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HIV/AIDS and Development: Unsolved Challenges for Africa

Oliver S Saasa
Institute of Economic and Social Research University of Zambia

The Poverty Challenge

Poverty in eastern and southern Africa touches about 150 million people or about half of the population of the region. The portion of the population living below the national poverty line ranges from 11% and 25% in Mauritius and Zimbabwe respectively, to 70% in Madagascar and 86% in Zambia. A review of dollar poverty data shows that the portion living on less than one dollar per day ranges from 11% in South Africa to 64% in Zambia, while 87% in Zambia and 89% in Madagascar live on less than two dollars per day.

Most poverty in Sub-Saharan Africa is found in the rural areas. Rates of poverty in the rural areas are very high (around 90%) in some countries, namely Malawi, Rwanda and Zambia. The principal economic activity for the rural poor will continue to be agriculture. If an agricultural/rural development effort can bring the countries with the lowest per capita income up to the level of the top low-income performer, this would imply significant strides in improving living standards. Poverty prevalence by county is shown in Table 2.

There are only two countries in the region (Burundi and Uganda) where the percentage of the population below the poverty line in urban areas exceeds that of rural areas. This may be because of migration to urban areas as a result of the war. In general, the rate of poverty is highest among small farmers, herders and fishermen. Smallholder agriculture is by far the main source of income and livelihood of the poor. Poverty in rural Africa, broadly speaking, is associated with lack of ownership or control over assets such as land, water, livestock and capital, insufficient access to a nutritionally adequate food basket, vulnerability (physical, economic and social), low and insecure income, weak social support networks and loss of dignity.

Within the agricultural sector, subsistence farmers are poorer than cash crop farmers while households with regular off-farm employment are better off than both. In Zambia, 89% of the poor work either in semi-subsistence agriculture or engage in casual farm labour in exchange for food. In Namibia, 75% of the poor live in rural areas and depend on subsistence agriculture, cash transfers and wage employment on commercial farms. In Zimbabwe, 89% of subsistence farmers in communal areas are poor compared to the national average of 6%. In Malawi, own-farm production is the main source of livelihood of the poor and accounts for 65% of smallholder income.

Poverty tends to be concentrated in households with farm sizes under one hectare and especially among those with less than one half hectare. However, across Sub-Saharan Africa there is wide variation in land productivity by agro-ecological zone. For example, in dryer areas smallholder farms are slightly larger on average sometimes reaching five to eight hectares. However, low land productivity in conditions of limited rainfall means that these farms may not even cover household subsistence needs. In most countries, poverty increases with decreasing land per capita.

Table 2 - Poverty rates by country, %

Source: World Bank (1998) World Development Indicators. World Bank: Washington DC.
UNICEF (1999) State of the World’s Children 2000. UNICEF: New York.
UNDP (1998 and 2000) Human Development Report. Oxford University Press: New York.

The human development approach gives more direct attention to people and the improvements of their lives as the central concern of development strategy and analysis. In place of GNP, the human development approach focuses on human development achievement, and the Human Development Index or HDI has been developed to measure this. This human development dimension is expressed, for the purposes of measurement, by a number of variables, namely, life expectancy at birth, the educational index measured by a combination of adult literacy and the rate of attendance in primary, secondary and higher education taken together; and standard of life, as measured by real per capita GDP (converted to dollars using purchasing power parities). In short, the HDI is a composite of three basic components of human development: longevity (measured by life expectancy), knowledge (measured by a combination of adult literacy and mean years of schooling), and standard of living (measured by purchasing power based on real gross domestic product per capita adjusted for the local cost of living). The HDI for a country shows the distance that it has to travel to reach the maximum possible value of 1.0, or its short fall. HDI values also allow comparisons across regions. HDI values for eastern and southern Africa (Table 3) are generally below 0.5, and several countries (Botswana, Burundi, Kenya, Zambia and Zimbabwe) have seen a reversal in progress made in previous decades in building human capability. The reversal is largely due to a drop in life expectancy due to HIV/AIDS.

Since the concept of human development is much broader than what the HDI shows, the UNDP Human Development Reports have, over the years, constructed more specific and disaggregated indices. Among these is the Gender-related Development Index (GDI), which uses the same variables as the HDI. However, GDI adjusts the average achievement of each country in terms of life expectancy, educational level and income, in accordance with the disparity in the achievements of women and men. The greater the disparity in basic human development, the lower will be the GDI of a country, compared to its HDI.

Per capita income can be a misleading indicator of poverty. While countries with a low per capita income tend to have a high portion of the population living under the poverty line, there are exceptions. Only ten percent of the rural population in Uganda lives below the poverty line, while the national GNP per capita in 1998 for that country was $330. Namibia and Botswana with relatively high per capita incomes, $2210 and $3310 respectively, still have a large share of the rural population living below the poverty line (70% and 55% respectively). These contrasts are set out in Table 4, which also shows comparative rankings of rural poverty rates and GNP per capita.

Table 3 - Human development indicators by country

Source: World Bank (1998) World Development Indicators. World Bank: Washington DC.
UNICEF (1999) State of the World’s Children 2000.
UNICEF: New York. UNDP (1998 and 2000) Human Development Report. Oxford University Press: New York.

The Human Poverty Index (HPI) has also been introduced to include, in a composite measure, several characteristics of deprivation in order to reach an overall judgement about the extent of poverty. It concentrates on deprivation in three essential areas of human life, already reflected in the HDI, namely, longevity (or vulnerability to death at a relatively early age), knowledge (exclusion from the world of reading and communication) and decent living standard (in terms of overall economic provisioning). Deprivation of the provisions required for a decent standard of living is measured by a combination of lack of access to clean water, and to health services and by the proportion of underfives who are severely and moderately underweight. The UNDP Human Development Report (2001) provides HPI estimates for 85 countries. The HPI exceeds 50% in Ethiopia and Mozambique; while for Malawi, Zambia and Uganda human poverty is around 40%.

These various measures are useful. However, caution needs to be exercised in quantifying poverty. Poverty is deeply human. Numbers cannot capture the whole story. This does not mean that economic growth indicators are unimportant. Economic growth can be a powerful means to eradicate poverty. Growth can raise the productivity and incomes of poor people, expanding opportunities and choices in a variety of ways. Sustained national GDP growth, combined with rising wages and productivity, was an important part of the historic ascent from poverty in the industrial countries. But these successes contrast with present realities in many developing countries of Sub-Saharan Africa. In too many countries, growth has failed to reduce poverty, either because growth has been too slow or stagnant or because its quality and structure have been insufficiently pro-poor.

Poverty in Sub-Saharan Africa is prevalent and continues to threaten the quality of life of the majority of people in this region. Poverty poses a serious challenge to the development of the continent and one of its outcomes, increased malnutrition, has complicated the current social welfare improvement efforts of many governments. The entry of HIV/AIDS has brought a new dimension to the continent's developmental challenge in a number of ways. The remaining part of this paper attempts to draw linkages between HIV/AIDS and development in Africa.

Table 4 - Countries ranked by rural poverty rates and GNP per capita

Source: IFAD (2000) Report of IFAD’s Workshop on Rural Poverty. IFAD: Rome.
UNICEF (1999) State of the World’s Children 2000.
UNICEF: New York. World Bank (2001) World Development Indicators. World Bank: Washington DC

The HIV/AIDS Challenge

Sub-Saharan Africa accounts for more than 70% of all HIV/AIDS cases globally. It is the only region where women living with HIV/AIDS outnumber men. Nearly 25 million Africans are living with HIV/AIDS, the vast majority of them adults in the prime of their working and parenting lives. Some 15 million people in Africa have already died of AIDS, with devastating social and economic impact. In the 30 Sub-Saharan African countries with the highest HIV/AIDS prevalence levels, the average life expectancy has already started to decline, standing at about 47 years, roughly seven years lower than what would have been the case in the absence of the pandemic. The lifetime risk of dying from AIDS has been rising in most African countries, standing at over 60% in Zambia, Zimbabwe, Botswana and Malawi (Figure 1).

The epidemic is costing the region close to one percent of economic growth each year, while imposing an unsustainable and mounting burden on households, firms and the public sector. While deteriorating health indicators and high levels of poverty are likely to make control of the epidemic more difficult, they too are in part the result of the epidemic. If new resources are not found, the decline in available public resources for HIV/AIDS prevention in Africa may severely undermine national capacities to mount timely and effective responses. Whereas people from all population groups may be exposed to HIV infection, some groups are more vulnerable to the infection than other groups. These include certain occupational groups accustomed to leaving their homes and families for extended periods of time, as well as sex workers. Street children and adolescents are also vulnerable. With limited alternative sources of income available, many girls enter into sexual relationships in exchange for money. The vulnerability of youth to HIV infection is also related to unclear perceptions about what constitutes risky behaviour, insufficient knowledge and incorrect information about sex, sexuality and sexual health. Traditionally, parents, guardians and teachers in Africa are uncomfortable discussing issues of sexuality with their children, a phenomenon that further complicates the intervention efforts. A summary of the facts about the spread of HIV in Africa is presented in Box 1.

Source: UNAIDS (1999) Presentation at the 11^th International Conference on AIDS and STDs in Africa. Lusaka, Zambia.

Impacts at the macro-level

The challenges of HIV/AIDS on the public and private sectors of Africa are obvious. AIDS threatens Africa’s capacity building effort.

Unlike most other communicable diseases, AIDS strikes the educated and skilled as well as the uneducated. Consequently, it reverses and impedes the continent's capacity by shortening human productivity and life expectancy. The long periods of illness of skilled personnel in employment result in considerable loss to the employer. The AIDS epidemic must be viewed as an immense challenge to capacity building and development. The social and economic devastation caused by HIV/AIDS in the last decade is greater than the combined destruction of the continent’s wars.

The complex relationship between economic growth and HIV/AIDS is increasingly being recognised: the epidemic affects economic growth and economic growth impacts on the epidemic. In most African countries, the economic shock of AIDS on the labour market has translated into severe loss in economic productivity. Given that AIDS disproportionately affects the working-age population, the epidemic affects both the quantity and quality of the labour force. The cost of overall production is likely to increase. An indirect effect on all sectors is the drop in consumer spending as the economic effects of AIDS spread throughout society. Correspondingly, a reduced access to income leads to adverse welfare impact on the household as resources for food and other basic necessities dwindle.

Impacts on families

While economists have placed considerable attention on the impact of HIV/AIDS at the macro level, the epidemic is taking a heavy toll at the household level, especially under ill-conceived home-based care programmes that do not take into full account the cultural, social and economic considerations that may compromise the health and safety of the caregivers. This is particularly so in countries where most people are poor and are ill equipped to shoulder the added expenses of caring for the sick.

At the household or family level, the impact of HIV/AIDS varies by geographic areas (rural/urban), by socio-economic status and size of the family and by the number and ages of independent children. The majority of those who die of AIDS are in their most productive years and often the sole breadwinners in the household or cluster of families. Impacts are felt through the loss of income, changes in the pattern of household expenditure, high expenditures on drugs (when there is access to drugs) and medical services, and dissolution of normal social relationships within the family. Families can exhaust their entire savings long before their infected members die, a phenomenon that has a serious adverse effect on the nutritional welfare of households. The illness and death of economically active adults result not only in higher medical expenses and lower incomes for family members, but it also creates hardships for survivors, especially women and children, having to lose access to land, housing, livestock and other assets. In some countries in Sub-Saharan Africa, women have no protected rights to inherit property from their husbands or fathers. Neither children nor women have any legal recourse to recovering their husbands' or fathers' property removed from them.

The HIV/AIDS epidemic has also compelled many households and extended families to absorb orphaned children and to care for the chronically ill patients. In 1996, a UNICEF-supported survey^1,2 of 1,000 households in Zambia found that 72% of households care for at least one orphan, up from 37% reported by a similar survey in 1993. In Zambia, there are some 650,000 children up to the age of 14 years who are orphaned because of AIDS.

Impact on industries

Businesses in those African countries where AIDS prevalence rates are high suffer from increases in mortality and morbidity among their workforce due to the pandemic. This has affected productivity and recruitment, while resulting in the loss of trained personnel in particular. The number of hours lost to illness and funerals continue to increase. This poses a serious threat to sustainable productivity. A study carried out at the Indeni Petroleum Company in Zambia³ showed that the economic impact of the pandemic, the cost of medical care, salary compensation for the families of deceased employees and funeral grants more than doubled between 1991 and 1993, and had exceeded profits by 1996. Medical expenses and training costs increased while person-hours were reduced.

As the epidemic persists, the private sector will be adversely affected in a number of ways. The workforce will change in structure by becoming younger, inexperienced and less well trained. A disproportionately high number of skilled personnel will be lost, contributing to reduced productivity. Stigmatisation and discrimination in the workplace targeted at people who are HIV-positive have evidently continued to compromise morale and performance⁴.

Impacts on agriculture

Agriculture, too, is adversely affected by HIV/AIDS and related illnesses as agriculture-based communities are depleted of able-bodied workers. Of particular concern is that the agriculture sector employs a large percentage of the labour force and accounts for a major portion of the gross domestic product and export earnings in many African countries. The effects of HIV/AIDS on this sector are, therefore, likely to reverberate throughout the national economies. The influences of the drought from 1990 to 1999 and severe flooding in recent years, particularly in southern Africa, have complicated an analysis of the impact of HIV/AIDS on the agricultural sector in the southern part of the African continent. Nevertheless, the loss of a productive labour force will have one or more of the following consequences:

· Reduction of land use under cultivation, as people are physically unable to work in the field;

· Reduction in crop yields, due to delays in carrying out certain agricultural interventions such as changes in cropping pattern;

· Changes in cropping patterns as some families have been known to switch to less labour-intensive crops;

· Decline in the range of crops per household as AIDS-affected families reduce the number of crops under cultivation to one staple crop;

· Reduction in the ability to control pests such as through weeding and other inter-cultivation measures due to shortage of labour;

· Loss of agricultural knowledge and farm management skills, due to the loss of one or both parents to AIDS, and

· Decline in livestock production as the urgent need for cash may force some families to sell their animals.

Impacts on education

High rates of mortality and morbidity aggravate existing human resource constraints. In addition to dwindling financial resources, human resources have been lost at an alarming rate - partly in response to relatively unattractive terms and conditions of service, but also by illness and death. In Zambia, for example, the Ministry of Education reported in 1998 that 1,331 teachers died as a result of AIDS⁵. A recent study noted that any capacity building within the Ministry of Education “must take into account the likelihood that some 20% of Ministry of Education personnel are HIV-positive, that the death rate will rise from 2.2-2.5% in 2000 to 4.2% in 2005, and that hours lost to sickness and funeral attendance will increase dramatically”⁶. The same report estimates that by 2005 deaths among teachers will amount to between 1,850 and 2,200 per year; that is, five or six teachers will die each day. This loss is larger than the current total output from all primary teacher-training colleges. The impact on education is not confined to the cadre of teachers, but also affects ministry staff and partner institutions, including the private sector.

Impacts on the health sector

There is an increased need for financial resources to handle escalating demand for hospitalisation. Bed occupancy in hospitals is now severely constrained in Sub-Saharan African countries. This means that treatment of opportunistic infections, especially those requiring admission, continues to place an unprecedented burden on the delivery of health services in these countries. There is an increased need for human resources to handle respond to the demand for care, while AIDS-related mortality among hospital personnel undermines the quality of service delivery. A study on mortality rates among nurses in two rural districts in Zambia (Monte and Choma districts in the Southern Province) were estimated for three time periods, 1980-85, 1986-88 and 1989-91. The mortality rate in the second period showed a fourfold increase compared with the first period and, by the third period, the increase was thirteen-fold (26.7 per 1,000 population). Information available from death certificates suggested that AIDS was the cause of the rise in mortality^7,8. The situation in Zambia, one of the hardest hit African countries, is summarized in Box 2.

The Way Forward: the need for crosscutting interventions

Firstly, at the broad crosscutting level, the first step should be the identification of the real constraints to economic and social progress which currently seem to explain, to a large extent, the adversity experienced in Africa today. They include the prolonged economic decline and successive droughts resulting in food insecurity in many communities, the costs and implications of debt and debt servicing, the very real limitations imposed by a limited and over-stretched government capacity, and the difficulties of introducing institutional reform. Programmes should address not only the immediate needs of the poor that are made worse by poverty, malnutrition and the HIV/AIDS epidemic. They should also address the underlying causes of these problems through effective broad-based strategies.

Secondly, the HIV/AIDS fight must be placed at the center of each African country's capacity building agenda. To the extent that AIDS depletes human capacity in many African countries, the epidemic must be confronted head-on. Specifically, capacity building in the health sector service delivery system is an imperative. There is need for health sector restructuring programmes to be responsive to the HIV/AIDS challenge. This calls for modes of health services delivery through, inter alia, strengthened capacity for hospital-based care for patients with HIV/AIDS. Similarly, there is an urgent need for capacity strengthening at the level of implementation through the development of integrated reproductive health frameworks that take into consideration a sufficient supply of drugs targetting the control and treatment of sexually transmitted diseases, the harmonisation of HIV/AIDS interventions by various sectors and training of both public and private sector health and allied workers. Both prevention and mitigation strategies can be found in several sectors beyond the health sector. Ministries of education, defence, information, youth, and women’s affairs, must harmonize their interventions through defined frameworks of cooperation and coordination. More importantly, the planning process that takes into account all these considerations should be decentralised and involve policy makers and decision-makers at the provincial/regional and district levels in a manner that is participatory and inclusive. Thirdly, there is need to develop robust, timely, and dependable monitoring and evaluation capacity as it relates to the HIV/AIDS epidemic. Unless countries have reliable data on HIV/AIDS prevalence and geographical patterns as well as information on those affected by the spread of epidemic (orphans in particular), it will be difficult to establish priority targets. In this regard, national sentinel surveillance data should be developed and monitoring and evaluation frameworks should be decentralised to provincial and district levels. Lastly, innovation in home-based care systems is needed, and the support that they need made available. The aim should be to ensure better quality home-based care at the household and community levels.

References

1. UNICEF (1998) Orphans and HIV/AIDS in Zambia: An assessment of orphans in the context of children affected by HIV/AIDS. UNICEF: Lusaka.

2. Hunter S (1997) Orphans and HIV/AIDS in Zambia: An assessment of orphans in the context of children affected by HIV/AIDS. UNICEF: Lusaka.

3. Ministry of Health, Zambia (1999) HIV/AIDS in Zambia: Background projections, impacts, interventions. Central Board of Health: Lusaka.

4. Matsinhe AD (2001) Human Rights: Living with AIDS in Mozambique. In: Voices from Africa; responses to HIV/AIDS. Non-governmental Liaison Service: Geneva.

5. Ministry of Health, Zambia (1999) HIV/AIDS in Zambia: Background projections, impacts, interventions. Central Board of Health: Lusaka.

6. UNICEF (1999) UNICEF Mid-term Review Report: Health and Nutrition Sector. UNICEF: Lusaka.

7. Ministry of Health/Macro International Inc (1997) Trends in demographic, family planning and health indicators in Zambia: 1980-1996. CSO:Calverton, Maryland.

8. Forgy L and A. Mwanza (1994) The economic impact of AIDS in Zambia. Report for the Ministry of Health and USAID. Lusaka.

Additional references used in the preparation of this paper

Chela C M et al (1995) Cost and impact of home-based care for people living with HIV/AIDS in Zambia, 1994. Ministry of Health and WHO: Lusaka.

Ching’ambo et al (1995) The Socio-economic impact of HIV/AIDS on selected sectors and industries in Zambia. A study commissioned by Sida, WHO and the Ministry of Health of the Republic of Zambia.

Drinkwater M (1993) The effects of HIV/AIDS on agricultural production systems in Zambia: a summary analysis of case studies conduced in the Mpongwe Area, Ndola Rural District and Teta Area, Serenje District. Ministry of Agriculture, Food and Fisheries: Lusaka.

Forster S (1993) Cost and burden of AIDS on the Zambian Health Care System: Policies to mitigate the impact of health services. USAID report: Lusaka.

Fylkesnes K, Sichone M, Ksaumba K (1997) A population-based HIV study using saliva specimens: socio-demographic determinants of infection in Zambia. Paper presented at the 10th International Conference on AIDS and STDs in Africa, Abidjan.

ILO (1995) The impact of HIV/AIDS on the productive labour force in Zambia. Eastern Africa Multidisciplinary Advisory Team, ILO: Geneva.

Ministry of Health/Macro International Inc (1997) Zambia Demographic and Health Survey, 1996. CSO and Macro International Inc.: Calverton, Maryland.

Ministry of Health (1999) Zambia Sexual Behaviour Survey, 1998. CSO: Lusaka.

Mukaka L, Kalikiti W (1995) Impact of HIV/AIDS on education in Zambia. Ministry of Health: Lusaka.

Sukwa TY, Kaona F, Musonda RM (1999) Preliminary report on multicentre study of factors determining differential spread of HIV in African towns (Ndola Site). Tropical Diseases Research Centre: Ndola.

World Bank (1997) Confronting AIDS: public priorities in a global epidemic. Oxford University Press: New York.

Zambia National AIDS/STD/TB & Leprosy Programme (1994) Strategic Plan 1994-1998: A time to act, a time to care. Lusaka.

Zambia National HIV/AIDS/STD/TB Council (1999) Zambia National HIV/AIDS Strategic Plan Summary 1999-2001 (draft). Lusaka.

Discussion

Chair The poverty and economic aspects of nutrition and HIV/AIDS are important. Poverty, particularly in this part of Sub-Saharan Africa is really a rural phenomenon. As Mrs. Monico pointed out, we have difficulty providing services to people in rural areas. In Africa, 83% of poverty is in the rural areas.

Question from the audience Why do we still see in many countries in this region poverty reduction strategies that do not address nutrition? Nutrition colleagues in these countries are struggling to be heard. Where is the accountability?

Comment from the audience The focus on poverty and malnutrition is well placed and very important. However, sexual practices are also an important factor in HIV/AIDS. Perhaps the hardest part of the epidemic to discuss is the power imbalance between men and women. This makes it very hard for women to protect themselves against HIV/AIDS.

Question from the audience It is disturbing to hear that in Zambia there is the practice of sending widows and orphans away from their father’s or breadwinner’s property. This also happens in Kenya along the Lake region. How can this be redressed?

Comment from the audience What Professor Saasa said is completely correct, but when we talk about Africa we need to bring up a couple more things to make the picture complete. This region is characterized by emergencies and armed conflict in more than half of the countries. This affects civilians more than soldiers. It is a private war. Private economic interest is the reason we have wars in so many countries. We need to understand this privatization of war. The situation is actually becoming worse. We also need to understand why the donors have left Africa and why they are not prepared to provide any significant support unless they control governments. More decisions are taken about matters of importance to Africa in the capitals of Europe and in Washington than by African governments themselves, and we need to understand this. Finally, when it comes to governance we are seeing an increase in corruption, not a decrease. We see the poor get poorer and the rich get richer. Just because we have so-called “multi-party elections” we don’t necessarily have democracy. These things need to be brought into the picture to understand why the HIV/AIDS catastrophe is very serious for the survival of this part of the world.

Question from the audience An emphasis on the health, nutrition, survival and productivity of those who remain behind when this terrible disease is dealt with is well placed. However, your interpretation of what is being done about breast-feeding is worrying. Exclusive breastfeeding, not mixed feeding, is the best method of infant feeding. Replacement feeding with formula should only be done if it is feasible, safe and there is adequate health care. Is it likely that all these things would be available? We cannot forget that 80% or more of the children who are breastfed are not going to get HIV from breastfeeding.

Oliver Saasa Nutrition strategies are not really factored in when developing poverty reduction strategy papers, currently, in countries in this region. We need to put this challenge to governments. We economists voice our concerns, but it really is a government issue. To what extent are governments prepared to listen and come on board? Nutrition and malnutrition are important areas and they ought to be addressed in poverty reduction strategies.

Sexual practices and imbalances between men and women are definitely areas of concern. The difficulty is what approach to take in programmes. One has to be very careful in designing interventions. Regarding “property grabbing”, in Zambia, we have legislation that stops people from coming in and grabbing property of the deceased away from the surviving spouse and children. The biggest problem is implementation. We have failed to use our legal system to bring the perpetrators to justice for several reasons. These reasons involve government and corruption. People have been released for crimes that should not have been forgiven. No government can be excused for allowing someone, such as an uncle, to grab everything and leave the children to die from poverty. The children are unable to obtain an education, unable to find adequate food. This is happening under our noses and under the governments’ noses and not much is being done about it.

Question from the audience Mrs. Monico, you talked about preparing counsellors for working with those infected with HIV/AIDS. Is this similar to peer counselling? Does TASO train those who are infected with HIV to counsel others who are infected?

Sophia Monico Yes, we do and we actually train even the caregivers to counsel themselves. We call it the “careful carers programme”. We also carry out peer education within companies where employees can go to fellow employees without coming to TASO.

Question from the audience A previous discussant was absolutely right to identify some of the underlying economic and political factors which make it so difficult to address this problem of HIV. Professor Saasa focused on the effects of HIV on peoples’ economic well being, on human resource capacity, on employment, and on agricultural productivity. Little was said about the reverse, apart from a brief reference by Dr. Piot. How is the current global macroeconomic situation impacting on the epidemic? How much is the rapidly accelerating inequity between and within nations driving this epidemic? How much is the increased poverty in rural and urban areas of Africa driving the epidemic by forcing women into sex for cash? It has been well documented that macro-economic deterioration is undermining basic health services so that effective and early treatment of sexually transmitted diseases becomes increasingly difficult in many countries. Even in South Africa, probably the richest country in Africa, we are finding that supplies of essential drugs to primary care centres are erratic. Why has so little been done to assess how economic policies are actually fuelling this epidemic? And why are the nutrition community and some of the UN agencies silent about these kinds of economic policies? These economic policies and institutions, particularly the World Trade Organization, are impacting on peoples’ ability to access cheap pharmaceuticals to treat HIV-related problems. They also affect trade relations among countries where poor countries are becoming increasingly dependent and increasingly bereft of the meagre economic resources which they have.

Oliver Saasa These economies exist within the global environment and therefore what happens at the global level in terms of resource transfers, commitment and actual direct transfer is pertinent. The policies that the multilaterals promote to encourage poverty reduction do have far-reaching implications. Take, for example, structural adjustment programmes. The idea was to reduce poverty but the instruments used were not sufficient to address poverty. Balancing the budget, lowering interest rates, expanding international trade are all good things in terms of net economic growth. However, they are not a remedy to poverty reduction. They are very important interventions. The World Bank and the IMF emphasized these aspects but they are not sufficient and, increasingly, we realize this. In fact, in the past two years the World Bank and the IMF have come out with more participatory approaches to poverty reduction. I do not know the situation in Kenya but, for me, the poverty reduction strategy papers that had been developed across Sub-Saharan Africa are apologies. The Bank and the IMF failed to come out and explain their transgressions. They then u-turned and said they have seen budgets being balanced and GDP growing, while poverty worsens. The sorts of policies that were encouraged from outside have not factored in the peculiarities of these countries, which to a large degree, do explain the extent of poverty. Poverty in Africa is not an isolated phenomenon which can only be explained by the problems of Africa and by Africans. We need to see whether the multilaterals are actually doing enough in terms of policy prescriptions and net transfers. The debt burden has to be addressed and UNICEF is at the forefront raising awareness of the consequences of debt. Debt severely constrains a country’s ability to tackle the HIV/AIDS epidemic. Therefore, it is important that Africa be understood and African initiatives be viewed in the context of the global situation.

Comment from the audience There is a loss of traditional livelihoods and there are no replacements in sight. The loss of livelihoods is having an effect on family integrity and cohesion which feeds into a whole series of problems in the region, including conflict. In other words, a loss of authority structures within households and within lineages coupled with poverty and disease, are feeding these problems.

Question from the audience How will TASO use food aid? How will TASO rationalize its use? Will food be tailored in terms of the nutritional needs of the AIDS client or as an income transfer for the household? A related concern is the lack of testing for HIV. Another speaker said that only one percent of mothers in antenatal settings know whether they are HIV positive or not. Why are the testing levels so low? Not only is testing important for food therapy and breastfeeding, it is also important in terms of human rights and the mobilization of people in terms of their own interests.

Sophia Monico Concerning food, USAID will advise TASO on the best uses of food aid. Although there is a transfer element, we are not considering income transfer. If TASO distributes corn soy blend (CSB) and cooking oil, this will generate savings from household budgets and clients can buy something else with the savings. Yet CSB is a supplement because it is a porridge and no one can live on porridge alone. Other foods are needed to complement the food supplies that TASO gets from USAID. CSB is very nutritious, so the food component of TASO’s work will add significantly to the nutritional value of clients’ diets.

About testing levels, one thing we have to realize (and this is why I say Uganda is fortunate) is that people only test when they see an advantage in testing. Why test at all? If there is a support system then I might test. If there is stigma and discrimination why should I test? Most people don’t test because of the environment in which they live. We have shown that wherever we have a TASO centre, we must also have a testing facility. All clients at TASO have been tested. Where we don’t have a centre, the testing facility does not work very well because there is no support system.

Chair In my travels over the last few weeks, I asked people involved in raising awareness of HIV/AIDS if they themselves had been tested. The answer was usually no. Somehow we have to get those who are involved in community mobilization to stand up and say “I have been tested”.

Question from the audience Please comment, Professor Saasa, on the correlation between malnutrition and expenditure budgets for military hardware, especially in the sub-Saharan Africa. In very poor countries, a big component of public resources is spent on the military.

Oliver Saasa The point is valid regarding how to apportion a small cake in the face of competing demands. Wars in Africa are a source of concern. Wars deplete limited human resources. Sometimes countries go to war for reasons of maintaining political stability which is required for economic development. This is made worse when external players come in and fuel the problem. The concern about military spending is also valid. Neighbouring countries do team up to solve a civil wars, using military tanks from another country; this is difficult to understand.

Question from the audience Why is it that the educated and skilled people in Africa are dying from AIDS? We have linked HIV/AIDS and poverty and we are talking about the rural poor. Yet, it is ministers, permanent secretaries and directors who are dying of AIDS. How many of us would not spend the whole night fighting with our spouses if we found condoms in their pockets? How many of us distribute the resources of Information-Education-Communications programmes to communities, yet we do not take these resources home to our spouses?

My second question is on the linkages between nutrition and HIV/AIDS and development. The linkages are obvious. Nutrition was seen as a sectoral issue: health. HIV/AIDS was seen as a sectoral issue: health. Now both are seen as development issues. Malnutrition leads to death, though not as loudly as AIDS. We have been talking about incorporating nutrition into development programmes and we can incorporate nutrition into HIV programmes, however, how can we incorporate the prevention of HIV transmission into nutrition programmes? This goes beyond breastfeeding and mother-to-child transmission. It concerns incorporating the prevention of HIV/AIDS into all aspects of nutrition. Can the international organizations guide us at the national level?

Chair From the international organizations’ point of view, first, we must realize that the problem of HIV/AIDS is multisectoral. We have to work together. The first defence is awareness. If people are aware we can begin to take action. Second, in many places even if testing is promoted, there is no testing equipment. Thus, national governments and international assistance both need to prioritize testing. If people are not tested it is difficult to know what kinds of packages to make available in communities. Nutrition programmes, indeed development activities in general, cannot and should not be done in isolation. No nutrition programme just comes to a community and says: this is what you are going to eat. It is important to work through community institutions. Nutrition education programmes can incorporate health messages. Schools can be used as centres for community mobilization. There are many activities at schools which could be built around messages for HIV/AIDS, such as messages about condoms. There is great resistance in some communities to even pronouncing the word condom.

There are many communities with activities on prevention or care, but the word condom is taboo.

Oliver Sassa Concerning the question why is it that the educated directors and ministers are the ones that are dying - actually, this is not the case. Their deaths hit the media, while the deaths of 200 people in a remote Kenyan village do not. The poor are hit severely, but the rich are not spared. The rich can afford to buy treatment for AIDS, they can afford to pay for services. However, death is not confined to the educated. Another aspect is that when an educated person dies, not only does the death capture the media, there is a ripple effect across society. Similarly, if the breadwinner dies an entire family of five or six or more members, is affected.

Sophia Monico The poor die less quickly in Uganda because they are more likely to seek services. In some circumstances they are more likely to get quality services. They can learn to cope with the disease burden. TASO has used food assistance to attract people to come for services. Most people who are very poor cannot afford food. Therefore food is an incentive for people to come for services.

Question from the audience Mrs. Monico, TASO is heavily reliant on food aid. Food aid is never sustainable. Is TASO looking at more sustainable means, or approaches that use locally-produced food?

Sophia Monico We do rely on food aid, but we are starting a programme with assistance from the World Food Programme called Food for Training. TASO will offer training to family members to use the little plots around their houses to plant food. This can complement what they buy in the markets. TASO may not be able to train clients because, in most cases, they are ill and weak. Nevertheless, we can train family members, even young children.