Lesson 9

Sub-Saharan Africa is the region of the world that is most affected by HIV/AIDS. An estimated 26.6 million people are living with HIV/AIDS and approximately 3.2 million new infections occurred in Sub-Saharan Africa in 2003. In 2002, the epidemic claimed the lives of an estimated 2.3 million Africans. Ten million young people (aged 15-24) and almost 3 million children under 15 are living with HIV. An estimated eleven million children have been orphaned by AIDS in Sub-Saharan Africa.

The extent of the epidemic is only now becoming clear in many African countries, as increasing numbers of people with HIV are now becoming ill. In the absence of massively expanded prevention, treatment and care efforts, the AIDS death toll on the continent is expected to continue rising before peaking around the end of the decade. This means that the worst of the epidemic's impact on these societies will be felt in the course of the next ten years and beyond. Its social and economic consequences are already being felt widely not only in health but in education, industry, agriculture, transport, human resources and the economy in general.

Large variations exist between individual countries. In some African countries, the epidemic is still growing despite its severity. Others face a growing danger of explosive growth. The sharp rise in HIV prevalence among pregnant women in Cameroon (more than doubling to over 11% among those aged 20-24 between 1998 and 2000) shows how suddenly the epidemic can surge.

National HIV prevalence rates vary greatly between countries. In Somalia and Gambia the prevalence is under 2% of the adult population, whereas in South Africa and Zambia around 20% of the adult population is infected.

In four southern African countries, the national adult HIV prevalence rate has risen higher than was thought possible and now exceeds 30%. These countries are Botswana (38.8%), Lesotho (31.5%), Swaziland (33.4%) and Zimbabwe (33.7%).

West Africa is relatively less affected by HIV infection, but the prevalence rates in some countries are creeping up. In west and central Africa HIV prevalence is estimated to exceed 5% in eight countries including Cameroon (11.8%), Central African Republic (12.9%), Côte d'Ivoire (9.7%) and Nigeria (5.8%).

Until recently the national prevalence rate has remained relatively low in Nigeria, the most populous country in sub-Saharan Africa. The rate has grown slowly from 1.9% in 1993 to 5.8% in 2001. But some states in Nigeria are already experiencing HIV prevalence rates as high as those now found in Cameroon. Already more than 3 million Nigerians are estimated to be living with HIV/AIDS.

HIV infection in Eastern Africa varies between adult prevalence rates of 1% in Somalia to 15% in neighbouring Kenya. In Uganda the countrywide prevalence among the adult population is 5%, but recent HIV infections appear to be on the decline in several parts of the country.

The prevalence of HIV infections among a country's adult population - that is, the percentage of the adult population living with HIV, is a measure of the overall state of the epidemic in a country. But the prevalence gives a less clear picture of recent trends in the epidemic, because it does not distinguish between people who acquired the virus very recently and those who were infected a decade or more ago.

Regular measurement of HIV prevalence amongst groups of young people can give an indication of the HIV incidence amongst them, that is, the number of new infections occurring. The steadily dropping HIV prevalence over the last few years, among 15 - 19 year olds in Uganda, provide a more accurate picture of the trend in the epidemic in Uganda, and in this instance the effectiveness of prevention efforts among young people.

In all affected countries the HIV/AIDS epidemic is bringing additional pressure to bear on the health sector. As the epidemic matures, the demand for care for those living with HIV/AIDS rises, as does the toll among health workers. In sub-Saharan Africa, the annual direct medical costs of AIDS (excluding antiretroviral therapy) have been estimated at about US$30 per capita, at a time when overall public health spending is less that US$10 for most African countries.

Health-care services face different levels of strain, depending on the number of people who seek services, the nature of their need, and the capacity to deliver that care.

As HIV infection progresses to AIDS, there is an increase in total hospitalisation. The 2001 Swaziland Human Development Report estimated that people living with HIV/AIDS occupied half of the beds in some health care centres in Swaziland. HIV prevalence among hospitalised patients was almost 33% in one Tanzanian hospital, making HIV infection the major cause of illness leading to hospitalisation. Without major interventions, the problem will worsen. The World Bank estimates that the number of hospital beds needed for AIDS patients could exceed the total number of beds available in Swaziland by 2004 and in Namibia by 2005¹.

The HIV/AIDS epidemic is also having a negative impact on the overall quality of care provided in hospitals. A shortage of beds, for example, means that people tend to be admitted only at the later stages of illness, reducing their chances of recovery, as some Kenyan hospitals have discovered. Lengthy hospital stays are being reported in Botswana's hospitals, along with staff shortages and staff burnout. Also, more time has to be spent diagnosing cases that are more complex as the epidemic deepens.

At the same time as the demand for health services is expanding, so more-health care professionals are being affected by HIV/AIDS. For example, Malawi and Zambia are experiencing a 5-6 fold increase in health worker illness and death rates. Increased workloads and stress might may also spur emigration by health professionals.

The antiretroviral programme in Botswana has faced an acute shortage of trained staff, which has had a significant effect on the programme. There are not enough trained staff to carry out the health checks required for enrolment on the programme, and this has contributed to the enrolment and treatment rates being lower than was first hoped. The problem is compounded by the fact that over 90% of the doctors are foreign and do not speak Setswana, the local language. Another problem faced when recruiting health care staff from abroad is that it takes time for them to become familiar with the local culture.²

The emergence of community-bases care programmes, often organised by people living with HIV/AIDS, has become one of the outstanding features of the epidemic. They are also playing a key role in easing the impact. Although many of these programmes are operated by religious groups or non-governmental organisations, the effectiveness of the care does depend on support from formal health, welfare and other social sectors. Also, a study in South Africa has suggested that while home-based care is not cheap it is still an affordable option for the care of people with HIV/AIDS.

The toll of HIV/AIDS on households can be very severe. Although no part of the population is unaffected by HIV, it is often the poorest that are the most vulnerable to HIV/AIDS and on whom the consequences are most severe. In many cases, the presence of AIDS means that the household will dissolve, as parents die and children are sent to relatives for care and upbringing. A study in Zambia revealed that 65% of households in which the mother had died had dissolved. But much happens to a family before this dissolution happens: HIV/AIDS strips the family of assets and income-earners, further impoverishing the poor.

A study in Côte d' Ivoire revealed that income in affected households was half that of the average household income. This was often the result not only of the loss of income due to illness among household members, but also because other members had to divert more time and effort away from income-generating activities³.

A study in three countries, Burkina Faso, Rwanda and Uganda, has calculated that AIDS will not only reverse efforts to reduce poverty, but will increase the percentage of people living in extreme poverty (from 45% in 2000 to 51% in 2015). In Botswana, household income for the poorest quarter of households is expected to fall by 13%. Income earners in these households are also expected to take on an average of four more dependants because of HIV/AIDS.

A study in South Africa found that already poor households coping with an AIDS-sick member were reducing spending on necessities even further. The most likely expenses to be cut were clothing (21%), electricity (16%) and other services (9%). Falling incomes forced about 6% of households to reduce the amount they spent on food and almost half of households reported having insufficient food at times.⁴

"She then led me to the kitchen and showed me empty buckets of food and said they had nothing to eat that day just like other days"⁴

It is estimated that in Burkina Faso, 20% of rural families have reduced their agricultural work or even abandoned their farms because of AIDS. In Ethiopia, AIDS-affected households were found to spend 11-16 hours per week performing agricultural work, compared with an average 33 hours for non-AIDS affected households.

Taking care of a person sick with AIDS is not only an emotional strain for household members, but also a major strain on household resources. Loss of income, additional care-related expenses, the reduced ability of caregivers to work, and mounting medical fees and funeral expenses together push affected households deeper into poverty. According to the study in Côte d' Ivoire, health care expenses rose by up to 400% when a family member had AIDS.

But the financial burden of death can also be considerable, with some families in South Africa spending three times the total household monthly income on a funeral.

It is hard to overemphasise the trauma and hardship that children affected by HIV/AIDS are forced to bear worldwide. Not only does HIV/AIDS mean children lose their parents or guardians, but sometimes it means they lose their childhood as well.⁷

As parents and family members become ill, children take on more responsibility to earn an income, produce food and care for family members. It is harder for these children to access adequate nutrition, basic health care, housing and clothing. Fewer families have the money to send their children to school.

Often both of the parents are HIV-positive in Africa. This has resulted that more children have been orphaned by AIDS in Africa than anywhere else. Also many children will be part of a generation of to be raised by their grandparents or left their own in child-headed households. As projections of the number of AIDS orphans rise, some calls have been heard for an increase in institutional care for children. This solution is not only expensive but also detrimental to the children. Institutionalisation stores up problems for society, which is ill equipped to cope with an influx of young adults who have not been socialised in the community in which they have to live. There are other alternatives available. An example is the approach developed by church groups in Zimbabwe, where they recruit community members to visit orphans in their homes where they live either with foster parents, grandparents, other relatives or in child-headed households.

The way forward is prevention. It is important to prevent children from becoming infected with HIV at birth and later on in their life. Also, generally preventing more people from becoming infected with HIV in the future, and care to prevent people from dying of AIDS is essential. Then fewer children will be orphaned by HIV/AIDS.

The extent to which schools and other education institutions are able to continue functioning (as part of the essential infrastructure of societies and communities) will influence how well societies eventually recover from the epidemic.

A decline in school enrolment is one of the most visible effects of the epidemic. This will in itself have an effect on HIV prevention, as a good basic education ranks among the most effective and cost-effective means of preventing HIV.⁸

"'Without education, AIDS will continue its rampant spread. With AIDS out of control, education will be out of reach'" - Peter Piot, Director of UNAIDS⁹

This reduction in the number of children attending school, will have a significant impact on the ability of many countries to achieve the Education For All targets.¹⁰

For example, research in South Africa showed that the number of pupils enrolling in the first year of primary school in 2001 in parts of KwaZulu-Natal Province, was 20% lower than in 1998. In the Central African Republic and Swaziland, school enrolment is reported to have fallen by 20-36% due to AIDS and orphanhood, with girls being most affected.

"If there is a shortage of money the girl child stays behind and the boy child goes to school. Even if a girl is more intelligent."¹¹

HIV/AIDS does not only affect pupils but teachers as well. A study in Zimbabwe found that 19% of male teachers and almost 29% of female teachers were infected with HIV.

Teacher absenteeism is increased by HIV/AIDS as the illness itself causes increasing periods of absence from class. Teachers with sick families also take time off to attend funerals or to care for sick or dying relatives and teacher absenteeism also results from the psychological effect of the epidemic.¹²

When a teacher falls ill, the class may be taken on by another teacher, may be combined with another class or left untaught. But even when there is a sufficient supply of teachers to replace losses, there can be a significant impact on the students.

"Some of the schools have lost teachers due to this disease. Eventually after a year or two they are replaced with another teacher. But they are not the same as the ones who have died. They cannot teach or do the work as well as the one affected by AIDS. And also the learners, the learners used to know their teachers very well." - School principal, Namibia- ¹³

The illness or death of teachers is especially devastating in rural areas where schools depend heavily on one or two teachers. Moreover, skilled teachers are not easily replaced. Swaziland has estimated that it will have to train 13,000 teachers over the next 17 years, just to keep services at their 1997 levels - 7000 more than it would have to train if there where no AIDS deaths.

HIV/AIDS dramatically affects labour, setting back economic activity and social progress. The vast majority of people living with HIV/AIDS in Africa are between the ages of 15 and 49 - in the prime of their working lives.

AIDS weakens economic activity by squeezing productivity, adding costs, diverting productive resources, and depleting skills. Also, as the impact of HIV/AIDS on households grows more severe, market demand for products and services can fall. The epidemic hits productivity through increased absenteeism. Comparative studies of East African businesses have shown that absenteeism can account for as much as 25-54% of company costs.

A study in several southern African countries has estimated that the combined impact of AIDS-related absenteeism, productivity declines, health-care expenditures, and recruitment and training expenses could cut profits by at least 6-8%. NamWater, Namibia's largest water purification company, has reported that HIV/AIDS was hindering its operation as absenteeism rose and productivity dropped. A study of a sugar mill in South Africa put the cost per worker per year at R9,500 (about £800). Of this, the cost of replacement workers, lost productivity, and absenteeism account for about a quarter each.¹⁴

Company costs for health-care, funeral benefits and pension fund commitments are likely to rise unexpectedly as early retirement and deaths rise. A study of a commercial agricultural estate in Kenya showed that AIDS-related medical expenditure exceeded projected expenses by 400%. Funeral costs are also provided by a number of employers in Africa and they are rising sharply.

As HIV/AIDS related costs have risen, so more and more employers have set up HIV/AIDS related programmes at their workplaces. These programmes work more effectively when they also consider the wider realities of the workers' lives. An example is the gold-mining districts in South Africa. The gold mines attract thousands of workers, often from poor and remote regions. Most live in hostels, separated from their families and as a result a thriving sex industry operates around many mines and high HIV prevalence is common. In recent years, mining companies have been working with a number of organisations to implement prevention programmes for the miners. These have included mass distribution of condoms, medical care and treatment for sexually transmitted diseases and awareness campaigns. However, work and social conditions make it difficult to achieve and sustain reductions in HIV and other sexually transmitted infection levels.

In Swaziland, an employers' anti-AIDS coalition has been set up to promote voluntary counselling and testing. The coalition not only includes larger companies but also small and -medium -size enterprises. In Botswana, the Debswana diamond company offers all employees HIV testing, and if they are HIV positive, they and their spouses are offered HIV antiretroviral drugs.¹⁵ This policy was introduced in 1999 when the company found that many of their work force were HIV positive. With a skilled workforce, it is financially worth their while to protect the health and therefore the productivity of their workers. They also discovered that retirements due to ill health and AIDS-related deaths had risen markedly. In 1996, 40% of retirements and 37.5% of deaths were due to HIV/AIDS. By 1999, the proportion had risen to 75% and 59% respectively.

In many countries of sub-Saharan Africa, AIDS is erasing decades of progress in extending life expectancy. Life expectancy reflects the conditions in a community, but also life expectancy affects conditions in the community. Average life expectancy in sub-Saharan Africa is now 47 years, when it would have been 62 years without AIDS. Life expectancy at birth in Botswana has dropped to a level not seen in Botswana since before 1950. In less than ten years time, many countries in Southern Africa will see life expectancies fall to near 30, levels not seen since the end of the 19th Century.¹⁶

Country	Before AIDS	2010
Angola	41.3	35.0
Botswana	74.4	26.7
Lesotho	67.2	36.5
Malawi	69.4	36.9
Mozambique	42.5	27.1
Namiba	68.8	33.8
Rwanda	54.7	38.7
South Africa	68.5	36.5
Swaziland	74.6	33.0
Zambia	68.6	34.4
Zimbabwe	71.4	34.6

By 2010, the populations of five countries - Botswana, Mozambique, Lesotho, Swaziland and South Africa will have started to shrink because of the number of people dying from AIDS. In two more countries, Zimbabwe and Namibia, the population growth rate will have slowed almost to zero.

Through its impacts on the labour force, households and enterprises, HIV/AIDS can act as a significant brake on economic growth and development. Besides the human cost, HIV/AIDS is having deep effects on Africa's economic development. In turn, this effects to Africa's ability to cope with the epidemic.¹⁷ The impact of HIV/AIDS on the economies of African countries is difficult to measure. The economies of many of the worst affected countries were already struggling with development challenges, debt and declining trade before HIV/AIDS started to affect Africa. Together with other factors, HIV/AIDS has had a devastating effect on many countries economies.

HIV/AIDS has an impact on labour supply, through increased mortality and morbidity. This is multiplied by the loss of skills in key sectors of the labour market. Long periods of AIDS-related illness reduce labour productivity. Government income also declines, as tax revenues fall, and governments are pressured to increase their spending, to deal with the rising prevalence of AIDS, as a result creating a potential financial crisis. One review reported that the annual costs associated with sickness and reduced productivity as a result of HIV/AIDS varied from US$17 per employee in Kenyan manufacturer firm to US$300 in the Ugandan Railway Corporation.¹⁸

A recent calculation has suggested that the rate of economic growth has fallen by 2-4% in sub-Saharan Africa. Meanwhile, some studies have forecast that, by 2015, the economies of Botswana and Swaziland would grow by 2.5% and 1.1% points less, respectively, than they would have in the absence of the epidemic. By the beginning of the next decade, South Africa, which represents about 40% of sub-Saharan Africa's economic output, faces a real gross domestic product 17% lower than it would have been without AIDS.

This page has only been able to outline some of the ways in which HIV/AIDS is already having a devastating impact on African countries. If the impact is going to be reduced in the future, then it is going to need many people and organisations to work together in many different areas.

The basic content component of this lesson was adapted from Jenni Fredriksson and Annabel Kanabus

UNAIDS (2002) 'AIDS epidemic update', December
UNAIDS (2002) 'Report on the global HIV/AIDS epidemic 2002', July

¹ Haacker M (2001) Providing Health Care to HIV Patients in Southern Africa. IMF Policy Discussion Paper.Washington:International Monetary Fund (PDP/01/3).
²HIV and AIDS in Botswana http://www.avert.org/aidsbotswana.htm
³Béchu N (1998)The impact of AIDS on the economy of families in Côte d 'Ivoire:Changes in consumption among AIDS-affected households.In :M Ainsworth,L Fransen and M Over (eds)Confronting AIDS: Evidence from the developing world: Selected background papers for the World Bank Policy Research Report .Brussels:EuropeanCommission.
⁴Henry J. Kaiser Family Foundation and Health Systems Trust (2002) ' Hitting Home: How households cope with the impact of the HIV/AIDS epidemic', October
⁵Food and Agriculture Organization of the United Nations (2001) Rural Women Carry Family Burdens.Focus,AIDS -A Threat to Rural Africa . ⁶Henry J. Kaiser Family Foundation and Health Systems Trust (2002) ' Hitting Home: How households cope with the impact of the HIV/AIDS epidemic', October
⁷HIV and AIDS orphans in Africa http://www.avert.org/aidsorphans.htm
⁸The World Bank (2002) 'Education and HIV/AIDS: A window of Hope', May
⁹Joint World Bank, Unesco UNAIDS Press release (2002) 'In turning the tide against HIV/AIDS, education is key', October 18
¹⁰EFA Global Monitoring Report, 2002: Is the World on Track? www.unesco.org/education/efa/index.shtml
¹¹Malaney P (2000)The impact of HIV/AIDS on the education sector in southern Africa.Consulting Assistance on Economic Reform II Discussion Paper No.81 (August).Boston:CAER II
¹²The World Bank (2002) 'Education and HIV/AIDS: A window of Hope', May ¹³Malaney P (2000)The impact of HIV/AIDS on the education sector in southern Africa.Consulting Assistance on Economic Reform II Discussion Paper No.81 (August).Boston:CAER II
¹⁴Haacker M (2002)The Economic Consequences of HIV/AIDS in Southern Africa. IMF Working Paper.Washington: International Monetary Funds (Africa Department) WP/02/38
¹⁵How widely available are HIV& AIDS antiretroviral drugs in Africa? http://www.avert.org/aidsdrugsafrica2.htm
¹⁶Stanecki K. A. (2002) 'The AIDS Pandemic in the 21st century', Draft Report, July 2002, XIV International Conference on AIDS, Barcelona, US Census Bureau
¹⁷Dixon S., McDonald, S and Roberts J. (2002) 'The impact of HIV and AIDS on Africa's economic development', BMJ 2002; 324:232-4
¹⁸Bollinger L., Stover J. (1999) The economic impact of AIDS', Glastonbury, CT: Futures Group International

Resources: Map of Africa showing the distribution of HIV/AIDS prevalence rates, and charts summarising the impact of HIV/AIDS on different sectors of the economy of African countries.

Procedure: With the aid of the map, lead students to discuss the distribution of HIV/AIDS prevalence in Africa. Ask students to list the countries in descending order of recent data on sero-prevalence. Follow up with a class symposium on the impact of HIV/AIDS on socio-economic conditions in Africa. Let a member of the class be the symposium facilitator. He/She should lead the symposium to discuss the impact on health, education (including teachers and children), economy and on the household. An appointed scribe for the class should summarise the major points. The role of the teacher should be to add more points (possibly derived from the Basic Content section of this lesson) after the class summary is presented.

(Please write answers to the questions in your notebook)

1. Draw a map of Africa showing the prevalence rate of HIV/AIDS. In a few sentences, summarise the distribution in sub-Saharan Africa by sub-region, that is: West, East, Central and Southern.

2. Describe the impact of HIV/AIDS on education and on the economy of your country.

3. State ways by which the impact of HIV/AIDS on education can be reduced and the role you as a VIHEAF student can play in implementing programmes aimed at reducing the impact.