations on education,civic sense, hygiene or health.The plan to enlist imams has beeninspired by a hugely successfulexperiment in Africa. It involvedmotivating and training imams inUganda, Senegal and Ghana who thenwent to their mosques and told people ofways to avoid HIV/AIDS. In Uganda, thiseffort was called the “Jihad AgainstHIV/AIDS”. The model, hailed by the UN,is now inspiring other countries with largeMuslim populations to devise a specificallyIslamic approach to HIV/AIDS preventionthat combines health information withKoranic teachings proscribing adulteryand pre-marital sex.But a contentious issue is the useof condoms. Imams fear thatrecommending them could promote sexoutside marriage. It took HIV/AIDSproject leaders in Africa a year to convinceimams that the condom was only beingpromoted after the failure of the first twolines of protection—abstaining from sexand having sex only within marriage.“Don’t forget that human beings haveweaknesses,” Islamic leaders were told.However, the message was ignored.Then campaigners tried another tactic,pointing out that knowledge of condomsdid not imply that they would be usedirresponsibly. After all, they argued,Muslims know all about alcohol but itdoesn’t mean they drink withoutrestraint. This argument seemed to work.Finally, after much deliberation, Islamicleaders consented to let imams promotecondom use.Another vital message the imams will beexpected to put across is the need forhumane behavior towards those who areHIV-positive. The imams will be urged toteach compassion and to condemn thetendency to stigmatise.5.8 A Renewed Call forAction: Prevention, Careand DevelopmentThis section focuses on two aspects ofpolicy responses: policies directly relatedto HIV/AIDS and policies that form thesocio-economic context of the epidemic.The latter are particularly important,given that HIV/AIDS arises fromdevelopmental failures and canexacerbate those shortcomings, if notaddressed in a holistic manner. Mostcountries in the region have policies todeal with a variety of social, economic,and cultural development issues,including poverty. Thus, there is soundprecedent for adapting andimplementing existing policies anddesigning new policies to controlHIV/AIDS and mitigate the impact of thedisease on individuals, households,communities, and nations. “What theHIV epidemic does is to illustrate onlytoo well the costs of previous failure, andthe fact that if we are to prevent anexpanding epidemic which hasenormous potential to disrupt not onlydevelopment but also social, economicand political structures, then we have toThe choice ofimams probablystems from thefact that, by virtueof leading prayersat a mosque, theycarry authority,enjoy mass reach,possess the powerto convince andthey have acaptive audienceevery riday.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 131

The Way orwardProvidingknowledge,awareness andskills to thepopulation at largeis absolutelynecessary tocontain the spreadof the epidemic.ensure better overall developmentperformance.” 20There is widespread agreement that thevulnerability to HIV/AIDS is linked topoverty. Unfortunately, the linkages havenot been adequately analysed to assistpolicy makers or advocacy groups inoutlining policy and programmaticresponses that alleviate conditions ofpoverty and reduce HIV vulnerability. Partof this problem stems from poverty beingviewed as a static condition rather thanas an outcome of processes of change. Asmentioned earlier, ‘impoverishment’ is amore comprehensive concept, suggestingas it does a dynamic set of processesleading to poverty. In previous sections,we have shown how some of theseconditions (unemployment, loss ofassets, lack of access to social services etc.)relate to HIV/AIDS.Role of prevention strategiesGiven the human development deficit inSouth Asia, in terms of levels ofachievement in literacy, longevity andlivelihood, as also fiscal compression ofthe 1990s, it is essential to put preventionstrategies at the forefront of the policyresponse to HIV. Providing knowledge,awareness and skills to the population atlarge is absolutely necessary to containthe spread of the epidemic.Prevention strategies must:l address sustainable behaviour change;l address the gap between knowledgeand practice;l integrate care and support for itssuccessful implementation;l must be tailored to specificpopulations such as:n men who have sex with men;n women and children;n injecting drug users;n armed forces /uniformed forces;n brothel and non-brothel-basedllsex workers and their clients; andn mobile populations (migrants,refugees, people displaced inconflict)incorporate principles of GIPA andinvolve PLWHA in such actions; andIntegrate HIV prevention strategieswith development actions such asenhancing livelihood opportunities,providing information and support forsafe mobility etc.It must be borne in mind that preventionstrategies have traditionally evolved in adeveloped country context, and,therefore, focused on individual behaviourchange, especially sexual behaviour.Given that household and communityvalues play a major role in South Asiansociety, it would be essential to tailorprevention strategies to addresscommunity concerns relating to HIV.This would ensure that prevention stepsfor ‘safer sex’ such as condom use are notseen as an endorsement of individualpromiscuity, but as agents for socialresponsibility.It would, thus, be important to enlist theSouth Asian communitarian traditionsand religious sanctions as allies in thebattle against HIV.Care and supportThe apprehensions regarding access totreatment and care arise from theselective calculation of the costs ofproviding treatment and care, whileignoring the need to assess the cost of notdoing this. Treatment, care and supportare part of the prevention continuum andeach element is incomplete without theother. Focusing primarily on prevention,without giving equal attention to care andtreatment, creates barriers in the way ofthe complete and active involvement ofPLWHA, thus weakening the effectivenessof responses. Moreover, communityRegional Human Development Report132 HIV/AIDS and Development in South Asia 2003

The Way orwardconcerns and extended family structuresin South Asia offer ample opportunitiesfor involving communities and familiesin providing home-based care, especiallysince the health infrastructure in thesecountries are unable to cope withcontinuous and long term care. Thequestion, therefore, is not whether toprovide care and access to treatment ornot, but rather how to do it. The followingissues must, therefore, be kept in mindwhen designing strategies for care,support and treatment:l understand the importance ofvoluntary counselling and testing;l act to prevent mother to childtransmission;l identify appropriate financingmechanisms;l seek support from the private sector;l manage TB as a major opportunisticinfection; andl aim towards treatment for all.5.9 Possible PolicyInitiatives on HIV/AIDSThe following are some of requisite policyorientedsteps to address HIV/AIDS inSouth Asia:l Collection and quick disseminationof relevant data. Given the currentlow prevalence rates of HIV in thecountries of South Asia, it is most costeffective to track prevalence throughselective surveillance systems that willmonitor changes in HIV/STI andbehaviour in the vulnerable groupswhere the disease tends tobe seen early on. Any policy intendedto gather HIV data from selectgroups must be accompanied byconfidentiality and by effectivecommunication to the public in orderto reduce stigma and to avoid thesense of complacency that theepidemic is associated only with thegroups from which data is obtainedl Demonstrate strong leadership,through commitment and action,and foster networks of leaders drawnfrom all levels of society, who willwork together to address theunderlying causes of HIV/AIDS andrevolutionise responses. Pioneeringleadership by governments is essentialfor containing the epidemic atnational, regional and global levels,as emphasised in the UNGASSdeclaration, and should becomplemented and enhanced byleadership from civil society and theprivate sectorl Reinforce commitments to the GIPAprinciples. This will also involve theprovision of substantive resources andsupport to national and regionalorganisations, groups and networks ofPLWHA, as well as to civil societyorganisations that work to supportand empower those vulnerable andmarginalised communities mostaffected by HIV/AIDS. This will playan important part in ensuring effectiveand rights-based responses bybuilding the capacity of those who aremost affected to play a central role inall responses to the epidemic.l Encouraging political, social,economic, religious and culturalleaders to openly discuss HIV/AIDSwith their constituents. UNAIDS andothers speak of “breaking the silence”that surrounds HIV/AIDS, sexuality,and inequalities that drive theepidemic. The family planningprogrammes provide a ready examplein which leaders with diverseperspectives joined in the discussion.In the case of HIV/AIDS, these leaderswill need reliable information in orderto offer clear, non-stigmatisingmessagesl Adapt lessons and examples fromother countries in the region andAfrica. Policy makers and opinionThe question,therefore, is notwhether to providecare and access totreatment or not,but rather how todo it.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 133

The Way orwardNations mustincludeconsideration of thecauses of HIV/AIDSin the design andimplementation ofall socio-economicprojects.lllllleaders need to be aware of theimpact of HIV/AIDS on families,communities, businesses and nationsin other countries in order tounderstand the grave proportions theproblem can assume if not tackledLearn from NGOs that have beenactive in prevention and care. NGOshave taken the lead in addressingHIV/AIDS, injecting drug use, genderequity, youth outreach, transportworkers health needs, and a variety ofother issues. Their experiences areinvaluable guides for informing policymakersand for strategic planningInclude consideration of the causes ofHIV/AIDS in the design andimplementation of all socioeconomicprojects. This will beespecially important for the regionwhere the epidemic is growing rapidly.This issue especially needs to be a partof any reconstruction programme inAfghanistan and in Afghan refugeecamps in Pakistan and IranAccord priority to policies andprogrammes for sex education foryoung people and adolescentreproductive health services. Caremust be taken to see that such effortscover all young people in formal andnon-formal settings as well as marriedadolescentsImplement policies and statementson multi-sectoral responses toHIV/AIDS within a humandevelopment paradigm. Such policiesalso need to complement andstrengthen inter-ministerial workinggroups. Multi-sectoral responseswill include government and civilsociety responses at all levels.Implementation of such multi-sectoralresponses will be a combination ofnational responses at various levelsand diverse forms of communitymobilisationContinue to advocate innovativelllpolicies and the implementation ofexisting policies promoting greatergender equality. This will involve notonly achieving greater equity insociety for women, but re-definingappropriate and responsible malenorms and behaviours (includingcondom use within marriage) thathinder equity. 21 Continued progresson revising inheritance laws, withreinforcement for changes in socialattitudes about inheritance rights, isessential for gender equality and forlong term response to women andchildren affected by HIV/AIDS.Draw up policies and potential lawsfor the protection of PLWHA fromdiscrimination. Other policies andlaws are likely to be needed to supportpeople affected by HIV/AIDS, e.g.,widows, orphaned children, traffickedwomen, who may lose property, beunable to attend school, or beexcluded from certain jobs because oftheir association with a person orgroup who is infected.Greatly expand business involvementin the arena of HIV/AIDS responsesas part of corporate socialresponsibility, including formulationof business and union policies.Governments can more aggressivelyengage businesses to develop policiesand prevention programmes, as hasbeen done in the Free Trade Zones ofSri Lanka. Standards of behaviour andresponsible sexual and socialpractices within the workplacecan have a significant influenceon behaviours outside the jobenvironment.Develop comprehensive responsesto reduce mobility-relatedvulnerabilities. Comprehensivestrategies and action on the ground toreduce such vulnerability at source,transit and destination areas need tobe developed on a priority basis.Regional Human Development Report134 HIV/AIDS and Development in South Asia 2003

The Way orwardlInvolvement of government sectorsdealing with armed personnel, paramilitaryforces, railways, mining,labour etc. which generate large-scalemovement is crucial to sustainableHIV/AIDS prevention and careamong mobile populations.Responses and strategies must ensurethat the migrant population is notstigmatised as a result of focusedinitiatives and that the rights ofindividuals to move are upheld as abasic human right.Develop polices and laws that operatein synergy to protect and enhance therights of those infected or affectedand recognise the centralimportance of a rights-basedapproach to effective responses. Inaddition, comprehensive efforts mustbe made—through sensitisation andawareness programmes and creativepartnerships with the media—to fostera normative environment in whichHIV-related stigma and discriminationare reduced and values of tolerance,acceptance and human dignity arepromoted. Only in such an environmentwill the full implementation ofrights-based laws and policies bepossible.5.10 Regional AgendaIn South Asia, as in many other parts ofthe world, the underlying factors thatmake people vulnerable to HIV/AIDStranscend borders. Hence, containing theepidemic within national borders aloneis not enough to make the response to theepidemic meaningful. There are alsodaunting challenges, ranging from acutegender inequality to severe stigma anddiscrimination of PLWHA, within theregion. This collective vulnerability of theregion—particularly that which arisesfrom the mobility of people, trafficking inwomen and children and conflicts—callsfor integrated, inter-country responses.Regional cooperation, a shared agendaand sharing of knowledge and experiencewill also strengthen the national-levelinitiatives and help cost-effectiveprogramming. To gainfully use thewindow of opportunity provided by theseemingly low prevalence rates in theregion, the following regional level actionsare required:l enhance regional cooperation andshared political commitment onHIV/AIDS issues among nations andgovernments;l promote regional networks betweencivil society partners across South Asiafor shared learning, capacityenhancement and the developmentof a strong, regional, civil society voice;l foster sustained, committedleadership in the region to raiseconcerns regarding HIV in South Asiaat regional and global fora, in order tomobilise international support andresources;l undertake concerted internationaladvocacy for the recognition of thevisibility and gravity of the epidemicin the region at the global level;l develop inter-country dialogue andcollaboration between governmentsto address issues of trans-borderconcern, such as migration, traffickingand conflict;l undertake advocacy to ensure theratification and implementation ofrelevant conventions and commitments,as well as develop newcommitments through regional forasuch as SAARC, particularly to protectthe rights of PLWHA and vulnerablepopulations;l develop regional-level strategies toaddress the common norms, valuesand taboos that fuel the epidemic andfeed the stigma and discriminationfaced by PLWHA and vulnerablegroups within the region;Regionalcooperation, ashared agenda andsharing ofknowledge andexperience willalso strengthen thenational-levelinitiatives and helpcost-effectiveprogramming.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 135

The Way orwardIn a region asdiverse andcomplex as SouthAsia, HIV/AIDSpolicy responsesand needs cannotfit into a singlemould and it is notappropriate to saywhat is adequateor needed for eachcountry.llllshare best practices from around theregion for learning and scaling upefforts;enhance scope for South-Southcooperation and developmechanisms for mentoring and ongoingtechnical support for enhancingcapacity;provide support in enhancing accessto treatment through inter-countrymemorandums of understanding(MoUs) and trade agreements for thesupply of cheap generic drugs; andprovide support for regional PLWHAnetworks and fora that will enable HIVpositive people across South Asiadevelop shared agendas and strategiesin order to advocate for the needs andrights of those infected and affected atregional and global levels.5.11 ConclusionIn a region as diverse and complex asSouth Asia, HIV/AIDS policy responsesand needs cannot fit into a single mouldand it is not appropriate to say what isadequate or needed for each country. Evenwithin countries, different socioeconomicconditions and past policyresponses shape how HIV/AIDS is viewedand addressed. The goal is to identify bothstrengths and gaps in policy responses inorder to guide further effective initiativesin this area. Special attention must begiven to policy responses relating tostigma and discrimination of PLWHA. Infact, these factors offer insights into howgovernments, businesses, and social andreligious groups address some of the keyfeatures of the epidemic, such as payingattention to the needs and interests ofalready marginalised socio-economicgroups or enforcement of legalprotections.The relative incipience—or evenabsence—of a coherent regional policyframework for HIV/AIDS in South Asia isstriking, given the long history of regionaldialogue on key development issues andthe existence of entities such as SAARC.Clearly, the debate on regional cooperationin South Asia needs to be broadenedbeyond trade and development to includean explicit recognition of HIV as a majorchallenge to development, peace andstability in the region.The countries of South Asia have begunthe process of creating policies torespond to HIV/AIDS. Within nationalAIDS programmes and ministries ofhealth, there is a sense of urgency toexpand the scope of policies andprogrammes. International donoragencies have played a facilitating role innational responses. NGOs possessgrowing experience in preventionprogrammes. Thus, a foundation exists inmost South Asian countries for shapingnew policies, particularly those that willdiscourage stigma and discrimination. Therole of existing inter-governmentalmechanisms and institutions for regionalcooperation, such as SAARC, would becritical. It would also be important todevelop regional strategies with regard tothe provision of HAART and the entiregamut of care and support services,customised to the requirements ofresource poor settings. Mechanismssuch as the South Asia Free Trade Area(SAFTA) and also bilateral tradecooperation agreements could addressthe concern of affordable drug pricing,especially in the post-Doha scenariowhere developing countries have awindow of opportunity in terms ofcompulsory licensing and parallelcountry importation.This could be the foundation for buildingnew responses, particularly those thatwill keep the epidemic at low levels andwill provide adequate care and supportRegional Human Development Report136 HIV/AIDS and Development in South Asia 2003

The Way orwardfor people who are and will becomeinfected. The overriding unknown is notwhether the epidemic will spread, for itsurely will. Rather, the unknown is thewillingness of groups at all levels of societyto openly address the disease, its causes,and effective means to control it. Thus, apart of the response is to speed up thetimetable for generating public andpolitical will. The level of motivation todo so is very mixed. HIV/AIDS can spreadrapidly, especially given the rightconditions. Across South Asia, thoseconditions exist and form pathwaysthrough which the epidemic can explodewithin the next several years. So long aspolicy-makers and opinion-shapers in allsectors ignore or deny the power of theepidemic, they are clearing thesepathways. Rather than serving theirconstituents, they are putting them at risk.Above all, there is a need to recognisethat the challenge of HIV in South Asiacan be met more effectively through ahuman development framework and notsolely through a public healthperspective. More importantly, there isneed to go beyond rhetoric and actuallychange the methodology through whichHIV/AIDS is currently being addressedin South Asia.“or there to be any hope of success in the fight against HIV/AIDS, the worldmust join together in a great global alliance.”Kofi Annan, UN–Secretary General, UNGASS Declaration of Commitmenton HIV/AIDSRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 137

EndnotesEndnotesChapter 11 While HIV infection rates may bestabilising in sub-Saharan Africa, home to70 per cent of those infected with thevirus, mainly because relatively few highriskindividuals remain uninfected, theepidemic is still growing in other parts ofthe world. Russia saw nearly a 50 percent increase in HIV infections in 2001,and the number of cases in Eastern Europeand Central Asia has risen by more thanone-third (UNAIDS/WHO, 2000, 2001).Concerns have also been voiced overcomplacency in the West (with thenumbers among some groups of youngmen in the United States now reported tobe infected with HIV rising rapidly) and inAsia.2 WHO, 2001; Kaul, Grunberg & Stern,19993 Mahbub-ul-Haq Human DevelopmentCentre, 2001.4 Indeed, HIV prevalence rates amongadults in some of the sub-Saharan Africancountries are extremely high, as, forexample, in Botswana with 38.8 per centand South Africa with 20 per cent(UNAIDS/WHO, 2002).5 It has been pointed out that figurespertaining to the magnitude of HIV/AIDSare, at best, estimates and not exactcalculations. There is one main point tobe made about data. The extent of HIV/AIDS in India is not really known andthere are only reports from a number ofsurveillance centres. The true prevalenceand incidence figures could be different.An estimate of the US NationalIntelligence Committee projects a veryhigh number in the near future. However,it is a controversial issue.6 NACO (India), 20007 UNAIDS/WHO, 20028 World Bank, 2002a9 Purohit, 2001; Gertler and Hammer,1997; Jain et al., 200010 Human poverty is more than incomepoverty. It is the denial of choices andopportunities for living an acceptable life(UNDP Human Development Report,1997)11 WHO, 200012 UNDP, 2001b13 Bloom and Mahal, 1997; Bonnel, 2000;Macarlan and Sgherri, 2001; Over, 199214 Barnett and Blaikie, 1992; Bharat, 1999;Bloom and Mahal, 1995; Mahal, 1996;Pyne, 1998, Barks-Ruggles, 2001Chapter 21 Collins and Rau, 20002 UNDP, 20023 UNICE, 20014 A study by Pitayanon et al. 1997 inThailand finds that “the economic impactof an adult AIDS death is sizeable andsignificant despite all the copingstrategies employed. The least able tocope were the poorest and least educatedhouseholds engaged in agricultural work.The economic impact of an adult AIDSdeath was more severe than the impact ofdeath from other causes. This is largelybecause AIDS infects a specificpopulation, mainly those alreadydisadvantaged and less able to cope withthe resulting adversity”.5 Bloom and Mahal, 1996; p.396 Bloom and Mahal, 1996 and Bloom andGlied, 19937 Dhaliwal, 20028 Middle East Times, 4 January 20019 Hodges-Aeberhard, 200010 Dhaliwal, 2002; Hodges-Aeberhard, 200011 Middle East Times, 4 January 200112 Bharat,1999; Verma et al., 200213 Bloom et al., 1997, p.19714 Varma, 199715 Mahal, 199616 See http://www.aidsnet.chRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 139

Endnotes17 Bandhu, 200218 UNAIDS/WHO, 200219 Tallis, 199820 The analyses, while very similar to anearlier work by Bloom et al. (1996), marka significant leap forward, in terms of thelarger number of countries for which dataare available, the increased length of thetime period over which the impacts of theepidemic can be assessed, and theavailability of better estimates of HIVprevalence and AIDS cases.21 Unfortunately, lack of good sentinelsurveillance data for HIV proved ahindrance in obtaining AIDS caseestimates for Nepal.22 The Hausman specification tests (seeTechnical Note B) reject the nullhypothesis of no reverse effect runningfrom life expectancy to HIV/AIDS.23 Our results are unchanged even if weexclude the sub-Saharan African countriesfrom our sample.24 Indeed, the same results hold even if theadult literacy rate variable is replaced byprimary and/or secondary enrolment rates,or by mean years of schooling in thepopulation aged 15 years and above.25 Stillwaggon, 200226 Bloom et al., 199727 Rao et al., 200128 Bloom, Mahal, Sevilla and River PathAssociates, 200129 Recent research in Cambodia, the countrywith the most advanced epidemic in Asia,demonstrates the poorest segments ofsociety have much less knowledge of howAIDS is transmitted and prevented. Peoplefrom this class are more likely to havesex at a younger age and use condomsless frequently. A study in Brazil showedthat three-quarters of people newlydiagnosed with HIV in the early 1980shad a university or secondary education,but by the early 1990s this share hadfallen to one-third.30 Bharat, 199931 World Bank, 200032 UNPA, 200033 UNDP, 200034 Lawyers’ Collective, 200035 UNIEM, 200136 The Behavioural Surveillance System(BSS) conducted by NACO of India revealsthat the poorest awareness was amongrural women in some states such as Bihar(20.6 per cent) and Uttar Pradesh (29.4per cent). (BSS survey, NACO, 2001)37 Zierler et al., 2000 find evidence from thestate of Massachusetts in the UnitedStates that economic deprivation has astrong positive association with theincidence of AIDS.38 Bloom et al., 199739 CPA media, 2001, p.1.40 Jeffreys, 2001; Kukis, 2001; WorldHealth Organization, 2001a41 Phongpaichit, 1982; Micaller, 200242 MAP 2001, p.2343 Wilson, 1999, p.1; Bryan, isher andBenziger, 200144 Wawer et al., 199645 ord and Koetsawang, 199146 National AIDS/STD Program, Bangladesh,200147 Bloom et al, 1997; National AIDS/STDProgram, Bangladesh, 2001, PakistanAIDS Prevention Society 2001; UNDP,2001; World Bank, 200048 Singh, 200149 MAP, 2001, p.2750 The research of Estebanez, itch andNajera (1993, pp.406-7) lends furthersupport to this conclusion by noting thefailure of methods focusing on isolationand imprisonment in order to controlsyphilis in the early twentieth century.51 Mahal, 1995; Canadian HIV/AIDS LegalNetwork, 200252 Philipson and Posner, 1995, p.83753 Bloom et al., 1997; Over, 200154 Gini co-efficient is an indicator of incomeinequality reflecting the distribution ofincome throughout the population. Ifincome is distributed equally across thepopulation, the co-efficient is equal tozero and if a few individualspredominantly hold the wealth, the coefficientis close to one.55 or more details, see Technical Note B56 Bloom et al., 199757 Bloom et al., 199758 Guinness and Alban, 2000, p.1059 Shepard, 1998, p.24760 Barnett et al., 200161 Bloom et al., 199762 Bloom, Mahal and River Path Associates,200263 Guinness and Alban 2000, and referencescited therein64 Barnett and Blaikie, 1992; Guinness andAlban, 2000, pp.7-865 Kwaramba, 199766 Bloom, Mahal and River Path Associates200267 Bloom, Mahal and River Path Associates2002, p.768 Bloom and Mahal, 1996 and referencescited therein; Giraud, 199369 Kanjilal and orsythe, 199770 Bollinger, Stover and Kibirige, 199971 Mahal, 200272 Bloom et al., 199773 World Bank, 199374 Kaplan and O’ Keefe, 1993; Over andPiot, 1993Regional Human Development Report140 HIV/AIDS and Development in South Asia 2003

Endnotes75 Bloom et al., 2001; Over, 199876 At the micro-level there is someevidence, mostly from sub-SaharanAfrica, to support the assertion that thepoor and the less educated are at greaterrisk from HIV infection (Bloom et al.,2001). However, Over (1992) alsopresented evidence of greater HIVprevalence among the economically betteroff in small samples of individuals. Butthere is evidence that this may changeover time. A study in rural Uganda, on theother hand, found that in a cohort ofnearly 20,000 adults aged 15-59 yearsfollowed over three and a half years, HIVassociatedmortality was highest amongthe better educated. This section is likelyto be hit hardest during the early stagesof the epidemic, but infection rates arenow falling quickest among them (Bloomet al., 1998). This has importantimplications for South Asia as well,especially as most countries haverelatively low average education levels.77 Bloom and Mahal, 1996; Bloom et al.,1997; Bloom et al., 200178 Bloom et al. 1997Chapter 31 UNAIDS/WHO, 20022 UNAIDS/WHO, 20023 UNAIDS/WHO, 20024 World Bank, 20025 UNAIDS/WHO, 20026 of longer duration7 It should be noted that while the SentinnelSurveillance data provide model-basedestimates for HIV prevalence, the data onHIV prevalence are not derived from exactcalculations. It has also been pointed outthat the reported AIDS cases may be apoor guide to the severity of the epidemic,as in many cases the death of an HIVpositive person may have actually beenattributed to an opportunistic infectionsuch as TB.8 NACO, 20009 World Bank, 2002b10 UNAIDS, 1998.11 World Bank, 2002b12 World Bank, 2002b13 Reid and Costigan, 2002; World Bank 2002a14 World Bank, 2002b15 World Bank, 2002a16 The study was conducted to determinethe relationship between injecting druguse, HIV and Hepatitis C among maleinjecting drug users in Lahore, Nai Zindagiwas commissioned by UNDCP andUNAIDS in January 1999 for a baselinestudy. Data was collected from 200 maleIDUs in Lahore.17 UNDCP/UNAIDS, 199918 Shrestha et al., 199819 Numerous studies have documentedtrafficking in women and children in SouthAsia. Nepal Human Development Report,1998; UNHCR, 1994; Wadhwa, 199820 Amarasinghe, 200221 UNAIDS, 2000b22 Nahar, Tunon, Barkat-e-Khuda, 200023 Ramachandran, 199924 Shadpour, 199925 Yakandawala and Ranathunga, 199926 Valley Research Group, 199927 UNDP, 2001a28 Sen, 200029 MHHDC, 199930 Subramanian, 1992; Dreze, 200031 International Save the Children, 200232 itzpatrick, 1994.33 Dreze, 200034 Goswami and Dutta, 1999; Manchanda,2001; Chenoy, 2002; Butalia, 200235 Dhar, 200236 Huntington, 2001; Sanghera, n.d.37 UNIEM, 200038 Rahman, 200139 ‘National Policies’ are usually required tobe approved by the legislative bodies ofcountries and adopted as ‘legislation’,prior to their implementation40 Khanna, Nadkarni and Bhutani, 199841 Bloem et al., 199942 Information provided by Ms. Sitara,UNDP, Afghanistan based in Islamabad. E-mail dated 21 August 2001.43 UNAIDS/WHO, 200244 Articles 27, 28, 32 and 43, Constitutionof the People’s Republic of Bangladesh45 www.youandaids.org/SouthAsia/sa_bhutan.asp#46 www.youandaids.org/SouthAsia/sa_bhutan.asp#47 Articles 14, 15, 21, The Constitution ofIndia48 ‘State’ refers to government, municipalbodies, state controlled bodies &corporations & bodies created by statute49 MX v ZY, AIR 1997 Bom 40650 NHRC, 200151 Statement by Dr. Ali Akbar Sayyari,Deputy Minister for Health & MedicalEducation, Islamic Republic of Iran at theUNGASS in HIV/AIDS, June 200152 Article 11(2), Part 3, The Constitution ofthe Kingdom of Nepal53 Article 11(3), Part 3, The Constitution ofthe Kingdom of Nepal54 Article 12(5), Part 3, The Constitution ofthe Kingdom of Nepal55 Article 22, Part 3, The Constitution of theKingdom of NepalRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 141

Endnotes56 Pradhan, 199857 Malla, 200158 World Bank 2002b59 Articles 25, 26 and 27, Part II,Constitution of the Islamic Republic ofPakistan60 World Bank 2002b61 World Bank 2002b62 Ordinance no. XL of 198163 Article 25(1) (a) Chapter III, TheConstitution of the Republic of Sri Lanka64 Article 11(2) Chapter III, The Constitutionof the Republic of Sri Lanka65 A doctor who acquired HIV from a bloodtransfusion in a semi-government hospitalwas told to find another job. (Samath,1997)66 Samath, 200167 www.youandaids.org68 World Bank, 2002b69 Statement by Ali-Akbar Sayyari , IslamicRepublic of Iran at the Special Session ofthe United Nations General Assembly onHIV/AIDS, 25 June 200170 Government of Pakistan, Ministry ofHealth and UNAIDS, 2000 World Bank,200171 World Bank, 2002b72 UNAIDS, 200273 World Bank, 2002a citing 1998-99National Sero-surveillance data74 Some of the information is adapted fromRoque and. Gubhaju, 200175 Iran News, July 24, 200176 Trang, 199977 Iran News, October 20, 200178 Agence rance-Presse, 200079 Maldives Human Development Report,2000Chapter 41 Some examples are the United NationsDeclaration of Commitment, June 2001and the Government of India’s NationalAIDS Prevention and Control Policy2 25 November 20003 Albertyn, 20004 U.S Committee for UN Population und,2002 (http://www/uscommittee.org/issue5_0.html)5 Australia, for instance, saw a greatdecrease in HIV/AIDS incidence when itintroduced a legal regime that protectedthe rights of those most at risk – sexworkers, injecting drug users – andintegrated PLWHA and vulnerable groupsby empowering them with information,access to services, decriminalisation,harm reduction etc.6 The Goa Public Health (Amendment) Act,1985 of the Indian state of Goa putanyone testing positive for HIV undermandatory isolation. This was lateramended to make such isolationdiscretionary.7 The Indian government has now adoptedan integrationist model in its NationalAids Prevention and Control Policy.8 Sabatier, 19889 Kirby, 200010 Justice Michael Kirby of the High Court ofAustralia at the plenary session on“Partnerships Across Borders AgainstHIV/AIDS”, 4th International Congress onAIDS in Asia and the Pacific, Manila,Philippines, 28 October 199711 Crandall and Moriarty, 199512 Bharat, 1999; Gilmore and Somerville,199413 CHANGE & ICRW, 200214 Goffman, 1963, defines stigma as a‘significantly discrediting’ attribute.15 UNDP & Sahara, 200216 Mr. X V. Hospital Z, [1998] 8 SCC 29617 Resolution 49/199918 According to MHHDC 2002, MaternalMortality Ratio (per 100,000 live births)1985-1999 weighted average is 492 forSouth Asia (excluding Afghanistan andIran)19 According to the Pakistan-based Lawyersfor Human Rights and Legal Aid (LHRLA),every year hundreds of women, of allages and in all parts of the country, arereported killed in the name of honour.During the first eight months of 2002,549 women became the victims ofbarbaric custom of Karo Kari (literallyblack man, black woman) in Pakistan andall the cases received wide publicity.Research by LHRLA showed that the realnumber of such killings is far greater thanthe number reported in the national printmedia. Honour killings are no longer onlyreported from remote rural areas but alsothoughless frequently-from towns andcities. The modes of killing vary, withpeople being hacked to pieces in Sindh,often in view of and with the implicit orexplicit sanction of the community. In theprovince of Punjab, such killings occur inan urban setting and appear based moreon individual decisions. The killings areusually carried out by shooting and are notalways carried out in public.20 The text in this and the subsequentsection draws heavily from Rivers andAggleton, 199921 Petchesky & Judd, 199822 Chinnock, 199623 McKenna, 199624 Silva et al., 199725 Bandhu, 2002Regional Human Development Report142 HIV/AIDS and Development in South Asia 2003

Endnotes26 ILO, 200027 AO, 199528 UNDP, 2001a29 USAID Bangladesh, 200330 CATW, 200231 STOP, 200232 World Bank, 2002b33 UNAIDS. It must be noted that the figuresquoted here are from 1995 because noauthenticated data are available forAfghanistan since 1995.34 Simkhada, 200235 ODI, 199936 Law made by judges through theirdecisions in the absence of statutes,which then become precedents andbinding law37 Articles 27, 28, 32 and 43, Constitutionof the People’s Republic of Bangladesh38 Article 22, Part 3, The Constitution of theKingdom of Nepal39 Al-Suood, 199540 Reid and Costigan, 200241 Article 1, Law on Combating Drugs,1991.42 Taking depended drug users off drugswithout decreasing doses slowly resultingin severe withdrawal symptoms43 UNDCP, 1999b44 Dr. Bayram Yeganeh, Director, IranNational AIDS Prevention Committee(www.aegis.com/news/ips/2001/IP010303.html-)45 Human Rights Watch, 200246 Lawyers Collective HIV/AIDS Unit, anIndian NGO, has itself filed approximately80 such cases in the last four years invarious Indian courts.47 Hindustan Times, November 13, 200248 Johari, V. and Divan, V., 200149 Khanna, A. and Salvi, S., 200150 Shreedhar and Colaco, 199651 Glick, 1993; Jayasuriya, 1995.52 Healthcare workers are at risk ofoccupational exposure to HIV. Exposuresoccur through needle-sticks or cuts fromother sharp instruments (percutaneousexposures) contaminated with an infectedpatient’s blood or through contact of theeye, nose, or mouth (mucous membrane)or skin with a patient’s blood.53 www.regentsparkclinic.com/Post_Exposure_Prophylaxis_HIV.php54 Grover, 199355 Goonesekere, 199856 HAART suppresses viral replication tovirtually undetectable levels in bloodtests. HAART also leads to the gradualreplacement of CD4 lymphocytes.Therapy is usually begun when the patientis diagnosed with clinical AIDS,irrespective of CD4 cell count, or has aCD4 cell count below 200 cells/mm3, oris diagnosed with WHO Stages II or IIIHIV disease with a total lymphocyte countbelow 1200/mm.3. Thus, only a certainproportion of a country’s population ofpeople living with HIV will require ARVsat any given time. ARVs work indifferent ways. Some inhibit the viralreplication process. Others prevent theentry of HIV into CD4 lymphocytes. HIVreplicates itself with the help of twoenzymes known as reverse transcriptaseand protease. The first class of Antiretroviraldrugs work by inhibiting one orother of these viral enzymes and are,therefore, known as reverse transcriptaseand protease inhibitors. Certain otherARVs belonging to the second categoryintervene relatively early in the infectionprocess. These drugs, known as fusioninhibitors, work by blocking the fusion ofHIV with the CD4 T lymphocyte, thuspreventing the entry of the virus into the Tcell.57 UNAIDS/WHO, 200258 Dr Joep Lange, President, InternationalAIDS Society, at the launch of theInternational HIV Treatment AccessCoalition in Geneva, December 200259 Marseille et al., 200260 Parallel importation of drugs allowsindividuals or bodies to import genericdrugs to the country in spite of brandeddrugs of the same generic being sold inthe country by agents of the mainproducer. The parallel drug importationallows the customer the choice of a widerange of generic drugs at a lower price61 UNDP, 200162 Pharmaceutical Research andManufacturers of America estimates R&Dcosts at $500-800 million63 The types of intellectual propertyprotected under TRIPS include copyrights,trademarks, geographical indications,industrial designs, integrated circuits,patents and trade secrets.64 ink, 2000; Watal, 200065 Correa, 200266 Compulsory licenses are licenses issuedby an administrative authority onpredetermined terms that allow non-patentholders to produce a patented product.67 “Members may provide limited exceptionsto the exclusive rights conferred by apatent provided such exceptions do notunreasonably conflict with a normalexploitation of the patent and do notunreasonably prejudice the legitimateinterests of the patent owner, takingaccount of the legitimate interests of thirdparties”. TRIPS Agreement, Article 30.68 Love 2002, Correa 2002 etc.69 Office of the UN High Commissioner forHuman Rights, 2002. (CESCR-CovenantRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 143

Endnoteson Economic, Social and Cultural Rights,CCPR-Covenant on Civil and PoliticalRights, CERD-Convention on theElimination of Racial Discrimination,CEDAW-Convention on the Elimination ofAll forms of Discrimination AgainstWomen, CAT–Convention Against Tortureand other Cruel, Inhuman or DegradingTreatment of Punishment, CRC-Convention on the Rights of the Child.70 The Central Asian Declaration on HIV/AIDS, 18 May 2001. The European UnionProgramme for Action: Accelerated Actionon HIV/AIDS, malaria and tuberculosis inthe context of poverty reduction, 14 May2001; The Abuja Declaration andramework for Action for the fight againstHIV/AIDS, tuberculosis and other relatedinfectious diseases in Africa, 27 April2001; The regional call for action to fightHIV/AIDS in Asia and the Pacific, 25 April2001; The Pan-Caribbean Partnershipagainst HIV/AIDS, 14 ebruary 2001; TheDeclaration of the Tenth Ibero-AmericanSummit of heads of State, 18 November2000; The United Nations MillenniumDeclaration, 8 September 2000; Thepolitical declaration and further actionsand initiatives to implement thecommitments made at the World Summitfor Social Development, 1 July 2000; Thepolitical declaration and further action andinitiatives to implement the BeijingDeclaration and Platform for Action, 10June 2000; The Baltic Sea Declaration onHIV/AIDS Prevention, 4 May 2000; Keyactions for the further implementation ofthe Programme of Action of theInternational Conference on Population andDevelopment, 2 July 1999; TheInternational Covenant on Civil andPolitical Rights; and the United NationsUniversal Declaration on Human Rights.71 While a Handbook for Legislators wasdistributed in 1999, the dissemination ofthe Guidelines has been criticised forbeing inadequate and governmentresponses have been termeddisappointing. A mechanism for measuringthe implementation of the Guidelines hasbeen proposed.72 Extract from 6th International Congress onAIDS in Asia and the Pacific, 2001,Regional Workshop on “HIVAIDS andHuman Rights: The Role of NationalHuman Rights Institutions in the Asia andPacific”73 Commission on Human Rights resolution2000/61 and Economic and Social CouncilDecision 2000/220.74 UN General Assembly Resolution 53/144(A/RES/53/144), 8 March 1999.75 Lawyers, activists and organisationsworking to defend human rights aroundthe world76 IDHRB, 199977 Extract from the 6th InternationalCongress on AIDS in Asia and the Pacific,2001, “Regional Workshop on HIVAIDSand Human Rights: The Role of NationalHuman Rights Institutions in the Asia andPacific”.78 Report of the National Conference onHuman Rights and HIV/AIDS, New Delhi,24-25 November 2000.This Conference was organised by NHRC,in Partnership with NACO, Lawyer’sCollective, UNICE and UNAIDS. Theobjective of the conference was to initiatethe process of developing a rights-basedresponse to the HIV/AIDS epidemic withinIndia, to be taken forward by variousState Human Rights Commission, policedepartments, representatives from thehealth-sector and State AIDS ControlSocieties in close collaboration with civilsocieties.or further information please refer to:(http://nhrc.nic.in / report hiv=aids.htm)79 UNAIDS/IPU, 199980 UNAIDS/IPU, 1999Chapter 51 South Asia high level conference on‘Accelerating the momentum in the fightagainst HIV/AIDS’ 3-4 ebruary 2003,UNAIDS&UNICE2 Mahal, 20023 Misra, Mahal and Shah, 2000; Philipsonand Posner, 1993; Kremer, 19984 This issue was also the theme for WorldAIDS Day 20025 Aggleton, 20006 UNAIDS, 2002a7 UNAIDS, 2002a8 These recommendations are drawn almostentirely from HIV/AIDS Related Stigmaand Discrimination: A Review andSuggested Ways orward for South Asia,UNAIDS, 2002a9 UNAIDS, 2002a10 Wong, 2000; Rupachandra, 2001; Rayand Sharma, 199811 Baden and Wach, 199812 Ministry of Women’s Development, 1987.13 Smith and Cohen, 200014 Smith and Cohen, 200015 CPTech, 200116 S.R. Kulkarni, All India Port and DockWorkers ederation, personalcommunication.17 Tata Steel, 200218 Nangia, 199819 Dhillon, 200220 Smith and Cohen, 200021 A good summary of the dimensions ofpromoting gender equity in Gupta, 2000Regional Human Development Report144 HIV/AIDS and Development in South Asia 2003

Annexure IRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 157

Annexure IRegional Human Development Report158 HIV/AIDS and Development in South Asia 2003

Annexure IAnnexure IConcluding observations by treaty monitoring bodies on issuesrelevant to the right to health and the response to HIV/AIDSCountry Treaty Concluding Observations, Comments SourceBangladeshCEDAWThe Committee was concerned about the fact that maternalmortality and infant mortality rates remained high and thatavailable primary health and reproductive health serviceswere still inadequate and often inaccessible to poor, ruraland marginalised women. Moreover, family planningservices still mainly targeted women, and not enougheducation on male responsibility in reproduction had beenintroduced. The Committee encouraged the Government ofBangladesh to strengthen its primary health andreproductive health services aimed at substantiallyimproving the health and well being of women.Committee on theElimination of All forms ofDiscrimination AgainstWomen, A/52/38/Rev.1,Part II, paras.409–464(12 August 1997).BangladeshCRCThe Committee is of the view that insufficient measureshave been adopted to promote widespread awareness ofthe principles and provisions of the Convention, and remainsconcerned at the lack of adequate and systematic trainingfor professional groups working with and for children,including judges, lawyers, law enforcement personnel,health professionals, teachers, social workers, personnelworking in child-care institutions for children and policeofficers. With regard to the implementation of Article 2 [thenon-discrimination clause] of the Convention, the Committeeexpresses its concern at the persistence of discriminatoryattitudes and harmful practices affecting girls, as illustratedby serious disparities, sometimes starting at birth andaffecting the enjoyment of the rights to survival, health,nutrition and education. The Committee also notes thepersistence of harmful practices such as dowry and earlymarriage. Discriminatory attitudes towards children bornout of wedlock, children who are living and/or working onthe street, child victims of sexual exploitation, children withdisabilities, refugee children and children belonging to tribalminorities are also a matter of concern.Committee on the Rights ofthe Child, CRC/C/15/Add.74, (18 June 1997).IndiaCEDAWThe Committee is concerned that women and girls areexploited in prostitution and inter-state and cross-bordertrafficking. It is also concerned that those women areexposed to HIV/AIDS and health risks and that existinglegislation encourages mandatory testing and isolation.Committee on theElimination of All forms ofDiscrimination againstWomen Twenty-secondsession, 17 January–4 ebruary 2000.MaldivesCEDAWThe Committee notes with concern that the health andnutrition of girls suffer after puberty and that maternalmortality and morbidity rates and the mortality rate of girlsCommittee on theElimination of All forms ofDiscrimination againstRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 159

Annexure ICountry Treaty Concluding Observations, Comments Sourceunder the age of five years remain at unsatisfactory levels.The Committee is also concerned that patriarchal andstereotypical attitudes have a negative impact on women’shealth and nutrition.Women, Twenty-fourthsession, A/56/38,paras.114–146 (15January–2 ebruary 2001)MaldivesCRCDespite the State party’s efforts in reducing the infantmortality rate and increasing child immunisation, theCommittee is concerned at the prevalence of malnutrition(stunting and iron deficiency) and high maternal mortality rate,as well as the limited access to safe water and adequatesanitation … The Committee is also concerned regardingproblems of adolescent health, in particular the high andincreasing rate of early pregnancies, the lack of access byteenagers to reproductive-health education and services, andthe insufficient preventive measures against HIV/AIDS …urthermore, the Committee expresses its concern at theinsufficient measures to promote breast-feeding of children,especially in health facilities. The Committee recommendsthat the State party promote adolescent health policies andprogrammes by, inter alia, strengthening reproductive-healtheducation and counselling services as well as improvingpreventive measures to combat HIV/AIDS … The Committeefurther suggests that a comprehensive and multi-disciplinarystudy be undertaken to understand the scope of thephenomenon of adolescent health problems, including thenegative impact of early marriages … The Committee alsorecommends that further efforts, both financial and human,such as the development of counselling services for bothyoung people and their families, be undertaken for theprevention and care of adolescents’ health problems and forthe rehabilitation of victims.Committee on the Rights ofthe Child, CRC/C/15/Add.91 (5 June 1998)NepalCEDAWThe Committee urges the Government to launch gendersensitisation and advocacy programmes aimed at the civilservice and opinion leaders, political decision makers, healthprofessionals and law enforcement officials so as to ensurethat a clear understanding of the obligations under theConvention is achieved. The Committee expresses concern atthe current law, which criminalises abortion, including incases of pregnancy through rape or incest. The Committeeconsiders that the current law on abortion contributes both tothe high maternal mortality rate in Nepal and the highernumber of women prisoners in that State. It is also concernedthat the proposed amendments to the current law continue tobe restrictive, allowing abortion only when the mother’shealth is in danger. The Committee urges the Government torevise existing legislation and to reconsider the proposedamendments so as to provide services for safe abortions. TheCommittee recommends that the Government prioritiseprevention of unwanted pregnancy through family planningservices and sex education. In these efforts, the Committeesuggests that the Government take account of generalrecommendation 24 on article 12, “Women and health”.Committee on theElimination of All forms ofDiscrimination againstWomen, Twenty-firstsession, A/54/38,paras.117–160(7–25 June 1999)Regional Human Development Report160 HIV/AIDS and Development in South Asia 2003

Annexure ICountry Treaty Concluding Observations, Comments SourceNepalICESCRThe Committee urges the State party to take remedialaction to address the problems of clandestine abortions,unwanted pregnancies and the high rate of maternalmortality. In this regard, the Committee urges the Stateparty to reinforce reproductive and sexual healthprogrammes, in particular in rural areas, ‘and to allowabortion when pregnancies are life threatening or a resultof rape or incest … The Committee requests that theState party, in its next periodic report, provide data aboutshorter-term health plans and more detailed informationabout mentally disabled persons and access to privatehospitals and institutions by the more marginalisedsectors of the population … The Committee is deeplyconcerned that the HIV/AIDS epidemic in the State partyis spreading at an alarming rate due to commercial sexand trafficking of women and children, and sex tourism.Committee on Economic,Social and Cultural Rights,Twenty-sixth(extraordinary) session(13–31 August 2001)PakistanCRCThe Committee is concerned to note that national healthplans appear to emphasise the training of doctors ratherthan of nurses and other health personnel, includingparamedics. Its attention has also been drawn to theapparent lack of clarity in the division of responsibilitiesbetween the provincial and federal levels for thedevelopment of a strong primary healthcare system…Active measures must be taken, in the view of theCommittee, to make widely known the provisions andprinciples of the Convention to adults and children alike.To assist in these efforts, it is suggested that political,religious and community leaders should be encouraged totake an active role in supporting efforts to eradicatetraditional practices or customs which discriminateagainst children, particularly the girl child, or are harmfulto the health and welfare of children. In addition, it isrecommended that training about child rights should begiven to relevant professional groups.Committee on the Rights ofthe Child, CRC/C/15/Add.18(25 April 1994).Sri LankaICESCRThe Committee notes with concern the existence ofdisparities between statutory law and customary law. Theage for marriage in statutory law is 18 years old but girlsas young as 12 years of age are able to marry undercustomary law, as long as the parents consent. TheCommittee is of the view that the practice of earlymarriage has negative impacts on the right to health, rightto education and the right to work, particularly of the girlchild. In statutory law, there is equality of inheritanceamong siblings while customary law discriminates againstmarried women who, unlike married men, may not inheritfamily property. In allowing customary law to prevail overstatutory law in this regard, the Government is notcomplying with its obligation to protect the rights ofwomen against discrimination.Committee on Economic,Social and Cultural Rights,E/C.12/1/Add.24(16 June 1998)Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 161

Annexure IAnnexure IIInternational Guidelines onHIV/AIDS and Human RightsGuideline 1: States should establish aneffective national framework for theirresponse to HIV/AIDS which ensures acoordinated, participatory, transparentand accountable approach, integratingHIV/AIDS policy and programmeresponsibilities across all branches ofGovernment.Guideline 2: States should ensure,through political and financial support,that community consultation occurs inall phases of HIV/AIDS policy design,programme implementation andevaluation and that communityorganisations are enabled to carry out theiractivities, including in the field of ethics,law and human rights, effectively.Guideline 3: States should review andreform public health laws to ensure thatthey adequately address public healthissues raised by HIV/AIDS, that theirprovisions applicable to casuallytransmitted diseases are notinappropriately applied to HIV/AIDS andthat they are consistent with internationalhuman rights obligations.Guideline 4: States should review andreform criminal laws and correctionalsystems to ensure that they are consistentwith international human rightsobligations and are not misused in thecontext of HIV/AIDS or targeted againstvulnerable groups.Guideline 5: States should enact orstrengthen anti-discrimination and otherprotective laws that protect vulnerablegroups, people living with HIV/AIDSand people with disabilities fromdiscrimination in both the public andprivate sectors, ensure privacy andconfidentiality and ethics in researchinvolving human subjects, emphasiseeducation and conciliation, and providefor speedy and effective administrativeand civil remedies.Guideline 6: States should enactlegislation to provide for the regulationof HIV-related goods, services andinformation, so as to ensure widespreadavailability of qualitative preventionmeasures and services, adequate HIVprevention and care information andsafe and effective medication at anaffordable price. States should also takemeasures necessary to ensure for allpersons on a sustained and equal basis,the availability and accessibility ofquality goods, services and informationfor HIV/AIDS prevention, treatment,care and support, including antiretroviraland other safe and effectivemedicines, diagnostics and relatedtechnologies for preventive, curativeand palliative care of HIV/AIDS andrelated opportunistic infections andconditions. States should take suchmeasures at both domestic andinternational levels, with particularattention to vulnerable individuals andpopulations. 11Guideline 6 was revised to this text at the 3 rd International Consultation on HIV/AIDS and HumanRights, Geneva, 25–26 July 2002 (OHCHR/UNAIDS).Regional Human Development Report162 HIV/AIDS and Development in South Asia 2003

Annexure IIIGuideline 7: States should implementand support legal support services thatwill educate people affected by HIV/AIDSabout their rights, provide free legalservices to enforce those rights, developexpertise on HIV-related legal issues andutilise means of protection in addition tothe courts, such as offices of ministries ofjustice, ombudspersons, health complaintunits and human rights commissions.Guideline 8: States, in collaboration withand through the community, shouldpromote a supportive and enablingenvironment for women, children andother vulnerable groups by addressingunderlying prejudices and inequalitiesthrough community dialogue, speciallydesigned social and health services andsupport to community groups.Guideline 9: States should promote thewide and ongoing distribution of creativeeducation, training and mediaprogrammes explicitly designed tochange attitudes of discrimination andstigmatisation associated with HIV/AIDSto understanding and acceptance.Guideline 10: States should ensure thatgovernment and private sectors developcodes of conduct regarding HIV/AIDSissues that translate human rightsprinciples into codes of professionalresponsibility and practice, withaccompanying mechanisms toimplement and enforce these codes.Guideline 11: States should ensuremonitoring and enforcement mechanismsto guarantee the protection of HIVrelatedhuman rights, including those ofpeople living with HIV/AIDS, theirfamilies and communities.Guideline 12: States should cooperatethrough all relevant programmes andagencies of the United Nations system,including UNAIDS, to share knowledgeand experience concerning HIV-relatedhuman rights issues and should ensureeffective mechanisms to protect humanrights in the context of HIV/AIDS atinternational level.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 163

Technical Note - ATechnical Note - AMethodology forcomputation of indices inthe HDRThe Human Development Index(HDI)The HDI is a summary measure of humandevelopment. It measures the averageachievements in a country in three basicdimensions of human development:l A long and healthy life, as measuredby life expectancy at birth.l Knowledge, as measured by the adultliteracy rate (with two-thirds weight)and the combined primary,secondary and tertiary grossenrolment ratio (with one-thirdweight).l A decent standard of living, asmeasured by gross domestic product(GDP) per capita (PPP US$).Before the HDI itself is calculated, anindex needs to be created for each of thesedimensions. To calculate thesedimensions indices—the life expectancy,education and GDP indices—minimumand maximum values (goalposts) arechosen for each underlying indicator.Performance in each dimension isexpressed as a value between 0 and 1 byapplying the general formula:actual value – minimum valueDimension index =maximum value – minimum valueThe HDI is then calculated as a simpleaverage of the dimension indices. Thegoalposts are as under:Goalposts for calculating the HDIIndicator Maximum Minimumvalue valueLife expectancy 85 25at birth (years)Adult literacy 100 0rate (%)Combined gross 100 0enrolmentratio (%)GDP per capita 40,000 100(PPP US$)The Gender-related DevelopmentIndex (GDI)While the HDI measures averageachievement, the GDI adjusts the averageachievement to reflect the inequalitiesbetween men and women in the followingdimensions:l A long and healthy life, as measuredby life expectancy at birth.l Knowledge as measured by the adultliteracy rate and the combinedprimary, secondary and tertiary grossenrolment ratio.l A decent standard of living, asmeasured by estimated earned income(PPP US$).The calculation of the GDI involves threesteps. First, female and male indices ineach dimension are calculated accordingto this general formula:Dimension index =actual value – minimum valuemaximum value – minimum valueRegional Human Development Report164 HIV/AIDS and Development in South Asia 2003

Technical Note - ASecond, the female and male indices ineach dimension are combined in a waythat penalises differences in achievementbetween men and women. The resultingindex, referred to as the equally distributedindex, is calculated according to thisgeneral formula:Equally distributed index = {[female populationshare (female index 1-ε )] + [male populationshare(male index 1-ε )]} 1/1-εε measures the aversion to inequality. Inthe GDI ε = 2. Thus the general equationbecomesEqually distributed index ={[female population share(female index -1 )]+[ male population share (maleindex -1 )]} -1which gives the harmonic mean of thefemale and male indices.Third, the GDI is calculated combining thethree equally distributed indices in anunweighted average.The Gender EmpowermentMeasure (GEM)Focusing on women’s opportunities ratherthan their capabilities, the GEM capturesgender inequality in three key areas:Why ε= 2 in calculating the GDIThe value of ε is the size of the penalty for gender inequality. Thelarger the value, the more heavily a society is penalised for havinginequalities.If ε =0, gender inequality is not penalised (in this case the GDIwould have the same value as the HDI). As ε increases towardsinfinity, more and more weight is given to the lesser achieving group.The value 2 is used in calculating the GDI (as well as the GEM).This value places a moderate penalty on gender inequality inachievement.1 Political participation and decisionmakingpower, as measured bywomen’s and men’s percentage sharesof parliamentary seats.2 Economic participation anddecision—making power, asmeasured by two indicators—women’s and men’s percentage sharesof positions as legislators, seniorofficers and managers and women’sand men’s percentage shares ofprofessional and technical positions.3 Power over economic resources, asmeasured by women’s and men’sestimated earned income (PPP US$).For each of these three dimensions, anequally distributed equivalent percentageGoalposts for calculating the GDIIndicator value Maximum value Minimumemale life expectancy at birth (years) 87.5 27.5Male life expectancy at birth (years) 82.5 22.5Adult literacy rate (%) 100 0Combined gross enrolment ratio (%) 100 0Estimated earned income (PPP US$) 40,000 100Note: The maximum and minimum values (goalposts) for life expectancy are five yearshigher for women to take into account their longer life expectancy.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 165

Technical Note - A(EDEP) is calculated, as a populationweightedaverage, according to thefollowing general formula:EDEP ={[female population share(female index 1-ε )]+[male population share(male index 1-ε )]} 1/1-εε measures the aversion to inequality. Inthe GEM (as in the GDI) ε = 2, which placesa moderate penalty on inequality. Theformula is thus:EDEP ={[female population share (female index -1 )]+ [male population share (male index -1 )]} -1For political and economic participationand decision making, the EDEP is thenindexed by dividing it by 50. The rationalefor this indexation: in an ideal society,with equal empowerment of the sexes, theGEM variables would equal 50 per cent,that is, women’s share would equal men’sshare for each variable.Finally, the GEM is calculated as a simpleaverage of the three indexed EDEPs.Source: UNDP, 2002Regional Human Development Report166 HIV/AIDS and Development in South Asia 2003

Technical Note - BTechnical Note - BAssessing the Impact ofHIV/AIDS on HumanDevelopmentOur approach to assessing the impact ofthe HIV/AIDS epidemic on humandevelopment involves (1) estimating itsimpact on the HDI or GDI in theaggregate; (2) assessing the impact onindividual components of HDI and/orGDI; and (3) using the results from (a) and(b) to assess what the value of HDI wouldbe if there were no HIV/AIDS.One way to estimate the effect of theAIDS epidemic on the HDI (or GDI) andits component variables would be toestimate the correlation across countriesbetween these variables and/orindicators of the HIV/AIDS epidemic –adult HIV prevalence and number ofreported AIDS cases. However, thisprocedure does not adequately controlfor other factors that might legitimatelyaffect life expectancy, literacy, schoolenrolment, and income and mightpossibly also be correlated withindicators of HIV/AIDS. To avoid thispotential bias, we must also account forthese other factors. This can be done in avariety of ways, one of which is simplycontrolling for pre-AIDS epidemic valuesof each component of HDI and GDI. Inother words, we are effectively trying todetermine whether HDI improved lessrapidly from 1980 to 1999 in countriesthat had to contend with more severeHIV/AIDS epidemics, relative to othersthat did not. This was the approachadopted by Bloom et al. (1996) and is theone that we adopt here.Specifically, our goal is to obtain anestimate in the context of the followingmodel:(1) Y it= ß 0+ ß 1Y i0+ ß 2Y i02+ π*AIDS i+ ε i[i = 1, 2, …N]Here, N is the number of countries in thesample and Y itrefers to the value of thedependent variable in country “i” at time“t”. Y i0refers to the value of the dependentvariable in country “i” at some pre-AIDSepidemic base year, labeled “0”. AIDSrefers to an indicator of the severity of theHIV/AIDS epidemic. The dependentvariable could be the value of the humandevelopment index (or the genderdevelopment index), or its components.The error-term ε i(i = 1, 2, …N) is anindependently and identically distributedrandom variable with zero mean andconstant variance. There is, of course, thepossibility of reverse causality if, as oneexpects, improvements in humandevelopment to influence thetransmission of HIV, and we consider thatin our analysis as well.A few points are worth noting about thespecification (1). The first is the nature ofthe relationship between the dependentvariable and its lagged quadraticcounterpart on the right hand side ofequation (1). In the case of at least thehuman development index, the genderdevelopment index, the adult literacyrates and the like that have well definedupper and lower bounds, one wouldexpect the following, all else being thesame: countries with greater initial valuesof the Y variable (Y 0), ought to have highervalues of Y t. However, the closer the initialRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 167

Technical Note - Bvalue is to the upper bound, the smallerthe degree of improvement that ispossible, so that in regimes where suchhuman development indicators areimproving over time, one might expect aconcave relationship between the initialvalue Y 0and Y t. Indeed, given that onemight also reasonably expect lifeexpectancy at birth to have an upperbound, so the concave relationshiphypothesized previously ought to hold forlife expectancy as well. Although it is lessapparent that same concave relationshipought to hold for the real GDP per capitacomponent, the well-known Solow-Swan growth model suggests that it must. 1In sum, one would prefer(a) ß 2< 0; and (b) ß 1> -2ß 2. Second, thenon-negativity of the sum of thedependent variables that are bound byunity suggests the desirable property that(c) 1 ≥“ß 0+ ß 1+ ß 2≥ 0. Ideally, one wouldlike to undertake the estimation proceduretaking account of these constraints on theparameters, but this was renderedunnecessary owing to the estimatedunconstrained coefficients satisfyingthem anyway.ResultsThe results of estimating differentversions of our specifications arehighlighted in Tables T2 to T5 and can besummarised as follows. First, HIV appearsto have a statistically significantassociation with progress in humandevelopment as indicated by the HDI (seeTables T2a – b). This result holds true bothin the case of HIV prevalence rates andincrease in the number of AIDS cases. Thisis the case whether one uses HIVprevalence rates (among those aged15–64 years in 1998), or indicators of theeffect of the AIDS epidemic, such as theaverage annual increase in the cumulativenumber of AIDS cases over the 1980-1998period, normalised by the populationaged 15–64 years in 1998. Although AIDSis more likely to be relevant in terms ofinfluencing life expectancy at birth asmeasured by the United Nationspopulation division, in practice, the useof either of the indicators—HIVprevalence or AIDS—does not seem toinfluence the results significantly. This isnot surprising, since the correlationcoefficient between the two is 0.87. 2Despite the much larger sample ofcountries, our OLS results are similar tothe findings of Bloom et al. (1996) that theHIV/AIDS epidemic has a statisticallysignificant negative association with theHDI. Our estimated coefficient of theAIDS variable is, however, much larger inabsolute magnitude (nearly five times theestimate of Bloom et al. (1996),presumably reflecting the fact that theeffect of a much larger AIDS epidemic,relative to the 1980–92 period (the focusof their study) is now beginning to be felton human development.The negative influence of the AIDSepidemic on human developmentbecomes even more apparent when oneallows for the possibility of reversecausality – that is, on the impact fromHDI to the spread of HIV. Table T2breports the results of estimates based onan instrumental variable (IV) approach.According to column (5) of the IVestimates reported in Table T2b, a 1 percent increase in the average annual rateof growth of cumulative AIDS prevalenceover the 1980–98 period has the potentialof reducing HDI by 0.17. This is apreferred estimate. For the full sampleof countries for which AIDS data wereavailable, we find that on average, thespread of the HIV/AIDS epidemicduring 1980-98 reduced HDI in 1999 byabout four per cent, relative to what itRegional Human Development Report168 HIV/AIDS and Development in South Asia 2003

Technical Note - Bwould have otherwise been – 0.715, asagainst 0.686.HIV and the GenderDevelopment IndicatorsThis sub-section assesses the influence ofHIV/AIDS on key gender dimensions ofhuman development. The indicatorsused are the GDI and two of its keycomponents – the ratio of female to malelife expectancy at birth, and the ratio offemale to male educational achievements(literacy rates, mean years of schooling inthe 15+ population, and female to maleratios of primary and secondaryenrolment rates).HIV and the GDIThe GDI is the un-weighted average ofthree “inequality” indices correspondingto each of its three components.Specifically, each component index, Xi(i = 1,2,3) is calculated to be the followingformula(2) X i= [θ X if1 -α + (1-θ) X im1 -α ] 1/1-α (i= 1,2,3)Here, X ifis the index of femaleachievements in component “i”, and X imis the index of male achievements incomponent “i” and θ is the female sharein total population. The parameter “α”indicates the preferred degree ofinequality aversion. In GDI calculations,it is taken to be equal to 2 (UNDP 2001).The GDI combines the relativeachievements of females and males inearned income, education and lifeexpectancy at birth, in such a way as topenalise gender-related inequalities in‘either’ direction. The GDI is the unweightedaverage of three ‘inequality’indices corresponding to each of its threecomponents. 3 The main results aresummarised in Tables T7–T9, whichpresent OLS estimates.The key dependent variable in theempirical analysis of this section isnational-level HIV prevalence estimatesin 1999 provided by UNAIDS. In terms ofexplanatory variables, we have previouslydiscussed the potential role of differentindicators of human development ininfluencing HIV transmission, such asincome, education, health, inequality,and civil liberties. Indicators ofinequality used in this paper include theratio of female to male literacy andfemale to male life expectancy at birth.In estimating some of the specificationswe also used an indicator for politicalrights and civil liberties developed byFreedom House (2002).Analysis also emphasises the role ofmigrant populations as a key factor in HIVtransmission. However, other factors alsomatter. One of them is the time elapsedsince the start of the epidemic.Results and DiscussionTable T10 provides descriptive statisticson the variables used in the analysis of thissection, and lists the countries for whichthe full set of such data were available. Thedata indicate that there is substantialvariation in the variables of interest acrossthe sample countries, with two keyexceptions – the ratio of female to malelife expectancy at birth and the ratio offemales to males in the age group 15-49years. Particularly noteworthy is that theestimated length of the epidemic variedfrom eight years in some countries to 21.5years in others. 4 This suggests that a‘steady state’ HIV prevalence will not be auseful assumption for estimationpurposes, a hunch that is confirmed bythe econometric results that are discussedfurther below. The data indicate aRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 169

Technical Note - Bsubstantial degree of gender inequality ineducational achievement as measured byratio of the female to male adult literacyrates in 1980. The gender inequality inliteracy rates was highly correlated with thehuman development achievement of acountry in 1980 – with a correlationcoefficient of 0.91. Gender inequality inliteracy was correlated to a somewhat lesserdegree with economic achievement, witha correlation coefficient of 0.79.The difference between the rate of growthof the urban population and the totalpopulation of a country during the periodfrom 1980 to 1990 was used as a roughproxy for the rate of growth of migrantpopulations from rural to urban areas overthe decade. The rate varied significantlybetween countries, with a mean annualaverage of growth of about 1.28 per centfor the full sample of 73 countries, a low of–0.14 per cent for Sri Lanka and a high of7.08 per cent for Mozambique.Sectoral costs of HIVAdditional estimates of the effects ofHIV/AIDS on health spending patterns isavailable from a study by Arndt and Lewis(2000) who used a 14-sector CGE modelto assess the economic impact of HIV inSouth Africa. In their framework, andunlike previous work, the health sectorwas explicitly accounted for along withassumptions on household andgovernment spending on health due toHIV/AIDS. Their paper suggests that thehealth sector in South Africa would notsuffer as much as the other sectors onaccount of HIV/AIDS over the 2001-2010period. They estimate the GDP in 2010under projected AIDS scenarios beingnearly 6.5 per cent higher than it wouldbe if the health sector was excluded fromthe GDP computations. 5 In fact,compared to the no-AIDS scenario, theoverall GDP under AIDS would be nearly17 per cent lower in 2010, whereas thecorresponding figure for value added inthe health sector would be 10 per cent asper their simulation results. 6Cost to NationsEarly work on the impact of HIV/AIDS ongrowth of real income (or real income percapita) inferred, rather than directlydemonstrated, the aggregate economicimpact of HIV/AIDS from thecombination of large projected numbersof prime-age HIV-positive individualsand the relatively high costs of treatingaffected people.More recent work on the aggregateeconomic impact of AIDS has essentiallytaken a more rigorous methodologicalroute and falls into mainly two groups.The first group derives its conclusionsfrom well-established economic models,customised in various ways to account forkey aspects of the AIDS epidemic. Itincludes analyses that use CGE models,as well as those using a neoclassical growthmodel. Kambou, Devarajan and Over(1992) simulated the economic impact ofthe AIDS epidemic using an 11-sectorCGE model of Cameroon. In theiranalysis, they assumed that the AIDSepidemic would claim the life of 30,000workers (or 0.8 per cent of the labour force)each year from 1987 to 1990, with deathsoccurring disproportionately among themore skilled segments of the work force.Thus, 6.0 per cent of the skilled urban workforce was assumed to die of AIDS eachyear, compared to 0.4 per cent of theunskilled rural labour force. In theirsimulations, the AIDS epidemic loweredthe rate of growth of real GDP by nearlytwo percentage points per year. Theirmodel did not suggest any significantchange in the growth of real incomeper capita.Arndt and Lewis’ model was intended tobe more comprehensive than that ofRegional Human Development Report170 HIV/AIDS and Development in South Asia 2003

Technical Note - BKambou, Devarajan and Over. It includedthe health sector, allowed for impacts onsavings on account of medicalexpenditures undertaken by thegovernment and households, labour forceimpacts, household and governmentallocations to health sector spending andexogenously given assumptions on trendsin sector productivity. Moreover, in theirmodel, the impact of the AIDS epidemicwas assumed to fall disproportionately onlow-skill segments of the labour force, inline with available evidence from SouthAfrica. 7 Dynamic elements wereincorporated by using outputs from theone-period CGE model as inputs into theCGE framework for subsequent years. Themain conclusion was that over the2000-2010 period, the annual rate ofgrowth of real GDP in South Africa undertheir projected AIDS-scenario would besubstantially lower in comparison to ano-AIDS scenario, with the differenceranging from 1 percentage point to2.6 percentage points, depending on theyear. The net effect would be a real GDPin 2010 that would be 17 per cent lower insize, compared to a no-AIDS case. Theyfound that per capita real GDP would alsosuffer on account of HIV/AIDS althoughnot as much as real GDP, being about8 per cent lower in 2010 compared to ano-AIDS scenario.In contrast to the studies above that relyon simulations conducted under variousassumptions of HIV/AIDS, an alternativeapproach is to econometrically estimatethe link between HIV/AIDS and nationaleconomic performance. Bloom andMahal (1997) used standard empiricalequations of the form found in Barro(1991) and Mankiw, Romer and Weil (1992)to measure the nature and strength ofstatistical associations between theprevalence of AIDS and the rate of growthof real GDP per capita, using crosscountrydata for 51 countries. The mainrationale for using an empirical approachis its potential use in taking account ofstandard influences of AIDS, as reflectedin simulation models of the typediscussed above, as well as others (suchas community responses to AIDS, lifecycle savings behavior by individuals andthe like) not readily captured by the latter.Indeed, one obvious benefit is in avoidingthe pitfalls of simulation models that relyon assumptions that often lack anempirical justification. The econometricapproach adopted by Bloom and Mahaltook into account the possibility ofsimultaneity bias resulting from the effectof economic growth on HIV transmission,as well as the possible non-linear natureof the relationship between HIVprevalence and economic growth. Theirmain finding was that the AIDS epidemichad a statistically insignificant effect onthe growth of real income per capita, withno evidence of reverse causality during theperiod 1980 to 1992.There are factors that can potentiallyconfound the results found in Bloom andMahal’s analysis. The first is the possibilitythat their study was undertaken at a timewhen HIV-prevalence rates were still toolow to have a detectable economic effectat the national level. 8 To be sure, Bloomand Mahal (1997) also presented resultsfor the impact of HIV/AIDS over theperiod 1987–92, when HIV might havebeen expected to have a greater effect oneconomies, relative to earlier years, butthe prevalence rates at the time wereobviously much lower than at present.Bonnel (2000) examined the associationbetween rate of growth of real income percapita during the period 1990–97 and aquadratic term in HIV prevalence (aftercontrolling for factors that couldpotentially confound the relationship)and found it to be negative andstatistically significant. He also concludedthat the HIV/AIDS epidemic depressedRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 171

Technical Note - Bthe rate of growth of real income per capitain Africa during the period 1990–97 bynearly 0.7 percentage points per year, atruly remarkable decline.McDonald and Roberts (2001) sought toaddress some of the above concerns, byusing panel data methods to estimate theimpact of HIV/AIDS, and using amodified version of the Mankiw, Romerand Weil (1992) empirical elaboration ofthe neoclassical growth model. Theirmain modeling contribution was inlinking HIV/AIDS to economic growth viaits impact on life expectancy, the latterserving as an indicator of health capital inan empirical equation of the link betweengrowth of real income per capita and itsdeterminants. They report the finding ofa statistically significant effect of theHIV/AIDS epidemic on life expectancyand, via life expectancy, on growth of realincome per capita. Their empiricalapproach of emphasising the role ofHIV/AIDS in influencing per capitaincome via life expectancy serves tohighlight the role of one major pathwaythrough which the AIDS epidemic willhave an effect on national economicperformance. Recent empirical work byBhargava et al. (2001) and Bloom,Canning and Sevilla (2001) using paneldata techniques also highlights the linkbetween life expectancy and economicgrowth, and could potentially be modifiedto serve as a means to understand the linksbetween HIV and economic growth.This note studies the link betweenHIV/AIDS and the growth of real GDP percapita. This is a useful exercise for threereasons. First, compared to the situationa decade ago, data is available for a muchgreater set of countries, a fact highlightedin the work of Bonnel (2000) andMcDonald and Roberts (2001). At thetime of Bloom and Mahal’s work, data foronly about 51 countries were available.Now, however, UNAIDS providesestimates of HIV prevalence in more than200 countries. Second, the quality of datahas improved compared to a decade ago.In particular, sentinel surveillance datafor women visiting antenatal clinics inmany countries offers a glimpse into HIVprevalencerates in a group reasonablyrepresentative of trends in the generalpopulation. 9A third factor has to do with the use of AIDScase estimates, instead of HIV, in ouranalysis. Use of AIDS data is desirable,because many of the adverseconsequences of the HIV/AIDS epidemicfor aggregate economic performance havedirectly to do with effects on the labourforce via premature death or morbidity,treatment costs and the fact that many ofthe individual responses to HIV are likelyto kick in at the AIDS stage when they aremore likely to be aware of their HIV status.Most developing countries have poorrecord-keeping systems, so, in alllikelihood, recorded AIDS cases will bebiased downwards. Thus model-basedapproaches to estimating AIDS cases havebeen used for developing countries.Data and Methodology forChapter 2The data used in the analysis wereobtained from several sources.Information about the HDI, its genderadjustedcounterpart, the GDI, lifeexpectancy at birth, literacy rates amongpeople aged 15 years and above,enrolment rates and real per capita GDPwas obtained from the HumanDevelopment Report 2001 10 and the WorldBank’s World Development IndicatorsDatabase. 11 In addition, we have utiliseddata on average years of schooling forpeople aged 15 years and above describedin Barro and Lee (2000), the degree ofopenness of an economy as measured byRegional Human Development Report172 HIV/AIDS and Development in South Asia 2003

Technical Note - Bthe ratio of exports and imports to GDPin World Bank (2001), population growthrates (World Bank 2001), proportion of thatpopulation that is Muslim and/or Judeo-Christian (Central Intelligence Agency(CIA) 2001), date of the first reported HIVand AIDS cases (United States Bureau ofthe Census 2001; Mann, Tarantola andNetter 1992), indicators of political freedom(Freedom House 2002) and urbanpopulation growth (World Bank 2001).Estimates of HIV prevalence for 1999 wereobtained from the UNAIDS countryepidemiological fact sheets. 12 These HIVprevalence estimates were obtained bycareful examination of sentinelsurveillance data sources among womenvisiting antenatal clinics in manycountries and other sources of HIV data,coupled with an extensive process ofdouble-checking and verifying estimatesof HIV so obtained. As a consequence,the full sample (as indicated in Table T10)had HIV prevalence data for 112countries, nearly double the number ofcountries for which HIV estimates wereavailable in 1996. 13Estimates of cumulative AIDS cases wereobtained as follows. For developingcountries, multi-year and multi-site HIVprevalenceinformation for womenvisiting antenatal clinics in sentinelsurveillance data was used. The numberof countries for which such data wasavailable was somewhat less than thecountries for which UNAIDS HIVprevalencedata were available, given thatthe analyses were restricted only tocountries for which several years (andseveral sites) of sentinel surveillance HIVprevalencedata were available for womenvisiting antenatal clinics. This was donein two steps, with the help of a set ofsoftware packages recently developed byUNAIDS. 14 First, data points obtainedfrom HIV sentinel surveillance were usedto fit a curve for the time profile for HIVprevalence with the Epidemic ProjectionPackage (EPP) developed by UNAIDS. 15Having obtained the times series of HIVprevalence rates, the second part of themethod involved using the SPECTRUMsoftware package that combinedpopulation estimates and projectionswith HIV prevalence rates to arrive atestimates of the incidence of AIDS casesand deaths, after taking into account theprogression rate from HIV to AIDS todeath. 16 The model also provides separateestimates of AIDS cases and deaths formales and females, if additional inputregarding the nature of the epidemic –primarily heterosexual, homo- or bisexual,or injecting drug use driven – isprovided. The computation assumed themedian time from infection to death ofabout nine years in developing countries,and involves the assumption of no ARVdrug use. 17 This assumption appearsreasonably valid for the developing world,most of which is not in a position to affordARVs, but not for developed countries.For the latter set of countries, we useddirectly the estimates of AIDS casesprovided by their governments, given thatthe reporting errors for AIDS cases in thedeveloped world can be expected to besmall, and nowhere near as large as thedeveloping countries, a group thatincludes the countries of South Asia, withpoor AIDS reporting systems. For thelatter group, indirect estimation via EPPand SPECTRUM, along the linesindicated above, was obviously moredesirable. In sum we were able to obtainAIDS incidence and cumulative AIDScase data for a total of 76 developing anddeveloped countries.Table T10 summarises, for the samplecountries, the main descriptive statisticsrelevant to our analysis of the potentialimpact of HIV on human development.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 173

Technical Note - BThe full list of countries is provided in thenotes to Table T10. The data indicate thesubstantial variation in HIV prevalenceamong adults, from negligible levels insome countries, to a high prevalence ofnearly 34 per cent in Botswana. The meanHIV prevalence in the full cross-sectionof countries, in contrast to Botswana’scase, is three per cent. As anotherexample of the variation in the spread ofthe HIV/AIDS epidemic across countries,the average annual increase in AIDS cases(taken as a proportion of per 100population aged 15–64 years in 1998)during the period from 1980 to 1998 wasabout 0.18 for the full sample, but rangedfrom 0 in some, to 1.93 in Botswana. Oursample of countries includes those withextremely low levels of humandevelopment in 1999—0.258 for SierraLeone –as also countries such as Norway,with an HDI of 0.939 in 1999. Similarvariation is apparent from data oneducation variables such as adult literacy,mean years of schooling and schoolingenrolment, life expectancy at birth andreal GDP per capita.a) The econometric model forHD Impact on HIV transmissionThe starting point of our discussion is thefollowing simple equation that can beused to describe the dynamics of HIVtransmission in an adult population,whose HIV prevalence rate is denotedby H. 18(3) dH/dt = (1 – H)*H p*ß *T - θ*HHere dH/dt is the derivative of H withrespect to time “t” and equation (3)describes the movement of HIVprevalence over time. H pis the infectionrate among the “sexual” partners of theabove population, ß is the proportion ofunprotected sexual interactions in anygiven interval and T is the rate oftransmission of HIV during unprotectedsex. θ denotes the proportion exiting fromthe infected pool in any time period.The HIV prevalence rate among partners,the proportion of people in thepopulation of interest who haveunprotected sex and the rate oftransmission of HIV will depend on anumber of variables, such as the level ofknowledge people possess about risk ofinfection, income levels and hence theopportunity cost of infection, concernsabout health (including one’s owninfection status, especially if there isassortative matching), opportunity,inequalities that allow some people to payoff others to incur increased risk as well asindicative of poverty, cultural norms thatgovern the practice of unprotected sexand the like. Specifically, let us assumethat the impact of these other forces is feltin such a way that(4) H p*ß *T = (α + π*x)*ρ*HHere x indicates all variables other thanan average individual’s HIV-status, H.H is taken to enter multiplicatively in thisformulation. Thus, we can write(5) dH/dt =(1 - H) * (α + π*x) *ρ*H - θ*Hand(6) dH/dt = (α*ρ + ρ*π*x - θ)*H -(α + π*x)*ρ*H 2This formulation, under differentassumptions, leads to three relatedeconometric specifications, as isdemonstrated below. The differentialequation in (6) has a readily obtainablesolution given by,(7) Z(t) = exp(-k*t) * z(0) + (m/k)*(1 - exp(-k*t))Regional Human Development Report174 HIV/AIDS and Development in South Asia 2003

Technical Note - BWherek = (α∗ρ + ρ∗π∗x − θ)m = (α + π*x)*ρz(t) = 1/H(t)As k→∞, Z(t) tends to the steady state“m/k”. We can also see that(8) Z(t) - (m/k) =[Z(0) - (m/k)]* exp(-k*t)Case I: In the special case whereθ = 0 (implying that m/k = 1), we havefrom (8), after taking logs on both sidesand substituting for z = (1/H)(9) ln(H/(1-H)) =ln (H(0)/(1-H(0))) + k*tor,(9’) ln(H/(1-H)) =ln (H(0)/(1-H(0))) + α∗ρ∗t + ρ∗π∗τ*xAssuming all countries start from roughlya similar sized epidemic (roughly 1 percent of some segment of the population),we can set forth the first version of oureconometric formulation as(10) ln(H/(1-H)) = δ + β*t + λ*t*x + εHere, δ, β and λ are parameters (orvectors of parameters) to be estimatedand ε is an “error” term with the usualproperties.Notice that the assumption of θ = 0 is astringent one, because it is effectivelyruling out a faster rate of exits, relative tothe rest of the population, from theinfected population in the model.Moreover, the assumption implies thatthe population heads to a steady stateHIV-prevalence level of unity, but with theproviso that the rate at which it get theredepends on the parameters and thex variables characteristic of each group.Case II: An alternative formulation is oneis where θ ≠ 0. If so, we can write fromabove(8’) Z(t) = exp(-k*t) * z(0) + (m/k)*(1- exp(-k*t))If we work with the assumption that weare still early in the epidemic, using alinear approximation around t=0 we canwrite(11) Z(t) ≈ Z(0)(1 – k*t) + m*tFrom this we have,(12) Z(t) ≈ Z(0) + (m – Z(0)*k)*tThe resulting econometric specificationis:(12’) 1/H(t) =Z(0) + ϕ + χ*t + µ*t*x + νWhere ν is an error term and (Z(0)+ ϕ) isconstant. Given that (12’) is the outcomeof a linear approximation, the estimationexercise also considered anotherspecification that allowed for the naturallog transform of (1/H) as the dependentvariable of interest.Case III: At the other extreme, one canfocus on the steady state outcomes forpurposes of estimation if one believes thatthe country HIV/AIDS epidemics are farenough advanced. In particular, goingback to(4) dH/dt =(α∗ρ + ρ∗π*x - θ)*H - (α + π*x)*ρ*H 2Putting dH/dt = 0, we have that in thesteady stateRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 175

Technical Note - B(13) H =(α∗ρ + ρ∗π∗x - θ)/[(α + π*x)*ρ]and(13’) (1 - H) = θ/[(α + π*x)*ρ]This gives rise to the followingeconometric specification(14) H*(1 – H) -1 = δ + λ*x + εThe statistical analysis of this paper onthe determinants of HIV prevalenceinvolves primarily the estimation of (9’),(12’) and its logarithmic counterpart, and(14). However, as discussed below thepaper also presents the results ofspecifications of the form in (15) below tocompare the results using national levelHIV prevalence data with those obtainedby Over (1998) who used this specificationto analyse urban HIV prevalence rates indeveloping countries.(15) ln (H*(1 – H) -1 ) = δ + λ*x + η*t + εb) Methodology of estimatingthe impact of HIVThe standard approach has been to usedata on HIV prevalence (taken to berepresentative of the whole population),combine it with a description of the rateat which HIV cases progress to AIDS andto death (normally approximated by aWeibull distribution, Bloom and Mahal,1997), along with a further assumptionabout the start date of the epidemic.Unfortunately, an infinite number of timeprofiles of HIV prevalence that canachieve the HIV prevalence at a point intime exist, even with these requirements.Thus the typical approach to derive thetime profile of HIV/AIDS cases has beento make an assumption that HIVincidence follows a gamma function ofone (or, two) parameter variety, add tothat a further statement about the peakyear of incidence, and then to choose thevalue of the gamma distributionparameter itself. 19 Bloom and Mahal(1997) introduced the methodologicalinnovation in a maximum likelihoodframework whereby the gammadistribution parameter was chosensimultaneously as part of the econometricspecification linking AIDS to economicgrowth. However, owing to data fromsentinel surveillance sites being availablefor several recent years and developingcountries, it is possible to directly derivethe time profile of HIV incidence usingcurve-fitting techniques and softwareprovided by UNAIDS for these countries.The methodology is more fully discussedin UNAIDS (2002b).For the purpose of examining the impactof AIDS on economic growth, were-estimated two empirical equations —(1) modified version of the empiricalspecification used in Bloom and Mahal(1997) with new data, for the period 1980to 1998, for 69 countries; and (2) a modifiedversion of the equation used by Bloom andWilliamson (1998). The set of countrieschosen was smaller than the countries forwhich UNAIDS provides HIV prevalencedata, in order to include only thosedeveloping countries for which a largenumber of sentinel surveillance data wereavailable for some years, for reasonablysized samples. The sample of countriesalso included developed nations fromEurope and North America, as well asAustralia, Japan and New Zealand, wherereported AIDS cases can be expected tobe a reasonably accurate indicator of thetrue AIDS cases. These were combinedwith data on range of geographicdemographic and socio-economicvariables as additional explanatoryfactors — real GDP per capita in 1980,government expenditures on educationand defence as a proportion of GDP, meanyears of schooling, the ratio of exports andRegional Human Development Report176 HIV/AIDS and Development in South Asia 2003

Technical Note - Bimports to GDP, rate of growth ofpopulation, the rate of growth of workingage population (15–64 years), whether thecountry was landlocked, quality ofinstitutions, whether located in tropicalregions, life expectancy at birth in 1980and the rate of growth of lagged per capitaincome. The sources of this data includedthe World Development Indicatorsdatabase, 20 the Penn World Tables, 21 Barro-Lee database on education indicators,Human Development Reports for variousyears, and Gallup and Sachs (2000).Our empirical approach was to estimatethe following equation, the same asequation (1) in Bloom and Mahal (1997,p.112), and equation (5) in Bloom andWilliamson (1998, p.431) after including aterm for AIDS.(16) Y i= α + βAIDS i+ X iπ + ε i(i=1,2, ..., N).Here Y iis the rate of growth of real incomeper capita, AIDS iis the average annualincrease in the cumulative adultprevalence of AIDS (the average annualincrease in the number of AIDS cases overthe estimation period, taken as aproportion of the population aged 15–64years in 1998), X iis a vector of variablesthat influence economic growth and ε iareindependently and identically distributederror terms, each with zero mean; α, βand π are parameters to be estimated. Amajor goal of our analysis is to obtain aconsistent estimate of the coefficient ofthe AIDS variable, β.The results of estimation of equation (1)by ordinary least squares, given the findingboth in Bloom and Mahal (1997) andBonnel (2000) of there being no statisticalevidence of a reverse causality going fromgrowth of real income per capita toHIV/AIDS. Estimation of equation (1) byinstrumental variable methods (resultsnot reported here) confirmed these earlierfindings. The estimation method does notrely on panel data methods and thus isopen to the methodological objectionsnoted previously. This is proposed to berectified in future work, as more HIVprevalence data becomes available. Theresults as reported here are also open tothe objection that they may becontaminated by the effects of classicalmeasurement error in the AIDS variable,which can influence the coefficient tobecoming statistically insignificant. Thisis more readily addressed by the use of IVmethods. However, as noted previously,the use of IV methods does not influencethe main results of this paper. Anotheraspect of the estimation method (for bothBloom and Williamson and Bloom andMahal specifications) is that thepopulation growth rate variable has beenadjusted to compensate for any AIDSdeaths that may have occurred. Doing soraises the “adjusted” rate of populationgrowth over that actually observed. Thisadjustment permits the coefficient of theAIDS variable to be interpreted as the sumof the direct effect of AIDS on growth ofreal income per capita, plus any indirecteffect on growth of real income per capita,working via the impact of AIDS onpopulation growth.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 177

Technical Note - BTable T1Human development trends in South Asia, by countryCountryAnnual rate Annual rate Annual rate Annual rate Annual rateof growth of growth of growth of growth of growthHDI (%) GDP per Life Adult literacyreedom House1990-99 capita (%) expectancy rate(%) Index (%)1990–99 1980–99 1980–99 1980–2000Afghanistan N.A. N.A. 0.71 N.A. 0.00Bangladesh 1.42 2.99 1.19 1.76 0.77Bhutan N.A. 3.16 N.A. N.A. 1.32India 1.26 3.73 0.79 1.70 0.00Iran 1.14 2.31 0.89 2.16 0.92Maldives N.A. N.A. 1.00 0.34 0.48Nepal 1.63 2.27 1.02 3.04 -2.23Pakistan 1.36 1.41 0.67 2.51 -0.43Sri Lanka 0.62 3.84 0.39 0.37 1.70Note: N.A. indicates not availableSource: Author’s calculations using World Bank, 2000 data.Table T2(a)HIV/AIDS and the Human Development Index, 1980-99, Ordinary Least SquaresRegressors Human Development Index 1999(1) (2) (3) (4) (5)Constant 0.04(0.04) 0.02(0.05) 0.06(0.03) -0.004(0.036) 0.02(0.04)HDI80 1.17(0.15) 1.20(0.20) 1.22(0.11) 1.41(0.13) 1.35(0.14)HDI80*HDI80 -0.17(0.12) -0.17(0.16) -0.25(0.09) -0.39(0.11) -0.34(0.11)HIV prevalence 1998(per 100 population -0.0043 -0.0045aged 15–64 in 1998) (0.0016) (0.0016)Average annualincrease incumulative AIDS -0.10cases 1980-98 (0.02)(per 100 populationaged 15–64 in 1998)Number ofobservations 93 67 93 67 67R-squared 0.957 0.966 0.974 0.983 0.984Source: Author’s calculations. Heteroskedasticity-corrected standard errors reported in parentheses.Regional Human Development Report178 HIV/AIDS and Development in South Asia 2003

Technical Note - BTable T2(b)HIV/AIDS and the Human Development Index, 1980–99, IV estimatesRegressors Human Development Index 1999(1) (2) (3) (4) (5)Constant 0.04(0.04) 0.02(0.05) 0.06(0.03) -0.01(0.04) 0.02(0.05)HDI80 1.17(0.15) 1.20(0.20) 1.25(0.11) 1.51(0.13) 1.46(0.17)HDI80*HDI80 -0.17(0.12) -0.17(0.16) -0.29(0.09) -0.50(0.11) -0.46(0.13)HIV prevalence 1998(per 100 population -0.0061 -0.0065aged 15–64 in 1998) (0.0012) (0.0011)Average annualincrease in cumulativeAIDS cases 1980-98 -0.17(per 100 population (0.03)aged 15–64 in 1998)Number ofobservations 93 67 93 67 67HausmanTeststatisticChi-sq(3) 16.16 20.81 33.76R-squared 0.957 0.966 0.970 0.979 0.975Note: Robust standard errors reported in parentheses. Specifications (3)-(5) are estimated using instrumentalvariables for the HIV/AIDS variables.Instruments: HDI80, HDI80-squared, Year of the start of the AIDS epidemic, proportion of population that isMuslim, the degree of openness of an economy (ratio of the sum of imports and exports to GDP in 1980), themean years of schooling in population aged 15 years and above (1980), the ratio of life-expectancy of femalesto that of males, and the rate of growth of population during 1970-80.Table T3(a)HIV/AIDS and life expectancy at birth, 1980–98, OLS estimatesRegressors Life Expectancy at Birth, 1998(1) (2) (3) (4) (5)Constant -30.48 -12.94 -26.17 -23.85 -21.85(12.06) (15.90) (8.00) (9.32) (9.79)Life expectancy, 1980 (years) 2.24 1.54 2.30 2.15 2.07(0.42) (0.56) (0.26) (0.32) (0.32)Life expectancy, 1980 Squared -0.011 -0.004 -0.012 -0.010 -0.010(0.004) (0.005) (0.002) (0.003) (0.003)HIV prevalence 1998 (per 100 -0.58 -0.54population aged 15–64 in 1998) (0.08) (0.09)Average annual increase incumulative AIDS cases 1980-98 -11.40per 100 population aged 15-64 (3.25)in 1998)Number of observations 112 76 112 76 76R-squared 0.874 0.891 0.936 0.943 0.947Source: Author’s calculations. Heteroskedasticity-corrected standard errors reported in parentheses.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 179

Technical Note - BTable T3(b)HIV/AIDS and life expectancy at birth, 1980–98, IV estimatesRegressors Life Expectancy at Birth, 1998(1) (2) (3) (4) (5)Constant -30.48 -12.94 -31.21 -32.44 -29.65(12.06) (15.90) (8.62) (9.53) (12.35)Life expectancy, 1980 (years) 2.24 1.54 2.53 2.54 2.49(0.42) (0.56) (0.28) (0.31) (0.41)Life expectancy, 1980 Squared -0.011 -0.004 -0.014 -0.014 -0.014(0.004) (0.005) (0.002) (0.003) (0.003)HIV prevalence 1998 (per 100 -0.78 -0.75population aged 15–64 in 1998) (0.15) (0.14)Average annual increase incumulative AIDS cases 1980-98 18.61(per 100 population aged 15-64 -(2.98)in 1998)Number of observations 112 76 105 73 73Hausman Test-Statistic 5.11 0.80 57.29R-squared 0.874 0.891 0.928 0.935 0.923Source: Author’s calculations. Heteroskedasticity-corrected standard errors reported in parentheses.Specifications (3)-(5) are estimated using instrumental variables for the HIV/AIDS variables.Instruments: HDI80, HDI80-squared, Year of the start of the AIDS epidemic, proportion of population thatis Muslim, the degree of openness of an economy (ratio of the sum of imports and exports to GDP in1980), the mean years of schooling in population aged 15 years and above (1980), the ratio of lifeexpectancyof females to that of males, and the rate of growth of population during 1970-80.Table T4HIV/AIDS and the adult literacy rate, 1980–98, OLS estimatesRegressors Adult Literacy Rate, 1998(1) (2) (3) (4) (5)Constant 10.35 10.40 10.65 11.14 10.97(3.07) (3.62) (3.10) (3.63) (3.64)Adult literacy rate, 19801.44 1.42 1.39 1.34 1.36(0.11) (0.13) (0.11) (0.13) (0.13)Adult literacy rate squared, -0.006 -0.005) -0.005 -0.005 -0.0051980 (0.001) (0.001 (0.001) (0.001) (0.001)HIV prevalence 1998 (per 100 0.09 0.12population aged 15–64 in 1998) (0.06) (0.06)Average annual increase incumulative AIDS cases 1980–98 2.23(per 100 population aged 15–64 (1.05)in 1998)Number of observations 112 75 112 75 75R-squared 0.965 0.965 0.966 0.966 0.965Source: Author’s calculations. Heteroskedasticity-corrected standard errors reported in parentheses.IV Specification found to be statistically indistinguishable from OLS specification using a Hausman test.Regional Human Development Report180 HIV/AIDS and Development in South Asia 2003

Technical Note - BTable T5HIV/AIDS and per capita real GDP, 1980–98, OLS estimatesRegressors Real GDP per capita, 1998(1) (2) (3) (4) (5)Constant -444.37 -274.09 -429.06 -105.00 -135.42(150.97) (133.16) (183.85) (209.52) (180.53)Real GDP per capita 19801.64 1.71 1.64 1.701.70(1995 US$) (0.13) (0.11) (0.13) (0.11) (0.11)Real GDP per capita 1980 -0.00001 -0.00001 -0.00001 -0.00001 -0.00001squared (1995 US$) (0.00000) (0.00000) (0.00000) (0.00000) (0.00000)HIV Prevalence 1998(per 100 population aged -3.20 -26.5215–64 in 1998) (21.66) (27.96)Average annual increasein cumulative AIDS cases1980–98 -470.02(per 100 population aged (370.98)15–64 in 1998)Number of observations 102 74 102 74 74R-squared 0.950 0.960 0.950 0.960 0.960Source: Author’s calculations. Heteroskedasticity-corrected standard errors reported in parenthesesTable T6Descriptive statistics (HIV/AIDS and inequality indices)Variable N Mean Standard Minimum MaximumDeviationHIV prevalence, 1999 112 2.977 5.755 0.003 33.831(per 100 adults 15–64)Annual average increase in cumulativeAIDS (per 100 adults, 15–64 years) 76 0.180 0.319 0 1.934Gender Development Index, 1999 108 0.681 0.194 0.260 0.937Inequality IndexLiteracy rate in population 15+, 1998 110 0.778 0.232 0.110 1.000Inequality IndexLife expectancy at birth, 1998 115 0.678 0.198 0.204 0.926Note: N refers to the number of countries in the sample.Source: World Bank, 2000; UNDP, 2000Countries: West Asia and Africa: Algeria, Benin, Botswana, Burkina aso, Burundi, Cameroon, CentralAfrican Republic, Chad, Cote d’Ivoire, Cyprus, Djibouti, Egypt, Ethiopia, Gabon, The Gambia, Ghana, IsraelJordan, Kenya, Libya, Madagascar, Malawi, Mali, Morocco, Mauritius, Mozambique, Namibia, Niger,Nigeria, Rwanda, Saudi Arabia, Senegal, Sierra Leone, South Africa, Swaziland, Syria, Tanzania, Tunisia,Uganda, Zaire, Zambia, Zimbabwe. Asia: Bangladesh, Cambodia, China, Hong Kong, India, Indonesia,Iran, Japan, Republic of Korea, Malaysia, Maldives, Myanmar, Nepal, Pakistan, Philippines, Singapore, SriLanka, Thailand, Vietnam. Latin America and Caribbean: Argentina, The Bahamas, Barbados, Bolivia,Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti,Honduras, Jamaica, Nicaragua, Panama, Paraguay, Peru, Trinidad and Tobago, Uruguay, Venezuela. NorthAmerica: Canada, Mexico, United States. Oceania: Australia, New ZealandEurope: Austria, Belgium, Denmark, inland, rance, Germany, Greece, Hungary, Iceland, Ireland, Italy,Malta, Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, Turkey, United KingdomRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 181

Technical Note - BTable T7HIV/AIDS and the Gender Development Index, 1980–2000, OLSRegressors Gender Development Index 2000(1) (2) (3) (4) (5)Constant 0.08 0.05 0.12 0.10 0.11(0.02) (0.02) (0.02) (0.02) (0.02)Inequality Index 0.79 0.81 0.71 0.69 0.67Life expectancy at birth 1980 (0.06) (0.07) (0.06) (0.07) (0.07)Inequality Index 0.17 0.19 0.20 0.25 0.25Adult literacy rate 1980 (0.04) (0.04) (0.04) (0.04) (0.04)HIV prevalence 1998 -0.0028 -0.0025(per 100 population aged 15–64 in 1998) (0.0009) (0.0008)Average annual increase incumulative AIDS cases 1980-98 -0.06(per 100 population aged 15–64 in 1998) (0.02)Number of observations 107 74 107 74 74R-squared 0.947 0.974 0.953 0.977 0.979Source: Author’s calculations. Heteroskedasticity-corrected standard errors reported in parentheses.Table T8HIV/AIDS and inequality index for life expectancy at birth, 1980–98, OLS estimatesRegressors Inequality Index for Life Expectancy at Birth, 1998(1) (2) (3) (4) (5)Constant -0.08 -0.005 -0.02 -0.02 -0.002(0.08) (0.093) (0.05) (0.06) (0.069)Inequality Index 1.52 1.14 1.57 1.52 1.43Life expectancy, 1980(0.28) (0.35) (0.17) (0.20) (0.22)Inequality Index -0.44 -0.07 -0.60 -0.52 -0.44Life expectancy, 1980 Squared (0.23) (0.29) (0.13) (0.15) (0.17)HIV prevalence 1998 -0.0097 -0.0092(per 100 population aged 15–64 in 1998) (0.0013) (0.0014)Average annual increase in cumulativeAIDS cases 1980–98 -0.19(per 100 population aged 15–64 in 1998) (0.06)Number of observations 112 76 112 76 76R-squared 0.886 0.900 0.948 0.955 0.954Source: Author’s calculations. Heteroskedasticity-corrected standard errors reported in parentheses.Regional Human Development Report182 HIV/AIDS and Development in South Asia 2003

Technical Note - BTable T9HIV/AIDS and the inequality index for adult literacy rate, 1980–98, OLS estimatesRegressors Inequality Index of Adult Literacy Rate, 1998(1) (2) (3) (4) (5)Constant 0.15 0.14 0.14 0.14 0.14(0.02) (0.02) (0.02) (0.02) (0.02)Inequality Index 1.401.43 1.39 1.42 1.42Adult literacy rate, 1980 (0.08) (0.09) (0.08) (0.10) (0.10)Inequality Index -0.56 -0.58 -0.55 -0.56 -0.56Adult literacy rate squared, 1980 (0.06) (0.07) (0.07) (0.08) (0.08)HIV prevalence 1998 0.0005 0.0005(per 100 population aged 15–64 in 1998) (0.0006) (0.0007)Average annual increase in cumulativeAIDS cases 1980-98 0.01(per 100 population aged 15–64 in 1998) (0.01)Number of observations 109 74 109 74 74R-squared 0.975 0.980 0.975 0.980 0.980Source: Author’s calculations. Heteroskedasticity-corrected standard errors reported in parentheses.IV Specification found to be statistically indistinguishable from OLS specification using a Hausman test.Table T10Descriptive statisticsVariable N Mean Standard Minimum MaximumDeviationHIV prevalence, 1999 (per 100adults 15–64) 112 2.977 5.755 0.003 33.831Annual average increase in cumulativeAIDS (per 100 adults, 15–64) 76 0.180 0.319 0 1.934Human Development Index, 1999 112 0.684 0.195 0.258 0.939Real income per capita, 1998 (1995 US$) 1107,534 11,155 11044,906Literacy rate in population 15+,1998 (per cent) 112 78.34 22.11 15.3 100Mean years of schooling 15+,1995 (years) 93 6.05 2.89 0.69 12.18Gross secondary enrolment,1995 (per cent) 91 67.27 36.29 5.4 146Gross primary enrolment, 1995 (per cent) 100 97.66 22.39 29.00 162.00Life expectancy at birth, 1998 (years) 115 65.65 11.88 37.4080.54Note: N refers to the number of countries in the sample.Source: World Bank, 2000; UNDP, 2000Countries: West Asia and Africa: Algeria, Benin, Botswana, Burkina aso, Burundi, Cameroon, Central AfricanRepublic, Chad, Cote d’Ivoire, Cyprus, Djibouti, Egypt, Ethiopia, Gabon, The Gambia, Ghana, Israel Jordan,Kenya, Libya, Madagascar, Malawi, Mali, Morocco, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda,Saudi Arabia, Senegal, Sierra Leone, South Africa, Swaziland, Syria, Tanzania, Tunisia, Uganda, Zaire, Zambia,Zimbabwe. Asia: Bangladesh, Cambodia, China, Hong Kong, India, Indonesia, Iran, Japan, Republic of Korea,Malaysia, Maldives, Myanmar, Nepal, Pakistan, Philippines, Singapore, Sri Lanka, Thailand, Vietnam. LatinAmerica and Caribbean: Argentina, The Bahamas, Barbados, Bolivia, Brazil, Chile, Colombia, Costa Rica,Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 183

Technical Note - BDominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Jamaica,Nicaragua, Panama, Paraguay, Peru, Trinidad and Tobago, Uruguay, Venezuela. North America:Canada, Mexico, United States. Oceania: Australia, New ZealandEurope: Austria, Belgium, Denmark, inland, rance, Germany, Greece, Hungary, Iceland, Ireland,Italy, Malta, Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, Turkey,United KingdomEndnotes1 The key idea here is that economies that are initially richer (that is, with a greater initial realGDP per capita) grow at a slower pace than those with lower levels of GDP per capita – theso-called “convergence hypothesis ” (for example, Barro 1991). Define the t-year growth rateof real GDP per capita as [Y(t) – Y(0)]/Y(0). This growth is negatively correlated with Y(0),according to the convergence hypothesis, i.e., one could say, for example [Y(t) – Y(0)]/Y(0) =(*Y(0), with (< 0. But this implies precisely the concave relationship we refer to in the maintext.2 Thus, it is not unreasonable to imagine that both the HIV and AIDS variables used in this paperare indicative of the morbidity and mortality associated with the HIV/AIDS epidemic.3 Specifically, each component index, X i(i = 1,2,3) is calculated to be the following formulaX i= [¸ X if1-±+ (1-¸) X im1-±] 1/1-± (i= 1,2,3)Here, X ifis the index of female achievements in component “i”, and X imis the index of maleachievements in component “i” and ¸ is the female share in total population. The parameter“±” indicates the preferred degree of inequality aversion. In GDI calculations, it is taken to beequal to 2 (UNDP 2001). Information on GDI in 2000 was obtained from the Human DevelopmentReport (2001), and information on education variables and life expectancy variables, separatelyby gender, from the World Development Indicators database of the World Bank (World Bank2000). The latter set of information was used to construct the component inequality indices forlife expectancy at birth in 1980 and 1998, and adult literacy rates for 1980 and 1998.Specifications similar to (1) were estimated to assess the impact of HIV/AIDS on inequalityindices, with one exception. Because GDI information for 1980 was unavailable, 1980 values ofthe component index for the adult literacy rate and the component index for life expectancy atbirth were used as explanatory variables to control for influences other than HIV/AIDS that couldpossibly influence GDI.4 The start date of the epidemic was assumed to be the year the first AIDS case was reported ineach country, or a population sample found with HIV prevalence exceeding 0.5 per cent, furtheradjusted by the commonly accepted starting year of the epidemic for each region.5 Arndt and Lewis, 2000, p.12; Arndt and Lewis, 20016 Arndt and Lewis 2001, p.167 Arndt and Lewis, 2000, p.98 Bonnel 2000, p.3, McDonald and Roberts, 2001, p.69 Some qualifications to this claim are necessary. It is not obviously true that HIV prevalencerates among women visiting antenatal clinics are representative of prevalence rates amongmen. Are these rates reasonably representative of HIV-prevalence rates among women in thereproductive age group? Many people do not visit antenatal clinics, most of which are locatedRegional Human Development Report184 HIV/AIDS and Development in South Asia 2003

Technical Note - Bin urban areas, so they are likely to have lower proportions of rural women. Second, youngwomen at high risk from HIV infection do not visit antenatal clinics on account of stigma. Third,HIV seems to lead to lower fertility rates, so that visitors to antenatal clinics woulddisproportionately represent individuals with lower HIV prevalence, relative to the whole group.inally, most of the sentinel surveillance sites are located in public facilities, so that there wouldbe socio-economic differences between women whose blood is tested for HIV in the sentinelsurveillance sites, and those who visit private facilities, and are not covered. These caveatssuggest that sentinel surveillance data would underestimate HIV prevalence among women inreproductive age groups. The relatively greater ease with which HIV is transmitted to women,compared to men, and the increasing role of heterosexual sex in HIV transmission in developingcountries, suggests however, at least one factor leading to a bias in the other direction whenusing ante-natal clinic HIV data to assess HIV prevalence rates among all adults.10 UNDP, 200111 World Bank, 200112 UNAIDS/WHO, 2001, UNAIDS, 2000b and d13 Bloom et al., 199614 UNAIDS, 2002b15 The main advantages of the EPP over its predecessor, EPIMODEL, is its ability to make muchmore effective use of larger set of data points on HIV-prevalence, and to be able to work with amuch broader set of variables influencing HIV-prevalence (Chin and Lwanga 1990, UNAIDS2002b). In particular, EPP involves the estimation of four parameters that describe the timeprofile of HIV prevalence in a population – the initial year of the epidemic, the initial proportion ofthe population at risk for HIV infection, the distribution of the population into not at-risk and atriskcategories, and the rate at which the at-risk population gets infected with HIV. or a givenpattern of progression from HIV to AIDS, given death rate among individuals not infected withHIV, birth rates of HIV-negative children, survival rates to age-15 among HIV-infected children,fertility reduction due to HIV and the rate of perinatal transmission, the EPP finds the (four)parameter estimates and the resultant temporal pattern of HIV prevalence that “best fits” theobserved HIV-prevalence data from sentinel sites. Essentially, this amounts to choosing theparameters so as to minimise the error sum of squares of the fitted curve (UNAIDS 2002b,p.41). A particularly attractive element of EPP is its distinguishing rural and urban HIV surveillancedata to arrive at separate (and combined) HIV prevalence estimates for rural and urban regions.16 or additional details, see UNAIDS 2002b17 The model also used assumptions about declines in fertility rates owing to HIV infection amongreproductive age women.18 See, for instance, Anderson and May 1991; Kremer 199619 Chin and Lwanga, 199120 World Bank, 200021 Summers and Heston, 1991Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 185

Statistical TablesStatistical TablesTable 1aHuman development indicators and indicesCountry HDI Life Adult Combined HPI 1 GDI GEMvalue expectancy literacy primary, Value(%) value Value2000 at birth rate (% secondary(years) age 15 and tertiary2000 and grossabove) enrolment2000 ratio(%)1999Afghanistan N.A. N.A. N.A. N.A. N.A. N.A. N.A.Bangladesh 0.478 59.4 41.3 37 42.4 0.468 0.223Bhutan 0.494 62 47 33 N.A. N.A. N.A.India 0.577 63.3 57.2 55 33.10.560 N.A.Iran (I.R.) 0.72168.9 76.3 73 17.0 0.703 N.A.Maldives 0.743 66.5 96.7 77 15.8 0.739 0.361Nepal 0.490 58.6 41.8 60 43.4 0.470 N.A.Pakistan 0.499 60 43.2 40 41.0 0.468 N.A.Sri Lanka 0.74172.191.6 70 17.6 0.737 0.274Note: N.A. indicates not availableSource: UNDP, 2002Table 1bTrends in HDICountry 1975 1980 1985 1990 1995 2000Afghanistan N.A. N.A. N.A. N.A. N.A. N.A.Bangladesh 0.335 0.353 0.386 0.416 0.445 0.478Bhutan N.A. N.A. N.A. N.A. N.A. 0.494India 0.407 0.434 0.473 0.511 0.545 0.577Iran (I.R.) 0.556 0.563 0.607 0.645 0.688 0.721Maldives N.A. N.A. 0.629 0.676 0.707 0.743Nepal 0.289 0.328 0.370 0.416 0.453 0.490Pakistan 0.345 0.372 0.404 0.442 0.473 0.499Sri Lanka 0.616 0.650 0.676 0.697 0.719 0.741Regional Human Development Report186 HIV/AIDS and Development in South Asia 2003

Table 2Demographic health indicatorsCountry Crude Crude Total Contraceptive Births Physicians Malaria Tuberculosis Infant Maternal Public Private PerDeath Birth ertility prevalence attended (per cases cases Mortality Mortality health health capitaRate Rate Rate (%) c by skilled 100,000 (per (per Rate Ratio expenditure expenditure health(per (per 1000 1995– 1995-2000 health people) 100,000 100,000 (per1000 reported (as % (as % expenditure1000 population) 2000 staff (%) 1990– people) people) live births) (per of GDP) of GDP) (PPPpopu- 1999 1995– 1999 d 2000 1999 2000 100,000 1998 1998 US$)lation) 2000 d live births) 19981999 1985–99Afghanistan 19.4 48.9 N.A. N.A. N.A. N.A. N.A. N.A. N.A. 820e N.A. N.A. N.A.(1995)Bangladesh 4.8 19.8 3.8 54 12 20 40 62 54 350 1.7 1.9 12Bhutan 9.0 39.9 5.5 N.A. N.A. 16 283 57 77 380 3.2 3.6 36India 8.5 25.8 3.3 48 42 48 193 123 69 540 N.A. 4.2 N.A.Iran (I.R.) 6.3 18.7 3.2 73 N.A. 85 27 18 36 37 1.7 2.5 128Maldives 4.0 20.0 5.8 N.A. N.A. 40 N.A. 55 59 350 3.7 4.0 150Nepal 10.0 33.6 4.8 28 12 4 33 117 72 540 1.3 4.2 11Pakistan 9.5 32.1 5.5 24 20 57 58 14 85 N.A. 0.7 b 3.1 18Sri Lanka 5.7 17.3 2.1 N.A. N.A. 36 1111 38 17 60 1.7 b 1.8 29 bRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 187Note: N.A. indicates not availableb - Data refers to 1999c - Data refers to married women aged 15-49, but the actual age range covered may vary between countriesd - Data refers to the most recent year available during the period specifiede - Source - UN Statistics Division, Millennium Indicators Database, 2002Source: UNDP, 2002Statistical Tables

Statistical TablesTable 3Profile of incomes, poverty and inequalityAfghanistan Bangladesh Bhutan India Iran (I.R.) Maldives Nepal Pakistan Sri LankaGDP (US$ N.A. 47.1 0.5 457 104.9 0.6 5.5 61.6 16.3billion)2000GDP Per N.A. 1,602 1,412 2,358 5,884 4,485 1,327 1,928 3,530Capita (PPP$)2000Population N.A. 29.1N.A. 44.2 N.A. N.A. 37.7 31 6.6below incomepovertyline (%)- $1 a day(1993 PPP$) (1983–2000)*Gini Index** N.A. 33.6 N.A. 37.8 N.A. 36.7 N.A. 31.2 34.4*Data refer to the most recent year available** The Gini index measures inequality over the entire distribution of income or consumption. A value of 0 represents perfectinequality, and a value of 100 perfect inequality.Note: N.A. indicates not availableSource: UNDP, 2002Regional Human Development Report188 HIV/AIDS and Development in South Asia 2003Table 4Information and communication indicatorsBangladesh Bhutan India Iran (I.R.) Maldives Nepal Pakistan Sri LankaTelephone mainlines 4 20 32 149 91 12 22 40(per 1000 people) 2000ax machines N.A. 1.7a 0.2 N.A. 14.3b 0.4 2 N.A.(per 1,000 people) 1999Personal computers 0.19 0.58 0.58 6.97 2.19 0.35 0.41 0.93(per 100 inhab.) 2000Internet hosts N.A. 16.46 0.81 0.38 N.A. 0.67 0.78 1.22(per 10,000 inhab.) 2001Cellular mobile subscribers 10 4 15 28 N.A. 2 23(per 1000 people) 2000Televisions N.A. 75 N.A. 40c 7 119 102 N.A.(per 1,000 people) 1999 7Cable subscribers N.A. N.A. 37.1N.A. N.A. 2.9 0.1 0(per 1,000 people) 1999Daily newspapers 9 N.A. 30 N.A. 10 11 21 29(per 1,000 people) 1996Note: N.A. indicates not available; inhab – inhabitantsSource: Row 1 & 5: UNDP, 2002; Row 3 & 4: ITU, 2002 http://www.itu.int/ITU-D/ict/statistics/; Row 2,6,7 & 8: MHHDC, 2001* Data refer to the most recent year available during the specified period; a: year 1996; b: year 1995; c: year 1997

Table 5Profile of military spendingAfghanistan Bangladesh Bhutan India Iran (I.R.) Maldives Nepal Pakistan Sri LankaDefence expenditure(US$ million, 1993 prices)–1985 N.A. 308 N.A. 7,207 N.A. N.A. 22 2,088 214–1999 500 9,520 50 2,820 570Defence expenditure N.A. 3.5 N.A. 2.0 N.A. N.A. 6.0 2.2 7.2annual % increase –(1985–1999)Military expenditure N.A. 1.3 N.A. 2.4 3.8 N.A. 0.9 4.5 4.5(as a % of GDP) 2000Defence expenditure(as a % of centralgovernment expenditure)–1980 N.A. 9.4 N.A. 19.8 N.A. N.A. 6.7 30.6 1.7–1999 3.9 9.5 2.1 21.0 30.3Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 189Public expen- N.A. 2.2^ 4.13.2 4.0 6.4 3.2 2.7 3.4diture oneducation(as % ofGNP)1995–97Public expen- N.A. 1.7 3.2 N.A. 1.7 3.7 1.3 0.7# 1.7#diture onhealth(as % of GDP)1998Defence expenditure(as a % of education andhealth expenditure)–1960 N.A. N.A. N.A. 68 N.A. N.A. 67 393 17–1995 46 57 22 181 100Note: N.A. indicates not availableSource: Rows 1,2,4: MHHDC, 2002; Rows 3, 5, 6: UNDP, 2002; Row 7: MHHDC, 2001Statistical Tables

Statistical TablesRegional Human Development Report190 HIV/AIDS and Development in South Asia 2003

Country act SheetsRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 191

Country act SheetsRegional Human Development Report192 HIV/AIDS and Development in South Asia 2003

Country act SheetsCountry act SheetsAGHANISTANIndicator Year Estimate SourcePopulation (millions) 2000 21.77 SYAP, UN ESCAP*, 2001Population growth (1999–2001) N.A. N.A. —Annual population growth (%) 2000 2.7 SYAP, UN ESCAP, 2001Population density (per sq. km) 1979(census) 20 SYAP, UN ESCAP, 2001Sex ratio (females per 1,000 males) N.A. N.A. —Crude Birth Rate (per 1000) 1999 48.9 SYAP, UN ESCAP, 2001Crude Death Rate (per 1000) 1999 19.4 SYAP, UN ESCAP, 2001Total ertility Rate (per woman) N.A. N.A. —Infant Mortality Rate (per 1000 live births) N.A. N.A. —Maternal Mortality Ratio (per 100,000 live 1995 820 UN Statistics Division,births)Millennium IndicatorsDatabase, 2002Human Development Index rank N.A. N.A. —Adult literacy rates (% age 15 and above) N.A. N.A. —Population below income poverty line(%) N.A. N.A. —($ 1 a day) (1993) (PPP US$)Urban population (%) * N.A. N.A. —Life expectancy (years) N.A. N.A. —GDP per capita (PPP US$) N.A. N.A. —Population using adequate sanitation 2000 12 UN Statistics Division,facilities (%)Millennium IndicatorsDatabase, 2002Population using improved water sources (%) 2000 13UN Statistics Division,Millennium IndicatorsDatabase, 2002Public expenditure on health (as % of GDP) N.A. N.A. —Private health expenditure (% of GDP) N.A. N.A. —Physicians per 100,000 population N.A. N.A. —Population with access to essential drugs (%) N.A. N.A. —HIV prevalence among adults (%) N.A. N.A. —Note: N.A. indicates not available* Statistical Yearbook for Asia and the Pacific (SYAP), United Nations Economic and Social Commission for Asiaand the Pacific (UNESCAP), 2001Country Profilel One of the poorest countries in the region.l Devastated by protracted armed conflicts since1978.l Large number of internally displaced persons.l Women’s rights suppressed for several years.l Lack of social and health infrastructure, whichimpedes access to essential services.l Placed at 173 out of a list of 191 countries by WHOin its June 2000 ranking of healthcare.l More than 2 million Afghan refugees in Pakistan.l More than 1.5 million Afghan refugees in Iran.Source: Country Profile and HIV/AIDS scenario extract from - www.youandaids.orgHIV/AIDS Scenariol Information on HIV/AIDS is scant.l Vulnerability factors indicate the possibility ofrapid spread of the epidemic if preventive effortsare not taken immediately.l Low socio-political and economic status ofwomen.l Large numbers of displaced people.l Extremely poor social and public healthinfrastructure.l World’s largest producer of opium, from whichheroin is derived.l Drug trafficking, use of injecting drugs and lack ofblood safety practices identified as factors thatcould fuel the epidemic.Regional Human Development ReportHIV/AIDS and Development in South Asia 2003 193

Country act SheetsBANGLADESHIndicator Year Estimate SourcePopulation (millions) 2000 137.4 Global HDR 2002Population growth (1999–2001) N.A. N.A. —Annual population growth (%) 1975–2000 2.4 Global HDR 2002Population density (per sq. km) 2001 (census) 834 SYAP, UN ESCAP, 2001Sex Ratio (females per 1,000 males) 2001 933 World BankCrude Birth Rate (per 1000) 1999 19.8 SYAP, UN ESCAP, 2001Crude Death Rate (per 1000) 1999 4.8 SYAP, UN ESCAP, 2001Total ertility Rate (per woman) 1995–2000 3.8 Global HDR 2002Infant Mortality Rate (per 1000 live births) 2000 54 Global HDR 2002Maternal Mortality Ratio (per 100,000 live births) 1985–99 350 Global HDR 2002Human Development Index rank 2000 145 Global HDR 2002Adult literacy rates (% age 15 and above) 2000 41.3Global HDR 2002Population below income poverty line(%) 1983–2000 29.1 Global HDR 2002($ 1 a day) (1993) (PPP US$)Urban population (%) 2000 25.0 Global HDR 2002Life expectancy at birth (years) 2000 59.4 Global HDR 2002GDP per capita (PPP US$) 2000 1602 Global HDR 2002Population using adequate sanitation facilities (%) 2000 53Global HDR 2002Population using improved water sources (%) 2000 97 Global HDR 2002Public expenditure on health (as % of GDP) 1998 1.7 Global HDR 2002Private health expenditure (% of GDP) 1998 1.9 Global HDR 2002Physicians per 100,000 population 1990–99 20 Global HDR 2002Population with access to essential drugs (%) 1999 50-79 Global HDR 2002HIV prevalence among adults (%) 2001

Country act SheetsBHUTANIndicator Year Estimate SourcePopulation (millions) 2000 2.1 Global HDR 2002Population growth (1999–2001) N.A. N.A. —Annual population growth (%) 1975–2000 2.3Global HDR 2002Population density (per sq. km) 1980 (census) 25 SYAP, UN ESCAP, 2001Sex Ratio (females per 1,000 males) N.A. N.A. —Crude Birth Rate (per 1000) 2000 39.9 SYAP, UN ESCAP, 2001Crude Death Rate (per 1000) 2000 9.0 SYAP, UN ESCAP, 2001Total ertility Rate (per woman) 1995–2000 5.5 Global HDR 2002Infant Mortality Rate (per 1000 live births) 2000 77 Global HDR 2002Maternal Mortality Ratio (per 100,000 live births) 1985–99 380 Global HDR 2002Human Development Index rank 2000 140 Global HDR 2002Adult literacy rates (% age 15 and above) 2000 47.0 Global HDR 2002Population below income poverty line(%) 1983–2000 N.A. Global HDR 2002($ 1 a day) (1993) (PPP US$)Urban population (%) 2000 7.1 Global HDR 2002Life expectancy at birth (years) 2000 62.0 Global HDR 2002GDP per capita (PPP US$) 2000 1412 Global HDR 2002Population using adequate sanitation facilities (%) 2000 69 Global HDR 2002Population using improved water sources (%) 2000 62 Global HDR 2002Public expenditure on health (as % of GDP) 1998 3.2 Global HDR 2002Private health expenditure (% of GDP) 1998 3.6 Global HDR 2002Physicians per 100,000 population 1990–99 16 Global HDR 2002Population with access to essential drugs (%) 1999 80–94 Global HDR 2002HIV prevalence among adults (%) 2001

Country act SheetsINDIAIndicator Year Estimate SourcePopulation (millions) 2000 1008.9 Global HDR 2002Population growth (1999–2001) 2001 21.34 Census of India, 2001Annual population growth (%) 1975–2000 1.9 Global HDR 2002Population density (per sq. km) 2001 (census) 312 SYAP, UN ESCAP, 2001Sex Ratio (females per 1,000 males) 2001 933 Census of India, 2001Crude Birth Rate (per 1000) 2000 25.8 SYAP, UN ESCAP, 2001Crude Death Rate (per 1000) 2000 8.5 SYAP, UN ESCAP, 2001Total ertility Rate (per woman) 1995–2000 3.3 Global HDR 2002Infant Mortality Rate (per 1000 live births) 2000 69 Global HDR 2002Maternal Mortality Ratio (per 100,000 live births) 1985–99 540 Global HDR 2002Human Development Index rank 2000 124 Global HDR 2002Adult literacy rates (% age 15 and above) 2000 57.2 Global HDR 2002Population below income poverty line(%) 1983–2000 44.2 Global HDR 2002($ 1 a day) (1993) (PPP US$)Urban population (%) 2000 27.7 Global HDR 2002Life expectancy at birth (years) 2000 63.3 Global HDR 2002GDP per capita (PPP US$) 2000 2358 Global HDR 2002Population using adequate sanitation facilities (%) 2000 31 Global HDR 2002Population using improved water sources (%) 2000 88 Global HDR 2002Public expenditure on health (as % of GDP) 1998 N.A. Global HDR 2002Private health expenditure (% of GDP) 1998 4.2 Global HDR 2002Physicians per 100,000 population 1990–99 48 Global HDR 2002Population with access to essential drugs (%) 1999 0-49 Global HDR 2002HIV prevalence among adults (%) 2001 0.8 UNAIDS 2002cNote: N.A. indicates not availableCountry Profilel Population exceeds 1 billion. Ethnicallyheterogeneous composition.l Due to differential levels of economicdevelopment across States in India, there is largepopulation mirgration within the countryl Extensive cross-border trade with neighbouringcountries (especially Nepal, Bangladesh,Myanmar, Sri Lanka and Pakistan).l Existence of some well-established sex work trafficroutes between Nepal and India and Bangladeshand India.l Refugee populations from Tibet, Sri Lanka andAfghanistan concentrated in certain parts of thecountry.l Regional disparities in social sector attainmentsbecause the subject (especially health, educationand social welfare) falls under the jurisdiction ofstate and Union Territories governments.HIV/AIDS Scenariol HIV prevalence estimated at 3.97 million, rankingsecond only to South Africa.Source: Country Profile and HIV/AIDS scenario extract from - www.youandaids.orglllllllFirst HIV case reported in 1986 in Chennai, thecapital of the southern state of Tamil Nadu.Rapid spread of HIV from urban to rural areas andfrom high-risk groups to the general population.(Infection has been reported from almost all thestates and Union Territories.)The second decade of the epidemic is marked byvisible heterogeneity.Epidemic slowly moving beyond its initialconcentration among sex workers. Sub-epidemicsare emerging with potentially explosive spreadamong groups of injecting drug users and menwho have sex with men.Epidemic shifting towards women and youngpeople. An estimated 25 per cent of all HIVinfections occurring among women. Adversegender bias adds to the biological vulnerability ofwomen.The burden of AIDS cases is beginning to be felt instates affected early.The city of Mumbai in the western state ofMaharashtra and the north-eastern state of Manipurhave recorded 20-40 per cent bed occupancy byHIV positive persons in certain referral hospitals.Regional Human Development Report196 HIV/AIDS and Development in South Asia 2003

Country act SheetsNote: N.A. indicates not availableISLAMIC REPUBLIC O IRANIndicator Year Estimate SourcePopulation (millions) 2000 70.3Global HDR 2002Population growth (1999–2001) N.A. N.A. —Annual population growth (%) 1975–2000 3.0 Global HDR 2002Population density (per sq. km) 1996 (census) 37 SYAP, UN ESCAP, 2001Sex Ratio (females per 1,000 males) N.A. N.A. —Crude Birth Rate (per 1000) 2000 18.7 SYAP, UN ESCAP, 2001Crude Death Rate (per 1000) 2000 6.3SYAP, UN ESCAP, 2001Total ertility Rate (per woman) 1995–2000 3.2 Global HDR 2002Infant Mortality Rate (per 1000 live births) 2000 36 Global HDR 2002Maternal Mortality Ratio (per 100,000 live births) 1985–99 37 Global HDR 2002Human Development Index rank 2000 98 Global HDR 2002Adult literacy rates (% age 15 and above) 2000 76.3Global HDR 2002Population below income poverty line(%) 1983–2000 N.A. Global HDR 2002($ 1 a day) (1993) (PPP US$)Urban population (%) 2000 64.0 Global HDR 2002Life expectancy at birth (years) 2000 68.9 Global HDR 2002GDP per capita (PPP US$) 2000 5884 Global HDR 2002Population using adequate sanitation facilities (%) 2000 81 Global HDR 2002Population using improved water sources (%) 2000 95 Global HDR 2002Public expenditure on health (as % of GDP) 1998 1.7 Global HDR 2002Private health expenditure (% of GDP) 1998 2.5 Global HDR 2002Physicians per 100,000 population 1990–99 85 Global HDR 2002Population with access to essential drugs (%) 1999 80–94 Global HDR 2002HIV prevalence among adults (%) 2001

Country act SheetsMALDIVESIndicator Year Estimate SourcePopulation (millions) 2000 0.3Global HDR 2002Population growth (1999–2001) N.A. N.A. —Annual population growth (%) 1975–2000 3.0 Global HDR 2002Population density (per sq. km) 2000 (census) 906 SYAP, UN ESCAP, 2001Sex Ratio (females per 1,000 males) N.A. N.A. —Crude Birth Rate (per 1000) 2000 20.0 SYAP, UN ESCAP, 2001Crude Death Rate (per 1000) 2000 4.0 SYAP, UN ESCAP, 2001Total ertility Rate (per woman) 1995–2000 5.8 Global HDR 2002Infant Mortality Rate (per 1000 live births) 2000 59 Global HDR 2002Maternal Mortality Ratio (per 100,000 live births) 1985–99 350 Global HDR 2002Human Development Index rank 2000 84 Global HDR 2002Adult literacy rates (% age 15 and above) 2000 96.7 Global HDR 2002Population below income poverty line(%) 1983–2000 N.A. Global HDR 2002($ 1 a day) (1993) (PPP US$)Urban population (%) 2000 27.6 Global HDR 2002Life expectancy at birth (years) 2000 66.5 Global HDR 2002GDP per capita (PPP US$) 2000 4485 Global HDR 2002Population using adequate sanitation facilities (%) 2000 56 Global HDR 2002Population using improved water sources (%) 2000 100 Global HDR 2002Public expenditure on health (as % of GDP) 1998 3.7 Global HDR 2002Private health expenditure (% of GDP) 1998 4.0 Global HDR 2002Physicians per 100,000 population 1990–99 40 Global HDR 2002Population with access to essential drugs (%) 1999 50–79 Global HDR 2002HIV prevalence among adults (%) 2001 0.1 UNAIDS 2002cNote: N.A. indicates not availableCountry Profilel Tourism is the main industry, accounting for 20per cent of the GDP and more than 60 per cent offoreign exchange receipts.l Over 90 per cent of government tax revenue comesfrom import duties and tourism-related taxes.HIV/AIDS Scenariol First case of HIV in the country confirmed in 1991.l The reported number of people with HIV, as of 31December 1998, was 58, of which 48 wereforeigners.l All the ten Maldivians were in the 15–49 years agegroup, the youngest being 23 and the oldest 42years of age.l Six persons have died of AIDS. Two appear to havecontracted the infection while working at touristresorts.l A number of factors make the country vulnerableto the spread of HIV, and the government has takenthe threat to a small population very seriously.Source: Country Profile and HIV/AIDS scenario extract from - www.youandaids.orgRegional Human Development Report198 HIV/AIDS and Development in South Asia 2003

Country act SheetsNEPALIndicator Year Estimate SourcePopulation (millions) 2000 23.0 Global HDR 2002Population growth (1999–2001) N.A. N.A. —Annual population growth (%) 1975–2000 2.2 Global HDR 2002Population density (per sq. km) 1991(census) 126 SYAP, UN ESCAP, 2001Sex Ratio (females per 1,000 males) N.A. N.A. —Crude Birth Rate (per 1000) 2000 33.6 SYAP, UN ESCAP, 2001Crude Death Rate (per 1000) 2000 10.0 SYAP, UN ESCAP, 2001Total ertility Rate (per woman) 1995–2000 4.8 Global HDR 2002Infant Mortality Rate (per 1000 live births) 2000 72 Global HDR 2002Maternal Mortality Ratio (per 100,000 live births) 1985–99 540 Global HDR 2002Human Development Index rank 2000 142 Global HDR 2002Adult literacy rates (% age 15 and above) 2000 41.8 Global HDR 2002Population below income poverty line(%) 1983–2000 37.7 Global HDR 2002($ 1 a day) (1993) (PPP US$)Urban population (%) 2000 11.8 Global HDR 2002Life expectancy at birth (years) 2000 58.6 Global HDR 2002GDP per capita (PPP US$) 2000 1327 Global HDR 2002Population using adequate sanitation facilities (%) 2000 27 Global HDR 2002Population using improved water sources (%) 2000 81 Global HDR 2002Public expenditure on health (as % of GDP) 1998 1.3Global HDR 2002Private health expenditure (% of GDP) 1998 4.2 Global HDR 2002Physicians per 100,000 population 1990–99 4 Global HDR 2002Population with access to essential drugs (%) 1999 0–49 Global HDR 2002HIV prevalence among adults (%) 2001 0.5 UNAIDS 2002cNote: N.A. indicates not availableCountry Profilel Among the poorest and least developed countriesin the world.l Nearly half of its population lives below thepoverty line.l One of the two countries in the world where lifeexpectancy of men is longer than that of women.l Ethnically and geographically diverse.l Seasonal and long-term mobility and migrationabroad is common.l Consumption of drugs is widespread.l No identifiable red light areas. The sex trade iscovert and takes place on the streets and in theparks of Kathmandu and major towns.l Trafficking of girls to India a major problem.l Number of Nepalese sex workers in Indiaestimated to range from 20,000 to 100,000 or more.HIV/AIDS Scenariol HIV epidemic characterised by high prevalenceamong groups involved in high-risk behaviour.l Prevalence among street sex workers inKathmandu rose from 1 per cent in 1992 to 16 percent in 1998.l Prevalence among injecting drug users rose froman estimated 2 per cent in 1991 to 50 per cent in1997. There are an estimated 20,000 IDUs in Nepal.l Prevalence among STD patients has beenfluctuating, ranging from 1 per cent to5 per cent in Kathmandu in 1998.l In essence, the prevalence ranged from noevidence to 3 per cent.l Sentinel surveys in pregnant women in 1991 and1992 in eight districts showed no evidence. (USCensus Bureau, HIV/AIDS Surveillance Data Base,June 2000)l The HIV situation is rapidly deteriorating from lowprevalence to concentrated epidemic.Source: Country Profile and HIV/AIDS scenario extract from - www.youandaids.orgRegional Human Development ReportHIV/AIDS and Development in South Asia 2003 199

Country act SheetsPAKISTANIndicator Year Estimate SourcePopulation (millions) 2000 141.3Global HDR 2002Population growth (1999–2001) N.A. N.A. —Annual population growth (%) 1975–2000 2.8 Global HDR 2002Population density (per sq. km) 1998 (census) 166 SYAP, UN ESCAP, 2001Sex Ratio (males per 100 females) 1998 108.1 Government ofPakistan, StatisticsDivision, PopulationCensus Organisation,2002Crude Birth Rate (per 1000) 2000 32.1 SYAP, UN ESCAP, 2001Crude Death Rate (per 1000) 2000 9.5 SYAP, UN ESCAP, 2001Total ertility Rate (per woman) 1995–2000 5.5 Global HDR 2002Infant Mortality Rate (per 1000 live births) 2000 85 Global HDR 2002Maternal Mortality Ratio (per 100,000 live births) 1985–99 N.A. Global HDR 2002Human Development Index rank 2000 138 Global HDR 2002Adult literacy rates (% age 15 and above) 2000 43.2 Global HDR 2002Population below income poverty line(%) 1983–2000 31.0 Global HDR 2002($ 1 a day) (1993) (PPP US$)Urban population (%) 2000 33.1 Global HDR 2002Life expectancy at birth (years) 2000 60.0 Global HDR 2002GDP per capita (PPP US$) 2000 1928 Global HDR 2002Population using adequate sanitation facilities (%) 2000 61 Global HDR 2002Population using improved water sources (%) 2000 88 Global HDR 2002Public expenditure on health (as % of GDP) 1999 0.7 Global HDR 2002Private health expenditure (% of GDP) 1998 3.1 Global HDR 2002Physicians per 100,000 population 1990–99 57 Global HDR 2002Population with access to essential drugs (%) 1999 50–79 Global HDR 2002HIV prevalence among adults (%) 2001 0.1 UNAIDS 2002cNote: N.A. indicates not availableCountry Profilel Among the low HDI countries, with poor indicatorsof social development and high levels of externaldebt.l One million Afghan refugees living in the borderareas.l Labour migration within and outside the countryis common.l Commercial sex work is widely prevalent.l Males too engage in sex work.l Injecting drug use is widespread.l Absence of universal screening of blood and bloodproducts.l Low condom usage.l Low education and literacy levels.l Low status of women and high rate of femaleilliteracy.Source: Country Profile and HIV/AIDS scenario extract from - www.youandaids.orgRegional Human Development Report200 HIV/AIDS and Development in South Asia 2003HIV/AIDS Scenariol Estimated HIV prevalence remains low at about0.1 per cent of the population.l Cases have been reported from all provinces butappear to have been confined mainly to peopleengaged in high-risk behaviour.l Most of the infected persons belong to the 20 to 49years age groupl Infection through the heterosexual route is themost common cause.l Infection through contaminated blood and bloodproducts and through IDU also prevalent.l An estimated 11 per cent of 60,000-100,000 injectingdrug users living with HIV/AIDS.

Country act SheetsSRI LANKAIndicator Year Estimate SourcePopulation (millions) 2000 18.9 Global HDR 2002Population growth (1999–2001) N.A. N.A. —Annual population growth (%) 1975–2000 1.3Global HDR 2002Population density (per sq. km) 1994(census) 229 SYAP, UN ESCAP, 2001Sex Ratio (females per 1,000 males) N.A. N.A. —Crude Birth Rate (per 1000) 2000 17.3SYAP, UN ESCAP, 2001Crude Death Rate (per 1000) 2000 5.7 SYAP, UN ESCAP, 2001Total ertility Rate (per woman) 1995–2000 2.1 Global HDR 2002Infant Mortality Rate (per 1000 live births) 2000 17 Global HDR 2002Maternal Mortality Ratio (per 100,000 live births) 1985–99 60 Global HDR 2002Human Development Index rank 2000 89 Global HDR 2002Adult literacy rates (% age 15 and above) 2000 91.6 Global HDR 2002Population below income poverty line (%) 1983–2000 6.6 Global HDR 2002($ 1 a day) (1993) (PPP US$)Urban population (%) 2000 22.8 Global HDR 2002Life expectancy at birth (years) 2000 72.1 Global HDR 2002GDP per capita (PPP US$) 2000 3530 Global HDR 2002Population using adequate sanitation facilities (%) 2000 83Global HDR 2002Population using improved water sources (%) 2000 83Global HDR 2002Public expenditure on health (as % of GDP) 1998 1.7* Global HDR 2002Private health expenditure (% of GDP) 1998 1.8 Global HDR 2002Physicians per 100,000 population 1990–99 36 Global HDR 2002Population with access to essential drugs (%) 1999 95–100 Global HDR 2002HIV prevalence among adults (%) 2001

Country act SheetsRegional Human Development Report202 HIV/AIDS and Development in South Asia 2003