What Really Drives the Epidemic?

Despite progress on prevention and treatment, AIDS continues to undermine every aspect of human development in hard-hit countries. Poverty sets the stage for the spread of the epidemic, and illness, often accompanied by stigma, drains health, resources and productivity within households, communities and countries. Epidemics may begin among more well-off groups, but the impact is shouldered by the poor and deepens existing inequalities.

Poverty decreases choices. It forces many to leave home in search of work, leaving them more vulnerable to risky behaviour. It leaves many impoverished girls and women vulnerable to exploitation, including trafficking, early marriage, and to selling sex -- many see sex work as one of the few options available to support themselves.^[1]

At the same time, poverty often limits access to interventions to prevent or help manage the virus.

For those with access to treatment and disposable income, AIDS can be a manageable chronic condition. For without access to treatment, AIDS usually means protracted illness and death. Even where antiretroviral drugs are free, many patients have to pay considerable ‘out-of-pocket’ costs that they can ill afford for transportation, tests and treatments for opportunistic infections.

Women living with HIV may lack access to information and treatment that could keep their infants from contracting the virus. Children who become caretakers or orphans often drop out of school, losing out on many opportunities to break out of poverty. Young people, who are over-represented among the world’s poor and unemployed, are increasingly at risk.

Community networks and extended families, particularly older women, are bearing the burden of care in poor communities. The voluntary work that people, often women, take on in response to the epidemic draws heavily from personal resources.

Countries with advanced HIV epidemics face substantial loss of teachers, health workers and other professional from illness and death, reduced national savings as resources are diverted from productive uses into consumption, and higher health costs and school dropout rates.

Prevention is 28 times more cost effective than treatment.^[2] With more than 7400 new HIV infections each day the world cannot reverse the pandemic without curtailing new HIV infections. International funding for annual HIV and AIDS programming in low and middle-income has increased tenfold in less than a decade to $13.7 billion in 2008. Yet, an estimated $25.1 billion will be required in 2010 to meet national AIDS targets.^[3]

Contents

• Get the Facts
  • HIV, Poverty and Development
  • HIV and Women
• What Needs to be Done
  • Links between the ICPD and the Millennium Development Goals
• Real Stories

Get the Facts

• More than 60 per cent of people living with HIV inhabit the world's poorest region: sub-Saharan Africa. The fact that most people living with HIV in sub-Saharan Africa are poor reflects the fact that the epidemic has now spread from wealthier groups throughout the generalized population in a region that has a high proportion of poor people. ^[4]
  
• The caretaking burden of AIDS in developing countries has largely been met by individuals, households and extended families.^[5]
   
• By the end of 2007, the number of people receiving AIDS treatment in low and middle income countries reached 3 million; however, that is only a fraction of the estimated 9.7 million people in need of treatment.^[6]
   
• Typically access to HIV prevention and treatment services is lowest among poor and marginalized populations. Persons with HIV who receive treatment survive, on average, 27.8 years instead of the 11.7 years expected in the absence of treatment.^[7]
   
• More than 15 million children worldwide have lost one or both parents to AIDS—over 12 million of them in sub-Saharan Africa.^[8]

HIV, Poverty and Development

• The connection between poverty and poor health is well established.
   
• Impoverished people often lack access to information and supplies to prevent infection and to the treatment, care and support that could keep them active and productive.
   
• AIDS primarily strikes people in their most productive years. In hard-hit countries, communities have lost large numbers of health workers, teachers, farmers and labourers, with disastrous effects for health and education systems, and nearly every economic sector.
   
• Real economic growth in Botswana is projected to decline 1.2 per cent to 2.0 per cent a year over the period 2001-2021 due to AIDS, resulting in the economy being 23 to 35 per cent smaller than it would have been otherwise.^[9]
   
• The impact of AIDS on poor households is clearly disproportionate. In India, the financial burden on households living with HIV was 82 per cent of income in the poorest quintile and just over 20 per cent among the richest quintile.^[10]
   
• In addition to contributing to prevention, treatment can help people with the virus to maintain or reassume productive economic activity. A study in Kenya observed a rapid improvement in labour productivity among tea pickers in 12 months after starting antiretroviral treatment.^[11]
   
• Companies in high-prevalence countries can expect AIDS to decrease productivity and increase costs for recruitment and training. A study in Africa has found widely varying HIV-related costs from 0.5–10 per cent of the total labour costs—which in some sectors would constitute a very significant proportion of company profit.^[12]

HIV and Women

• Women account for half of all people living with HIV worldwide. In sub-Saharan Africa, nearly 60 per cent of people living with HIV are women, and three out of four infected young people are female. Young women comprise two-thirds of those under 25 who are HIV-positive.
   
• Heterosexual transmission accounts for over 70 out of every 100 cases globally.^[13]
   
• The burden of care for the sick falls disproportionately on women and girls. In eastern and southern Africa, where the prevalence of both HIV and poverty are very high, 90 per cent of caretaking is provided at the household level, 75 per cent of that by women.^[14]
   
• Women are physiologically more vulnerable than men to heterosexual transmission of HIV. Power dynamics between men and women, as well as violence and discrimination, compound women’s vulnerability.
   
• Estimates of the proportion of sex workers globally reached by HIV prevention services ranges from 16 to 60 per cent.^[15]
   
• Less than 1 per cent of global funding for HIV prevention to date has been targeted toward sex workers.^[16]
   
• Women's susceptibility to HIV is further enhanced in members of marginalized or migrant populations: National data from Nigeria shows a 30- 37 per cent infection rate among sex workers, compared to 4 per cent for the general population. Research in Viet Nam, revealed that women migrant workers were twice as likely as other women to become HIV positive.^[17]
   
• War and conflict increases the vulnerability of women to sexual violence and rape, therefore increasing their vulnerability to HIV.

What Needs to be Done

• Prevention is the key to ending the epidemic and its brutal human cost. It has been shown to work in sustained, intensive programmes, and is 28 times more cost-effective than treatment.^[18]
   
• Know your epidemic, so that the mix of prevention actions can respond to the specific characteristics (epidemiological, cultural, economic, capacities) of the local epidemic and the needs of key populations.
   
• Ensure that access to sexual and reproductive health services, including HIV prevention, treatment, care and support, reaches the poorest, and most marginalized populations, including sex workers, injecting drug users and men who have sex with men.
   
• Expand economic opportunities for women.
   
• Empower young people.
   
• Build supportive environments and partnerships that facilitate universal access to needed services, including life choices and occupational alternatives to sex work for those who want to leave it.
   
• Directly address the inequalities that drive HIV transmission in different contexts.^[19]
   
• Provide long-term, high-level domestic and international investment in HIV prevention and treatment in the world's poorest countries.^[20]
  
• Support the community networks that are on the front lines of responding to the epidemic, including community-based organizations, religious and faith-based groups, and those working with young people and most-at-risk populations.
   
• Support development strategies, such as income-generation and micro-finance programmes, that can help women achieve sustainable livelihoods.
   
• Link poverty eradication and employment programmes to sexual and reproductive health and HIV interventions.
   
• Because HIV and poor reproductive health are fueled by poverty and other root causes, responses to both health issues should be closely linked and mutually reinforcing.
   
• Address the HIV-related needs of migrants (whether or not they are documented), refugees and displaced persons.
   
• Reliable local and national data disaggregated by sex and age are critical to effective response.

Links between the ICPD and the Millennium Development Goals

In 1994, the International Conference on Population and Development recognized that AIDS represents an enormous challenge to reproductive health and to public health and human development overall, and explicitly called for concerted action by civil society, national governments, and international organizations and donors to control and prevent the epidemic. These calls have been reiterated and built upon in subsequent international forums.

Stopping and preventing AIDS is the heart of MDG6 (Combat AIDS, malaria and other diseases) but is also critical to the achievement of most of the other Millennium Development Goals. Failure to stem the epidemic will make the goals on poverty reduction (MDG1), universal education (MDG2), and reduced child mortality (MDG4) unattainable for dozens of countries. Many of the approaches and interventions needed to prevent HIV, such as empowering women, preventing mother to child transmission of HIV, and promoting condom use and access to reproductive health, also have positive impacts on gender equality (MDG3) and maternal health (MDG5).

Real Stories

“Taking It to the Streets: Bringing HIV Prevention and Treatment to the Vulnerable Communities in Côte d'Ivoire.”

“She ran away from her home in Nigeria after her husband died in an accident. And she refused to marry his younger brother as is the custom in her region. With no means to support her two boys and two girls, or pay for their school fees, she turned to sex work to ensure her family’s survival”.

Read more: The United Nations Population Fund, 31 March, 2008. http://www.unfpa.org/public/News/pid/1025

References

1. UNAIDS Guidance Note on HIV and Sex Work (2009), page 22, footnote 81
2. Fact sheet for the High-level Event on the Millennium Development Goals, United Nations Headquarters, New York, 25 September 2008
   http://www.un.org/millenniumgoals/2008highlevel/pdf/newsroom/Goal%206%20FINAL.pdf (accessed March 2009)
3. Based on the country-defined targets for 2010, it is estimated that an investment of US$ 25.1
   billion (US$ 18.9 billion–US$ 30.5 billion) will be required for the global AIDS response
   in 2010 for low- and middle-income countries. UNAIDS (February 2009) .What countries need: Investments needed for 2010 targets
   http://data.unaids.org/pub/Report/2009/20090210__investments_needed_2010_en.pdf
4. Peter Piot, Robert Greener, Sarah Russell, Squaring the Circle: AIDS, Poverty, and Human Development in PLoS Medicine
   http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040314&ct=1#journal-pmed-0040314-b004 (accessed March 2009)
5. Loewenson, R., 'Learning from diverse contexts: Equity and inclusion in the responses to AIDS', AIDS Care: Psychological and socio-medical aspects of HIV/AIDS, vol. 19, supplement 1, 2007, a special issue on Community Responses to HIV and AIDS, commissioned by the UN Research Institute for Social Development, p. S83.
6. Fact Sheet, op cit.
7. United Nations Population Division, 2008 Revision
8. Joint United Nations Programme on HIV/AIDS, 2008 Report on the Global AIDS Epidemic, UNAIDS, Geneva, 2008, p. 218
9. UNDP, The Economic Impact of HIV/AIDS in Botswana, March 2007. http://www.unbotswana.org.bw/undp/docs/economic_impact_study_executive_summaryfinal.pdf (accessed March 2009)
10. Asian Development Bank, UNAIDS (2004) The impact of HIV/AIDS on poverty in Cambodia, India, Thailand, and Vietnam. Available: http://www.adb.org/Documents/Reports/Asia-Pacific/APO-HIV.pdf. Accessed 19 September 2007.
11. Piot, Greener, Russell, op cit
12. Piot, Greener, Russell, op cit
13. Fact Sheet op.cit.
14. UNAIDS, Accelerating action against AIDS in Africa, Geneva, UNAIDS, 2003.
15. The UNAIDS 2008 Report on the Global AIDS Epidemic reports that 60.4% of sexworkers were reached with HIV prevention services (defined as the proportion who know where they can receive an HIV test and have received condoms in the past 12 months), a marked increase on previous years…Other data sources indicate lower coverage levels, for example the 2006 Annual Review the International AIDS Alliance states that globally only 16% of sex workers have access to basic HIV services.
16. UNAIDS Guidance Note on HIV and Sex Work (2009)
17. Asian Development Bank (2005) Gender Network News. Special issue: Perspectives on gender and HIV/AIDS. Available: http://www.adb.org/Documents/Periodicals/GNN/newsletter-13.pdf. Accessed 19 September 2007.
18. Fact Sheet, op cit.
19. Piot, Greener, Russell, op cit
20. UNAIDS. What Coutries Need: Investments needed for 2010 targets. http://data.unaids.org/pub/Report/2009/20090210__investments_needed_2010_en.pdf