INTEGRATING HIV/AIDS
 
 
 

Professor Desmond Cohen and Dr. Sheila Smith

HIVDEV Consultants

October 2002
 
 
 

Not to be circulated in altered form without the permission of the authors
 

NEPAD: 
INTEGRATING HIV/AIDS
 

I: Setting the Policy Context

All development strategies must begin from a realistic assessment of the
current situation, so that plans are rooted in what is achieveable given the
initial resources and constraints. The context within which NEPAD is set
needs to recognize the pervasiveness of the problem of HIV/AIDS, as a major
determinant of the current situation. HIV/AIDS is undermining development in
many countries:
 

   * it is leading to a deterioration in indicators that had been improving,
     such as life expectancy, literacy and primary school enrolment;Ý

   * it is reducing capacity in all social and economic sectors, as a result
     of the mortality and morbidity of highly skilled and experienced people
     who cannot be replaced quickly or easily, but only after long periods
     of training and skill acquisition;

   * it is lowering general levels of education as enrolments fall among
     children who lose parents as a result of HIV/AIDS and as educational
     capacity is lost because of mortality among teachers, educational
     administrators and teacher trainers;

   * Ýit is leading to a retreat into subsistence production in agriculture
     as a result of reductions in the economically active population ? the
     group most likely to be HIV-positive;
 

   * it is reducing productive capacity in all sectors because of the
     decline in key categories of skill, especially managerial capacity;
     these declines in economic activity in turn are reducing levels of tax
     revenue, which lowers the capacity of the public sector to undertake
     its functions at a time of dramatically increased demand for public
     services in health, education and training.
 

These effects of the HIV/AIDS epidemic are not felt uniformly in Africa, but
significant numbers of countries in the region are now experiencing
declining development indicators as a direct result of HIV/AIDS, even
countries which had been manifesting evidence of improvements in general
living standards of their people.

In order for NEPAD to become a more realistic framework for African
development, HIV/AIDS must be integrated into all policies and programmes,
at all levels. Otherwise any positive contributions which NEPAD may make
will risk being undermined by the epidemic.
 

A. Millennium Development Goals and Development Performance

It is necessary to set the MDG goals for African development
against the reality of what has been achieved in the past decade or so. Only
then is it possible to judge the feasibility of what may be achieved under
NEPAD, and what may be the key strategic obstacles faced by policy makers in
Africa. The following is a brief summary of the main goals and achievements,
and is not intended as other than key background information for assessing
the likelihood ofÝ NEPAD'sÝ proposals being implemented. The MDG for
HIV/AIDS, to have halted the spread of HIV by 2015, and begun to reverse the
incidence of new infection, is dealt with the next section.

It is worth noting that data and indicators for many African countries
involve uncertainties with respect to their quality and reliability.
Furthermore, the use of averages for comparative purposes has the effect of
hiding what has been happening to the poorest people: averages often
disguise the absence of progress with respect to the poorest, in the same
way that aggregation also masks what is happening to other subgroups in the
population. These caveats need to be kept in mind when assessing the
following targets and historical performance.
 

1. Eradicate extreme poverty and hunger

Nearly half the population of Africa [300 million people] live on less than
1$ a day: if current trends continue, by 2015 Africa will account for 50%
ofÝ the poor of the developing world [up from 25% in 1990]. During the 1990s
the region experienced a decline in GDP per capita of 0.6% per annum, and
because economic growth was highly skewed between countries, approximately
half the total population are actually poorer in 2002 than they were in
1990. It is also the case that income and wealth distributions are extremely
unequal in many countries, and with improved growth rates such inequalities
are likely to increase rather than to diminish. It follows that to achieve
the MDG of reducing by 50% the proportion of people in Africa whose incomes
are less than 1$ a day by 2015, will require very rapid GDP growth if the
poorest are to benefit.

Many African countries have made very little progress in eradicating hunger
and malnutrition in the 1990s. It is estimated that the numbers of people
suffering malnutrition has increased to some 200 million in recent decades
and the problem is especially severe in Central, East and Southern Africa
where almost a half of the population of 360 million is estimated as being
undernourished. Women and children are especially vulnerable to food
insecurity and malnutrition, with the latter being especially important as a
cause of under-five mortality. Trends have actually been reversed during the
1990s in those countries most affected by adverse growth in GDP and by the
effects of HIV/AIDS. Indeed UNDP/UNICEF recently concluded that, " During
the 1990s, the spread of HIV/AIDS had a devastating effect on families and
communities. The loss of productive capacity among families affected by
HIV/AIDS had a major impact on food production and on nutritional
well-being".
 

2. Achieve universal primary education

The target is that by 2015 children everywhere, boys and girls, will be able
to complete a full course of primary schooling. While African countries saw
some progress in educating children during the 1990s this was not nearly
enough to meet the goal set for 2015. In over a third of countries every
other child is not in school; while some countries have increased their
enrolment rates [such as Uganda and Malawi] other countries actually
experienced declines [such as CAR, Lesotho and South Africa]. There continue
to be significant urban-rural gaps in enrolment, and in some countries the
enrolment ratio in urban areas is some 2 to 3 times higher than for rural
populations. Unless the educational targets are substantially achieved in
the coming decade then not only will millions of children be deprived of
their right to basic education but many of the other targets will also be
unachievable. A better-educated population is essential for the achievement
of democratic states in Africa and for improvement in systems of governance.
It is wholly improbable that economic growth and poverty reduction targets
can be met without a better-educated and skilled population, and a more
educated population is essential for improving labour productivity. Improved
access to education for girls is also crucial for achieving progress on
maternal and under-5 mortality, and for progress generally in the area of
reproductive health.
 

3. Improve maternal health and reduce child mortality

This MDG encompasses 2 aims: to reduce by two-thirds the under-five
mortality rate by 2015, and to reduce by three-quarters the maternal
mortality ratio by the same date. At the present time 15% of all children in
Africa will not live to see their fifth birthday. Progress in reaching U5MR
seems to have been reversed during the past two decades, and some countries,
such as Botswana and Kenya, have actually seen increases in U5MR due to
HIV/AIDS. There also remain significant gaps between urban and rural rates
in many countries, and it is clear that the probability of a child dying is
much greater in poorer families than in richer ones [the probability is
twice as high for children in the bottom 20% of the income distribution as
it is in the top 20%].

African countries currently account for about one third of all maternal
deaths worldwide, with about 250,000 women dying during pregnancy and
childbirth every year. These trends seem if anything to have worsened during
the past decade, in part associated with deteriorating health care systems.
But the primary problem, apart from poor access to health care, continues to
be the continued high levels of fertility, and thus persistently high risks
of maternal mortality. The comparative rates of maternal mortality between
developing country regions strikingly emphases the gap between Africa and
other regions ? in Africa a woman faces a 1 in 13 chance of dying in
childbirth compared with 1 in 160 in Latin America and 1 in 280 in East
Asia.
 

4. Ensure environmental sustainability

There are major tasks facing Africa in protecting its environment and in
achieving access to basic services so important for health and the standard
of living. Access to water seems to have been somewhat reversed for urban
populations during the 1990s, and although rural populations have increased
access it has been at an extremely slow rate. If the MDG target is to be
reached by 2015 then an additional 400 million people would need to be
provided with safe water ? an almost inconceivable rate of new investment.
In parallel with problems of clean water are continued poor levels of
sanitation, carrying with it a multitude of health and other social
problems. These trends are occurring within an overall set of conditions in
which further deterioration is taking place in the environment, with rapid
depletion of forest resources and further land degradation. It is estimated
that 90% of the rural population continues to depend on traditional sources
of energy [which in part explains the continued losses of forested areas].
With continued population pressure these trends can only worsen, unless
there is massive investment in alternative energy sources.
 

5.Develop a global partnership for development

Here the goals are to strengthen external performance through de-regulation
of the financial and trading system, greater participation in trade with the
rest of the world, and through debt negotiations to establish a situation
where debt ratios are sustainable. In the 1990s all of the trends in these
conditions were negative, with consequences for the rate at which social and
economic development could take place. Many countries had stagnant and
declining exports, falling terms of trade, diminished export diversification
[increased concentration on primary exports], and rising debt service
payments.

Africa's share of world trade fell from a level of 5% in the 1980s to around
3% in the 1990s. While the need for external finance increased as a result
of the trends in trade, in fact the flows of ODA and of private capital
actually fell. On average, by the end of the 1990s, the debt service ratio
stood at 189%, while the ratio to GNP was 66% [many countries face much
worse debt ratios]. As a result many countries spent on debt servicing as
much as 3 to 5 times more than their expenditure on social services ? with
devastating consequences for those most dependent on the state for education
and health.

The overall assessment of the performance of Africa in the past
decade by UNDP/UNICEF is stark. They conclude, " Not only was progress
inadequate, much of it by-passed the poor. Global goals are primarily meant
to help the situation of the poor and the disadvantagedÖunfortunately the
poor have benefited proportionately little from "average" progress, as
witnessed by widening disparities in terms of income, education and
mortalityÖÖEven worse, little or no progress was achieved in reversing the
HIV/AIDS pandemic. "
 
 

B. HIV Prevalence in sub-Saharan Africa? The Evidence

Of the global total of 40 million persons living with HIV in
2001 almost 70% [28.1 million] are in sub-Saharan Africa. In Africa
infection is concentrated in the socially and economically productive groups
aged 15-45, with slightly more women infected than men. There are
significant differences in the ages of infection of girls and boys, with
infection occurring at younger ages for girls (with girls and young women in
some countries outnumbering boys and young men by factors of 5 or 6 in the
age range 15-20). It is estimated that 24 million persons have died from
HIV-related illnesses since the start of the epidemic worldwide, of whom
more than 19 million were Africans.

It follows that the cumulative affected population in Africa, taking into
account spouses, children and elderly dependents, must be of the order of
235 million [28 million currently living with HIV plus 19 million who have
died times a factor of 5 to represent those directly affected]. This is a
staggering proportion of the total population in sub-Saharan Africa ?
something like one-third of Africans are directly affected by the HIV
epidemic.Ý Few people can remain unaffected in indirect ways, i.e. through
the illness and death of relatives, friends and in their workplaces and
their communities.

The levels of HIV prevalence in parts of Africa are extremely high - in
Southern Africa there are increasing numbers of countries with HIV infection
rates among adults in excess of 20%.Ý The gap between rural and urban HIV
rates -- previously substantial -- is now narrowing rapidly in many
countries. For some urban populations HIV is now as high as 40-50% -- rates
of infection earlier considered wholly improbable. For example in Botswana
HIV prevalence in the capital city, Gaborone, has risen from 15% in 1992 to
39% in 1998. In the case of Francistown the prevalence was estimated at 43%
in 1998, and 10 of the country's 15 sentinel sites now have HIV rates in
excess of 33%. The overall HIV prevalence rate for the adult population in
1999 was 36%, making Botswana the country with the highest level of any
country.Ý It is now projected that over the next 10 years that Botswana will
lose a quarter or thereabouts of its total population to AIDS. This is in a
country which has done remarkably well since independence and one where
there has been sustained social and economic development. But it is still a
country where about half the population lives in poverty, concentrated
particularly amongst female-headed households.

It is estimated that there are presently some 11 million
children in Africa who have lost one or both parents to HIV-related
illnesses, and that by 2010 these numbers are projected to increase to some
20 million. The most severely affected countries in terms of AIDS orphans in
the year 2001, according to UNICEF/UNAIDS, are Ethiopia [989,000]; Kenya
[892,000]; Malawi [468,000]; Nigeria [995,000]; Uganda [884,000], Tanzania
[815,000], Zambia [572,000] and Zimbabwe [782,000].Ý These are truly
staggering numbers. In some countries the proportion of all children under
15 years of age who have lost one or both parents to AIDS may be as high as
20%, possibly even higher, by the end of the first decade of the new
millennium. It should be noted that AIDS orphans account for only a
proportion of the total number of orphans from all causes, so that the
overall problem is even more serious. The most recent estimate [2002] is
that the total number of orphans in Africa in 2010 will be 42 million of
whom 47% will be AIDS orphans. These trends have direct implications for
intergenerational poverty and impose immense challenges for policy makers.

HIV infection is not confined to the poorest people even though
the poor account absolutely for most of those infected in Africa. There is
limited evidence for a socio-economic gradient to HIV infection, with rates
higher as one moves through the educational and socio-economic structure
[see the UNAIDS Report on the Global HIV/AIDS Epidemic, 1998, where there is
a discussion of the apparently puzzling fact that HIV is higher amongst the
most literate]. It follows that the relationships between poverty and HIV
are far from simple and direct, and more complex forces are at work than
just the effects of poverty alone. Indeed many of the non-poor in Africa
have adopted and pursued lifestyles which expose them to HIV infection, with
all the social and economic consequences that this entails.

It follows that the capacity of individuals and households to
cope with HIV and AIDS will depend on their initial endowment of assets -
both human and financial. The poorest by definition are least able to cope
with the effects of HIV/AIDS so that there is increasing immiseration for
affected populations. Even the non-poor find their resources diminished by
their experience of infection (morbidity and death), and there is increasing
evidence in urban communities of an emerging class of those recently
impoverished by the epidemic.

The effects of HIV and AIDS are reflected in the changes in Life Expectancy
(Table1) which is the best summary indicator of the effects of HIV and AIDS
on countries with high levels of HIV prevalence. These data are remarkable
for what they illustrate of the demographic impact of the epidemic on
African populations.Ý In many countries adult mortality has doubled and
trebled over the past decade and this is directly attributable to HIV and
AIDS. What is now being experienced by these populations are levels of Life
Expectancy which were typical of the 1950s.
 
 

Part II: Integrating HIV/AIDS in NEPAD

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