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AIDS in the Twenty-First Century: What is needed?
BRIEF REPORT
HIV/AIDS in the Twenty-First Century: What is needed?
by Insaf Hag-Mousa and Walter Kipp
Insaf Hag-Mousa, MD, MSc, PhD (candidate), has been involved in health research at different universities since 1997, including the London School of Hygiene and Tropical Medicine (London, UK), the Karolinska Institute (Stockholm, Sweden), and the University of Alberta (Edmonton, Alberta, Canada). Her interest in health research has focused on reproductive healthrelated issues, particularly for women living in developing countries. Walter Kipp, MD, MPH, PhD, is Professor for International Health in the Department of Public Health Sciences at the University of Alberta, Edmonton.
Introduction HIV/AIDS is the most serious health threat in our history; to date it has killed more people than the plague in the Middle Ages. It is now well understood that HIV/AIDS doesn’t stop with the deaths of patients. Its impact goes far beyond individual lives and seriously affects communities and entire nations.1 Most professionals involved in HIV/AIDS research and program implementation are occupied with addressing the immediate needs and challenges of individual patients and high-risk groups. However, they are sometimes so busy with this immediate type of work (which is of course very important) that they tend to neglect the longer term aspects of this epidemic. It has become evident that there is much less information available in the literature about the social and economic impacts of HIV/AIDS (especially for sub-Saharan Africa) compared to biomedical, clinical, and preventative aspects. We need to anticipate the future to fully recognize the destructive impact of HIV/AIDS. For example, in Botswana it is predicted that life expectancy will drop from 65 in 1995 to 29 in 2010, a decrease of 35 years. This massive decrease, never before observed in such a short period of time, may lead to the collapse of national governments and indeed entire nations with resulting anarchy and unrest. A strategy to better understand the long-term impact of HIV/AIDS would help improve planning to address the destruction that this disease is causing to millions around the world.
D
Impact of HIV/AIDS eveloping countries, particularly in sub-Saharan Africa, comprise the region that is most affected by this disease. Beyond its impact on the health status, HIV/AIDS impacts both the social and economic dimensions of life. The social impact results from the stress related to HIV/AIDS and the decline in quality of life because of the deterioration of the infected person’s physical, psychological, social, and/or emotional well-being, with the knowledge that death is the inevitable outcome.1-3 Because of this, family relationships, women’s reproduction and family health are directly and negatively affected by HIV/AIDS. Also, women are particularly affected because they find themselves responsible for the care of their AIDS infected partner, often well aware that they are HIV positive too.4 HIV/AIDS is also a gender issue of utmost importance. HIV infection at a younger age (resulting in deaths at a younger age for women vs. men), huge caregiving responsibilities for infected family members, blame for being the cause of an HIV infection, stigmatization, and loss of educational opportunities for young girls, are examples of the gender-related issues. Economically, the disease is known to have swept out decades of modest progress that has been made in some developing countries.4,5 Individuals and households become poorer because of the inability of family members to work and generate income. This is either because of HIV/AIDS, i.e. being absent from work for many days, or because of job loss based on
36
Healthcare Management Forum Gestion des soins de santé
discrimination against HIV employees at work. Absenteeism makes HIV/AIDS patients look unproductive and less desirable for employment. In addition, HIV/AIDS brings an additional financial burden to families. Families spend most of their scarce resources for the care of infected family members. If the AIDS patient is the male head of the household, healthcare for him is the top priority and all household resources are used for healthcare and the purchase of drugs. At the national level, the loss of the productive years of the young and economically important population in these countries has contributed to the decrease in the national economic growth of many developing countries. 1,4 For the year of 2000, the global economic losses due to HIV/AIDS were estimated to be similar to those attributed to the oil crisis in 1973. The increase of poverty among families living the HIV/AIDS experience has also affected the education of children. Children, particularly girls, often have to drop out of school because they have to help with household chores and provide care for the sick, thus losing part (or all) of their education.4,6 Even boys experience difficulty continuing their education because of the lack of financial resources to pay for their school fees and/or the need for labour on the family farm.4,6
Action needed Given all these factors it is obvious that the future for some developing countries in sub-Saharan Africa is full of uncertainty. Therefore, a call for action seems more urgent now than ever before. Because HIV/AIDS is affecting every aspect of people’s lives, solutions cannot be found in medical wards and by physicians only. HIV/AIDS has multiple roots; therefore a multi-sectoral approach is the only way to combat it. In most high prevalence countries in sub-Saharan Africa, the multi-sectoral approach has not been fully realized yet, although Uganda and Senegal have made some progress. African governments need to deliver on different fronts. Healthcare, education, social services, agriculture extension services, and community/household
economics are some examples. For many countries, healthcare was already stretched to the limits before HIV/AIDS arrived. With hospital wards now mostly occupied by patients with AIDS-related medical conditions, existing health services threaten to collapse. This is also true for other sectors such as agriculture, where sub-Saharan Africa has lost some seven to eight million farmers in the past due to HIV/AIDS. This represents another severe loss in know-how and labour in the agriculture sector. There is a need to refinance existing healthcare services to deliver quality care including equitable distribution of antiretroviral drugs for HIV/AIDS patients. Efforts to de-stigmatize the disease have to be intensified, because the stigma around HIV/AIDS still prevents many people from seeking care. Public healthcare programs need outreach services to serve households and communities in remote areas in order to provide both quality treatment and preventative HIV/AIDS services.7,8 Expanding and improving the education system for all children, particularly for poor children, should be a priority for all governments in developing countries. Young girls will benefit the most because education will hopefully increase their chances of escaping the poverty cycle and hence decrease their susceptibility to contracting HIV/AIDS.4, 6 To keep girls in schools should be a top priority of each government when designing educational policies.6 Schools can also act as the vehicle to deliver effective health education messages on HIV/AIDS transmission, prevention, and treatment to school students. We know from a number of studies, that school attendees are more likely to adopt safe sex behaviours than those not attending school.9 Social services have to play an important role in providing care and support to HIV/AIDS patients and their families. Caregiving to AIDS families should be a responsibility shared between families and social services in order to keep affected families functioning despite the overwhelming caregiver burden. Social services could also help in destigmatizing HIV, which would alleviate some of the stress HIV-affected families usually endure.
In most of the sub-Saharan countries severely affected by HIV/AIDS (possibly with the exception of Botswana, South Africa and Namibia), the resources required for a comprehensive response to the epidemic are not available. Therefore, the international donor community has to be willing to finance HIV control on a long-term basis (not years, but decades). The priorities for long-term support should be based on long-term goals instead of the short-term commitments which still prevail and which are prone to fast changes and “fashionable trends”. These trends are not suitable for the long-term goals required for successful HIV/AIDS work. Up till now it seems that the international commitment to deal with this issue has been less than sufficient for the magnitude of the problem.
Conclusion The future of developing countries most seriously affected with HIV/AIDS will depend on long-term commitments. Developing countries need to maximize what they have within their own resources, and allocate and use their limited budgets in a very cost-effective way. Since it is the long-term sustainability of HIV/AIDS program activities which are required for success in the long term, long-term commitments “at home” are vital. Since the future of those developing countries most seriously affected will still depend on foreign aid, international donors will also need to commit for the long term immediately, since time to make a difference is running out. References 1. Barnett T, Whiteside A. AIDS in the Twenty-First Century: Disease and globalization. New York (NY): Palgrave Macmillan; 2002. 2. Baylies C. The impact of HIV and family size preference in Zambia. Reproductive Health Matters 2000;8(15):77-88. 3. Forsythe S, Rau B. Evolution of socioeconomic impact assessments of HIV/AIDS. AIDS 1998;12(Suppl 2):S47-S55. 4. United Nations Population Fund. State of World Population 2002. People, poverty and possibilities: making development work for the poor; 2002. 5. United Nations Development Program. Human Development Report 2003. Millennium Development Goals: A compact among nations to end human poverty. New York: Oxford University Press; 2003. 6. United Nations Children’s Fund. The state of the world’s children 2004. Girls, education and development; December 2003. 7. UNAIDS. AIDS Epidemic Update. Geneva, Switzerland: UNAIDS/WHO; 2002. 8. UNAIDS. A review of household and community responses to the HIV/AIDS epidemic in the rural areas of sub-Saharan Africa. Geneva, Switzerland: UNAIDS; 1999. 9. Kipp W, Ndyanabangi B, Diesfeld HJ. Reproductive health behaviors among in-school and out-of-school in Kabarole district, Uganda. African Journal for Reproductive Health 2004; in press.
Healthcare Management Forum Gestion des soins de santé
37
HIV/AIDS in the Twenty-First Century: What is needed?
by Insaf Hag-Mousa and Walter Kipp
Insaf Hag-Mousa, MD, MSc, PhD (candidate), has been involved in health research at different universities since 1997, including the London School of Hygiene and Tropical Medicine (London, UK), the Karolinska Institute (Stockholm, Sweden), and the University of Alberta (Edmonton, Alberta, Canada). Her interest in health research has focused on reproductive healthrelated issues, particularly for women living in developing countries. Walter Kipp, MD, MPH, PhD, is Professor for International Health in the Department of Public Health Sciences at the University of Alberta, Edmonton.
Introduction HIV/AIDS is the most serious health threat in our history; to date it has killed more people than the plague in the Middle Ages. It is now well understood that HIV/AIDS doesn’t stop with the deaths of patients. Its impact goes far beyond individual lives and seriously affects communities and entire nations.1 Most professionals involved in HIV/AIDS research and program implementation are occupied with addressing the immediate needs and challenges of individual patients and high-risk groups. However, they are sometimes so busy with this immediate type of work (which is of course very important) that they tend to neglect the longer term aspects of this epidemic. It has become evident that there is much less information available in the literature about the social and economic impacts of HIV/AIDS (especially for sub-Saharan Africa) compared to biomedical, clinical, and preventative aspects. We need to anticipate the future to fully recognize the destructive impact of HIV/AIDS. For example, in Botswana it is predicted that life expectancy will drop from 65 in 1995 to 29 in 2010, a decrease of 35 years. This massive decrease, never before observed in such a short period of time, may lead to the collapse of national governments and indeed entire nations with resulting anarchy and unrest. A strategy to better understand the long-term impact of HIV/AIDS would help improve planning to address the destruction that this disease is causing to millions around the world.
D
Impact of HIV/AIDS eveloping countries, particularly in sub-Saharan Africa, comprise the region that is most affected by this disease. Beyond its impact on the health status, HIV/AIDS impacts both the social and economic dimensions of life. The social impact results from the stress related to HIV/AIDS and the decline in quality of life because of the deterioration of the infected person’s physical, psychological, social, and/or emotional well-being, with the knowledge that death is the inevitable outcome.1-3 Because of this, family relationships, women’s reproduction and family health are directly and negatively affected by HIV/AIDS. Also, women are particularly affected because they find themselves responsible for the care of their AIDS infected partner, often well aware that they are HIV positive too.4 HIV/AIDS is also a gender issue of utmost importance. HIV infection at a younger age (resulting in deaths at a younger age for women vs. men), huge caregiving responsibilities for infected family members, blame for being the cause of an HIV infection, stigmatization, and loss of educational opportunities for young girls, are examples of the gender-related issues. Economically, the disease is known to have swept out decades of modest progress that has been made in some developing countries.4,5 Individuals and households become poorer because of the inability of family members to work and generate income. This is either because of HIV/AIDS, i.e. being absent from work for many days, or because of job loss based on
36
Healthcare Management Forum Gestion des soins de santé
discrimination against HIV employees at work. Absenteeism makes HIV/AIDS patients look unproductive and less desirable for employment. In addition, HIV/AIDS brings an additional financial burden to families. Families spend most of their scarce resources for the care of infected family members. If the AIDS patient is the male head of the household, healthcare for him is the top priority and all household resources are used for healthcare and the purchase of drugs. At the national level, the loss of the productive years of the young and economically important population in these countries has contributed to the decrease in the national economic growth of many developing countries. 1,4 For the year of 2000, the global economic losses due to HIV/AIDS were estimated to be similar to those attributed to the oil crisis in 1973. The increase of poverty among families living the HIV/AIDS experience has also affected the education of children. Children, particularly girls, often have to drop out of school because they have to help with household chores and provide care for the sick, thus losing part (or all) of their education.4,6 Even boys experience difficulty continuing their education because of the lack of financial resources to pay for their school fees and/or the need for labour on the family farm.4,6
Action needed Given all these factors it is obvious that the future for some developing countries in sub-Saharan Africa is full of uncertainty. Therefore, a call for action seems more urgent now than ever before. Because HIV/AIDS is affecting every aspect of people’s lives, solutions cannot be found in medical wards and by physicians only. HIV/AIDS has multiple roots; therefore a multi-sectoral approach is the only way to combat it. In most high prevalence countries in sub-Saharan Africa, the multi-sectoral approach has not been fully realized yet, although Uganda and Senegal have made some progress. African governments need to deliver on different fronts. Healthcare, education, social services, agriculture extension services, and community/household
economics are some examples. For many countries, healthcare was already stretched to the limits before HIV/AIDS arrived. With hospital wards now mostly occupied by patients with AIDS-related medical conditions, existing health services threaten to collapse. This is also true for other sectors such as agriculture, where sub-Saharan Africa has lost some seven to eight million farmers in the past due to HIV/AIDS. This represents another severe loss in know-how and labour in the agriculture sector. There is a need to refinance existing healthcare services to deliver quality care including equitable distribution of antiretroviral drugs for HIV/AIDS patients. Efforts to de-stigmatize the disease have to be intensified, because the stigma around HIV/AIDS still prevents many people from seeking care. Public healthcare programs need outreach services to serve households and communities in remote areas in order to provide both quality treatment and preventative HIV/AIDS services.7,8 Expanding and improving the education system for all children, particularly for poor children, should be a priority for all governments in developing countries. Young girls will benefit the most because education will hopefully increase their chances of escaping the poverty cycle and hence decrease their susceptibility to contracting HIV/AIDS.4, 6 To keep girls in schools should be a top priority of each government when designing educational policies.6 Schools can also act as the vehicle to deliver effective health education messages on HIV/AIDS transmission, prevention, and treatment to school students. We know from a number of studies, that school attendees are more likely to adopt safe sex behaviours than those not attending school.9 Social services have to play an important role in providing care and support to HIV/AIDS patients and their families. Caregiving to AIDS families should be a responsibility shared between families and social services in order to keep affected families functioning despite the overwhelming caregiver burden. Social services could also help in destigmatizing HIV, which would alleviate some of the stress HIV-affected families usually endure.
In most of the sub-Saharan countries severely affected by HIV/AIDS (possibly with the exception of Botswana, South Africa and Namibia), the resources required for a comprehensive response to the epidemic are not available. Therefore, the international donor community has to be willing to finance HIV control on a long-term basis (not years, but decades). The priorities for long-term support should be based on long-term goals instead of the short-term commitments which still prevail and which are prone to fast changes and “fashionable trends”. These trends are not suitable for the long-term goals required for successful HIV/AIDS work. Up till now it seems that the international commitment to deal with this issue has been less than sufficient for the magnitude of the problem.
Conclusion The future of developing countries most seriously affected with HIV/AIDS will depend on long-term commitments. Developing countries need to maximize what they have within their own resources, and allocate and use their limited budgets in a very cost-effective way. Since it is the long-term sustainability of HIV/AIDS program activities which are required for success in the long term, long-term commitments “at home” are vital. Since the future of those developing countries most seriously affected will still depend on foreign aid, international donors will also need to commit for the long term immediately, since time to make a difference is running out. References 1. Barnett T, Whiteside A. AIDS in the Twenty-First Century: Disease and globalization. New York (NY): Palgrave Macmillan; 2002. 2. Baylies C. The impact of HIV and family size preference in Zambia. Reproductive Health Matters 2000;8(15):77-88. 3. Forsythe S, Rau B. Evolution of socioeconomic impact assessments of HIV/AIDS. AIDS 1998;12(Suppl 2):S47-S55. 4. United Nations Population Fund. State of World Population 2002. People, poverty and possibilities: making development work for the poor; 2002. 5. United Nations Development Program. Human Development Report 2003. Millennium Development Goals: A compact among nations to end human poverty. New York: Oxford University Press; 2003. 6. United Nations Children’s Fund. The state of the world’s children 2004. Girls, education and development; December 2003. 7. UNAIDS. AIDS Epidemic Update. Geneva, Switzerland: UNAIDS/WHO; 2002. 8. UNAIDS. A review of household and community responses to the HIV/AIDS epidemic in the rural areas of sub-Saharan Africa. Geneva, Switzerland: UNAIDS; 1999. 9. Kipp W, Ndyanabangi B, Diesfeld HJ. Reproductive health behaviors among in-school and out-of-school in Kabarole district, Uganda. African Journal for Reproductive Health 2004; in press.
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