The context

Joyce Sibasa looks after her grandchildren at home in Winterveldt, South Africa [Simon Rawles]

HIV and AIDS are complex issues, presenting many interrelated challenges for CAFOD’s work. Here, we explain a number of these challenges in more detail

Missing generation

• Ill-health and early death, caused by AIDS and HIV related illnesses, rob communities of skilled workers, largely at the time when they are most economically valuable (aged 18-40).
• Entire communities in sub-Saharan Africa exist where there’s a ‘missing generation’. Between 1990 and 2002, life expectancy in Zambia fell from 46 years to just 33 years.
• Whole families have nobody of working age, teenagers care for grandparents and young siblings or babies are cared for by elderly grandparents who themselves would normally be under the care of their children.
• In 2004, the International Labour Organisation estimated that by 2015 twelve percent of the workforce in Africa will have been lost to HIV and AIDS. The loss of skilled workers is a severe barrier to economic growth and sustainable development.
• Any economic progress that a family or community may make can be wiped out by HIV or AIDS.
• Between 1980 – 2000 the average per capita ‘growth’ in GDP in sub-Saharan Africa was -0.58%[1] . This part of the world has got poorer in the two decades since HIV and AIDS were discovered.
• Economies can actually end up regressing, as opposed to growing. For example, the knowledge held by an older farmer of how to maximise the output from his land would normally be passed on to his son. But if the adult farmer dies early due to HIV or AIDS, this knowledge will be lost and the land will go to waste.

[1] Institute for International Economics, The Pattern of Economic Growth 1950-2000,

Poverty

• For a variety of reasons, someone living in poverty is more likely to become infected with HIV. Similarly, someone living with HIV or AIDS is much more likely to be in, or to fall into, poverty.
• For someone living in poverty, treatment for HIV can be too expensive, without which they will fall ill more often as a result of the illnesses caused by the virus.
• They will be unable to work and earn a living, they may use up their savings on healthcare and be left with no financial safety net. Such poverty will cause them to fall ill more frequently and ultimately, die sooner.
• There is a ‘burden of care’ on families of the sick. Children drop out of school to become carers, adults leave paid employment for the same reason. In rural areas this is at the expense of crop cultivation meaning a family will go hungry and fall further into poverty.
• People who are malnourished (as many living in poverty are) have a less robust state of health, resulting in a weaker immune system and increased susceptibility to illnesses relating from HIV and AIDS.
• For women and young girls facing extreme poverty, with little or no means of earning a living, bartering sex for food, money or clothes may be the only way of survival for them and their families. This increases their risk to HIV infection.
• So, while poverty increases susceptibility to HIV infection, HIV also creates poverty, resulting in a vicious cycle.

Treatment

• Drugs, whether anti-retrovirals (ARVs), which help to delay the onset of HIV, or for opportunistic infections arising from HIV, can never provide the whole answer to treating HIV and AIDS. Good health services and infrastructure, a healthy lifestyle and adequate nutrition are all also essential components of effective treatment.
• A report by the Human Sciences Research Council in 2003 found that average spending on HIV and AIDS by governments across six countries in southern Africa was totalling just USD$1 per capita.
• The cost of testing prevents many people knowing their HIV status, meaning many don’t know they are infected so don’t get treatment. Even if they do know they have HIV, many people don’t understand what treatment is available to them or how they can get it. Even then, those who do know their status and what treatment is available may not get it as it’s too expensive.
• Having said this, anti-retroviral drugs (ARVs), which help to delay the onset of HIV, and testing, are becoming more affordable to developing countries. However, governments are still unable to pay for all the drugs/test kits they need and the expensive infrastructure, such as clinics, monitoring and transportation, needed to administer them.
• A study by Medilinks found that between May 2001 and December 2002 the cost of the lowest priced ARVs more than halved from $385 (£195) a year to $128 (£65).
• However, as existing ARVs become more widely used, the Human Immuno-deficiency virus will mutate meaning current drugs become less effective. In the future, cheap drugs currently being used will need to be superseded by so called ‘second generation’ ARVs. These are still expensive and subject to restrictive patent laws, making them too expensive for developing countries to buy (see Facts and Figures).
• Likewise, the drugs needed to treat infections and illnesses that result from living with HIV, things like tuberculosis, oral thrush and Kaposi sarcoma, are also unaffordable for those who need them most.

Gender inequality

• In developing countries laws, culture, biology and male dominated economies mean women are often subordinated by men.
• They often have no say whatsoever with their partners on sexual matters. This may be due to a fear of violence, their lower social status or their economic dependence on men.
• They may know their husband has other sexual partners, so could have the virus, but are powerless to stop the risk of him infecting them.
• Also, women are more likely to become sexually active at an earlier age than men and be involved in sex work, so again are at higher risk of infection.
• HIV and AIDS create an increased burden of care on women, preventing them from earning a living and often, increasing their dependence on men.
• Conversely, cultural factors such as stereotypes, peer pressure and migratory working conditions mean men are more likely to have multiple sexual partners and use sex-workers resulting in their increased risk to infection.

Stigma and discrimination

• In many communities in the developing world there is still a real lack of understanding about how HIV is transmitted, often resulting in unnecessary discrimination against those living with the virus.
• Such stigma and discrimination takes many different forms, from the fear and ignorance of an individual to the wider social behaviour of a community.
• For example, on an individual level a father will often refuse to leave any of his estate to a child with HIV, ‘because they’re just going to die anyway.’ At a community level, men are often unwilling to let their wives go for HIV counselling or treatment in case others in the community find out.
• Living with HIV can result in the loss of ones home, education, job or insurance and isolation from ones community and church.
• Such attitudes and behaviour mean many people living with the virus fail to get tested or acknowledge the implications their infection could have on them and those around them. They then risk passing it on to others or missing out on what treatment and support is available.
• Also, by discriminating against people living with HIV and AIDS communities may themselves suffer. For example, a community may not want a teacher to work if she has HIV, the community then loses the skills of the teacher and she, her livelihood.

Nutrition

• A healthy diet gives the body key nutrients it needs to fight HIV and delay the onset of AIDS-related illnesses.
• Also, a healthy diet is essential in order for any treatment against HIV to be effective and in order to fight the illnesses inevitably caused by a weakened immune system.
• People in developing countries are often malnourished when they begin receiving treatment and if taken without food, the treatment can induce vomiting. This means that any treatment they may receive is even less effective.
• It is becoming increasingly common for individuals to refuse ARV treatment and even tuberculosis treatment, because they know they cannot be sure of eating properly and will thus render their treatment ineffective.
• With healthy eating habits and the proper treatment of HIV with anti-retroviral and other drugs, it is perfectly possible for people living with HIV to live long and healthy lives. This would allow development to be sustained and poverty to be reduced.

Conflict

• A conflict situation will increase risk of HIV infection for the people affected by it.
• During conflict, a lack of safe blood supplies can assist the transmission of HIV, as can a lack of sterilised injecting equipment.
• Schools and health service infrastructure are destroyed, meaning programmes for treatment and prevention education are lost.
• Instances of sexual violence and other human rights abuses increase during conflict, causing HIV to spread. This is happening more and more as rape is increasingly being used as a weapon within conflict.
• In what can often be life or death situations, women may be forced to exchange sexual favours for food, shelter, other basic supplies or indeed, survival itself.
• Of the 17 countries which have more than 100,000 children orphaned by AIDS, 13 are involved in conflict or on the brink of emergency.[1]

[1] UNICEF http://www.unicef.org/aids/index_armedconflict.html

Children affected and infected

Affected

• Living with a family member who has HIV can result in a child feeling guilt about the situation or anxiety about their future and their sick family member. They may lose a strong source of emotional support and affection.
• A child might be forced out of education as they care for siblings or sick adults or they may lose an important role model.
• As well as suffering loss and bereavement, children orphaned by AIDS may have to head an entire household, whilst lacking skills and education. They will be more vulnerable to HIV infection themselves and may be without any means of earning a living, leaving them far more likely to end up in living poverty.

Infected

• Children suffer from a greater lack of access to ARVs and other medicines (due to their lack of finances and relative lack of power). They also greatly feel the affects of stigma and discrimination.
• In too many instances, treatment for children has been neglected, with no dosages or formulations of many drugs being appropriately made for children, even when they may be available to adults living in the same community.
• Babies can be infected with HIV if their mother has the virus - either before or during birth, or through breast-feeding. However, all of these risks can be vastly reduced if appropriate drugs and care are made available.

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