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Chapter 1

The human, social and economic consequences

Epidemics of disease are like famines, wars and natural catastrophes in one major respect: they invariably bring further disasters in their wake. Globally, HIV/AIDS epidemics are already having a disastrous domino effect. Millions of children are orphaned, communities are destroyed, health services are overwhelmed, entire countries face hunger and economic ruin.

The disease affects the poor most severely: they are the most vulnerable to infection, and the poorest families are hardest hit by the suffering, illness and death caused by the disease. The effects include devastating financial hardships that lead in turn to further tragic consequences. The disease forces poor families deeper into poverty, and it also condemns households that were relatively wealthy to a similar fate.

Large-scale negative changes to patterns of economic and social behaviour are likely to result from the epidemic’s impact on population structure and adult life expectancy (26). Beyond the loss of income and the diversion of income to health expenditures, families resort to various “coping” strategies with negative long-term effects, including migration (27), child labour, sale of assets and spending of savings. Families suffering from the illness or death of one or more of their members experience both the direct costs of medical and funeral expenditures and the indirect costs of the impact of the illness on productivity (28, 29).

HIV/AIDS is changing the very structure of populations. There are increased dependency ratios in many African countries, for example, with smaller numbers of working-age adults on whom both children and elderly relatives depend; a situation that is becoming more severe.

The psychological effects on young people of seeing their immediate elders dying in huge numbers at such young ages, and consequent fears for their own future, are immense and will have profound effects on economic development. Moreover, as parents (most of them young adults) die prematurely, they fail to hand on assets and skills to their children. In this way, HIV/AIDS weakens the process through which human capital – people’s experience, skill and knowledge – is accumulated and transmitted across generations (30).

The crisis of children having lost either or both parents to HIV/AIDS has been afflicting Africa for a decade, and will get worse. Today there are about 14 million such children in the world of whom the vast majority are in Africa, but the projected total number will nearly double to 25 million by 2010 (31, 32), a nation of children equal to the total population of Iraq. At that point, anywhere from 15% to 25% of the children in a dozen sub-Saharan countries will be orphans. Even in countries where HIV prevalence has stabilized or fallen, such as Uganda, the numbers of orphans will continue to rise as parents already infected continue to die from the disease. When orphans were relatively few, they could be cared for by extended families, but the numbers are now too great and many children end up living on the street.

Women: unequally at risk

Women in many countries are already facing severe hardships resulting from inequality, discrimination and victimization, and HIV/AIDS often exacerbates the hardships. In fact, these very factors help explain why women suffer disproportionately from the disease. About 58% of all people living with HIV/AIDS in the WHO African Region are women. They are infected at younger ages than men by, on average, 6–8 years. Young women are often forced into unequal sexual relationships and are frequently unable to negotiate safer sex. The unequal losses of life among women resulting from this situation will create an imbalance in the adult population, with consequences that are unknown. One likely and ominous outcome, however, is that mature men will seek younger and younger women as partners, which in turn intensifies some of the risk factors for HIV spread.

The underestimated economic threat

In many countries, the cumulative effects of the epidemics could have catastrophic consequences for long-term economic growth and seriously damage the prospects for poverty reduction. Until recently, most experts believed that a generalized HIV/AIDS epidemic at 10% adult prevalence would reduce economic growth by about 0.5% per year (33). Several country-based studies have suggested that HIV/AIDS epidemics result in a reduction in gross domestic product (GDP) of around 1%, but recent economic studies and estimates suggest a much bleaker picture of current and future economic effects (30, 34).

Studies previously misinterpreted the effects of epidemics as being similar to those caused by one-off shocks, such as natural disasters or international economic downturns, which many economies can absorb and which are beyond the control of planners. Predictions have also frequently reflected assumptions that the worst-hit countries in Africa had an excess of labour, and suggested that a contraction in workforce numbers might lead to more efficient use of land and capital. The belief was that GDP per capita would actually increase if a fall in GDP were lower than the fall in population. Similarly, it had been thought that the destruction of the labour force and hence the reduction in labour supply caused by HIV/AIDS could result in an increase in the productivity of each remaining worker because each would have more land and capital with which to work. The result of these misinterpretations and assumptions was a widespread failure nationally and internationally to revise economic policies to take account of HIV/AIDS.

HIV/AIDS will have long-term and widespread effects that will last for generations, and which do not reveal themselves in many economic studies. Ill-health and premature death lead to wasted investment in human capital and globally reduce the incentives to invest in building for the future. An inadequate response to HIV/AIDS will allow the disease to continue to destroy education systems and other vital institutions, reduce human capital and the ability to transmit it, and contribute to a long-term decline in savings and investment. There will therefore be substantial benefits in responding to epidemics – even those of low prevalence.

The threat of institutional collapse

The implications of reduced life expectancy in adults for societies heavily burdened by HIV/AIDS are becoming clear, though previous poor performance of institutions has sometimes obscured the specific impact of HIV/AIDS (35). Institutional malfunctioning in Africa, for example, has been concealed by long-running inefficiency and low performance expectations. The survival and functioning of institutions in a number of southern African countries are now threatened. Incapacity is critical. Already there are major shortages of qualified personnel in key organizations. Posts are vacant or occupied on an “acting” capacity. Continuity of staff is low because of deaths and the reshuffles they occasion. Morale is equally low. Numerous studies and anecdotal evidence point to the slowing down and near paralysis of agricultural services, judiciaries, police forces, education systems and health services.

Many African businesses have also been severely affected by reduced labour supply, especially the loss of experienced workers in their most productive years, increased absenteeism, reduced profitability and loss of international competitiveness (36). Threats to regional security caused by the epidemic are another example of indirect impacts that may negatively affect economic activities such as tourism (37) or inflows of foreign investment (38).

Across southern and eastern Africa, the education sector is suffering as the loss of teachers exceeds those being trained (39). This is not only a result of AIDS-related illness and death: some teachers are being hired by the private sector, which is also in need of skilled personnel, while others are migrating. The effects are masked by the fact that fewer children enrol in school because HIV/AIDS-affected families cannot afford school fees or need their children to work at home. The result will be lower educational achievement, with negative implications for efforts to reduce poverty, improve gender relations and decrease HIV transmission, and for the overall health of those who survive. The effort to enrol all children in school by 2015 (one of the Millennium Development Goals) is being undermined with long-term negative consequences.

One of the many tragedies of HIV/AIDS is that it often strikes hardest where health systems are weakest, and deals a double blow. Systems that in any case cannot cope are weakened further by HIV/AIDS deaths and disability among large numbers of health personnel (see Chapter 4). In low-income countries which were already suffering from a lack of health care workers, health care systems are overburdened. In Côte d’Ivoire and Uganda, 50–80% of adult hospital beds are occupied by patients with HIV-related conditions. In Swaziland, the average length of stay in hospital is six days, but in 80% of cases increases to 30 days for patients with tuberculosis associated with HIV (40).

The impact of HIV/AIDS on the health sector is often enormous. The severity and complexity of clinical opportunistic conditions are associated with high hospitalization rates, inpatient mortality and increasing treatment costs. In some sub-Saharan countries, the rate of general hospital bed occupation by AIDS patients is frequently higher than 50%. The introduction of antiretroviral therapy, however, has been shown to lead to a sharp reduction in HIV/AIDS-related mortality, morbidity and care expenditures, with substantial improvements in the quality of life of patients. Chapter 4 deals at length with the key issues linking HIV/AIDS, health systems and treatment expansion.

Given the daunting social and economic consequences of the spread of HIV, the need for effective and wide-ranging methods of prevention is as clear as it has been since the very first days of the epidemic in the 1980s. The next section looks at the current range of prevention and care strategies in play around the world.

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