Summary of meeting held at ODI 29th November 2000.

Speakers: Alan Whiteside, University of Natal and Tony Barnett, University of East Anglia.
Chair: Simon Maxwell

HIV/AIDS, poverty and development

1) Alan Whiteside started by stating his disappointment with the WDR in terms of HIV/AIDS. Very few of the WB's main strategies, centred around opportunity, empowerment and security, are attainable taking the effects of the epidemic into account. 'Can Africa Claim the 21st Century', another recent World Bank publication, proved equally disappointing in this respect. For Africa AIDS is the number one problem; unfortunately the World Bank has failed to recognise this. Not only are the development targets unattainable due to the AIDS epidemic (especially in parts of Africa), but indeed the very way in which development is practised will have to be rethought.

2) Quoting Tony Barnett, Whiteside described AIDS as a 'long wave disaster…that is a long time in the making and in which the major effects have already begun to occur long before the magnitude of the crisis is recognised and any response is possible' . In fact, the situation is worse than people realise; predictions about AIDS made a decade ago were far too positive.

3) The epidemic curve of HIV/AIDS can be divided into four:
i) the wave of HIV infection
ii) the wave of tuberculosis (most common opportunistic infection in Africa)
iii) the wave of AIDS illness and death
iv) the wave of impact (includes household poverty and orphaning)
Other epidemic curves are usually more predictable; illness leads to death and ultimately the epidemic curve goes down. With AIDS we simply do not know, all we can say for certain is that HIV will ultimately lead to AIDS and death - there is no recovery. What we do not know is what will happen to the epidemic curve in the aftermath of massive AIDS related deaths.

4) A recent survey from South Africa shows that 1 in 5 women attending ante-natal clinics are HIV positive. In Botswana, 37% of women attending ante-natal clinics are infected. We know that the rate of HIV infection will rise significantly in the future, and that most deaths occur in young adults. What will this mean for international development goals?
- In terms of reducing child mortality in Africa we can rather expect a significant increase; up to 30% of children born to HIV positive mothers will be infected and most die before the age of 5.
- In terms of life expectancy the epidemic has equally devastating effects: US estimates show that by 2010 life expectancy in Botswana will be reduced to 29 years.

5) The South African President has claimed that poverty causes AIDS. Does it? The simple answer is no. HIV causes AIDS. But what causes HIV? In Africa and Asia HIV is transmitted mainly through heterosexual intercourse, whereas in Eastern Europe the main source of transmission is needle sharing by intravenous drug users. In terms of sexual intercourse, the chances of transmission in a healthy person is not too great. However, factors such as the type of virus and the stage of infection do matter in terms of facilitating transmission as does the presence of other sexually transmitted diseases. Behavioural factors are of course crucial in this respect. In South Africa for example, people often have several partners at once in contrast to the assumed serial monogamy in the UK. However, sexual behaviour cannot be seen in isolation; migration, the status of women and their (lack of) access to economic resources, general health care etc. are all important factors. Thus, poverty in itself does not cause an AIDS epidemic but certainly contributes to it. However, more than poverty, inequality is a crucial factor (e.g. rich men buying sex from poor women). So yes- attacking poverty is important, but there are multiple factors that need to be addressed.

6) Tony Barnett took up Whiteside's last point, and claimed that the World Bank in fact does recognise a relationship between GNP per capita/income inequality and HIV infection. High HIV infection rates occur along with high income inequality, whereas countries with a high GNP per capita have lower rates of infection. This constitutes at least recognition that there is a relationship between poverty/inequality and HIV/AIDS. This is not a direct or simple relationship but it cannot be excluded from any consideration of poverty programmes or programmes that talk about 'trickle down'. There might not be time to let things 'trickle down'!
Although Africa is usually thought of in conjunction with AIDS, India in fact has the largest HIV positive population in any one country in the world. In China, rising income inequality along with high syphilis and gonorrhoea occurrences raises concerns regarding rapid increases in HIV infection rates. Unofficial estimates indicate that there may be as many as 10 million HIV positive people in China.

7) The youth/adult additional deaths caused by AIDS have huge implications for both health care and the division of labour and production. AIDS has already caused changes in population distribution in some African countries. Original findings from Barnett and Blaikie's research in Uganda in 1989 indicated changed population structure at the local level at that time. The main changes resulted in less good ratios between dependents and producers. A recent US Bureau of the Census model for Botswana in 2020 shows this Ugandan experience being repeated more than a decade later with a dramatically changed dependency ratio (age/gender distribution); this will have serious implications in terms of food availability, medical spending, care of orphans etc. A decline in life expectancy will affect employers and organisations and ultimately have a macro-level impact. On a household/community level, the effect will be seen most clearly in terms of farming systems and food production www.fao.org/sd/wpdirect/wpre0075.htm, and orphaning. Many orphans will lack basic care and grow up without being parented; some might experience orphaning not only once, but 2 or 3 times (i.e. when parents, then carers die). Care of elderly is also a major issue; who will provide crucial care if a large percentage of young adults are ill or die?

8) Barnett concluded by summing up the key areas in terms of the effect of AIDS:
- skills structure
- orphans and elderly (altered dependency ratio)
- inter- and -intra household dynamics and sharing
- trauma
- organisations (carry cost of medications and other employee related liabilities)
- employment
- subsistence agriculture
All of these are potentially impoverishing issues, and will have to be taken into account for any development intervention to be effective. Regrettably, the WDR has not taken these issues seriously.

9) In the discussion that followed it was pointed out that this was indeed welcome analysis: on the occupational side death (and following lack) of teachers have serious implications for education; many children may be forced into child labour; and how will businesses deal with the loss in social capital? A personal perspective on the link between poverty/inequality and risk of HIV infection was provided: In a compound in Botswana, a maid who was paid more than the usual salary still saw it necessary to earn money by 'having boyfriends' in order to send money back to her family. Only when this was discovered and the maid offered far better terms did the men stop coming. This illustrates the very real situation girls may find themselves in; their socio-economic situation may determine whether or not they are putting themselves (and others) at high risk of HIV infection. Tony Barnett commented that the knock-on effects of AIDS on teachers and other occupational groups are indeed incredibly important. In terms of child labour, an aspect often not discussed is military labour. The combination of civil unrest, arms and orphans is a very serious issue.

10)The chair asked whether there was a certain element of 'doom and gloom' in the analysis and the examples used in the presentation. Many countries in Africa do not have high rates of HIV, and some of the countries with previously high rates have seen a significant decline (e.g. Uganda and Thailand). Whiteside replied that the situation described will (if it isn't already) be reality for most of Africa, parts of Asia and Eastern Europe. According to UNAIDS, the lifetime risk of dying of AIDS for a 15 year old boy in Botswana is 85%; this is nothing but disturbing statistics. Many of the countries reporting low infection rates often do not have reliable data. And yes- there have been a few 'success-stories' however these are few and far between and the constant challenge is to stop the curve from rising. It was pointed out from the audience that that very incomplete data exist, especially in countries in unrest. Until now there has been no attempts to deal with HIV/AIDS in refugee camps. There might well be an element of 'doom and gloom' that we don't even acknowledge ourselves.

11) The role of businesses was then commented on: There is a need to encourage businesses to go beyond the business framework - businesses do not exist in a vacuum; they could be involved in both combating poverty and encouraging behavioural change. It was furthermore pointed out that the Caribbean is an area that has been largely neglected in terms of HIV/AIDS - despite an alarmingly high HIV infection rate. The worrying in this situation is that it is not taken onboard at local level nor by agencies such as the World Bank or the World Health Organisation.

12) Concluding, Whiteside and Barnett argued that the main message of AIDS and the effects we are seeing today is that we can not go on doing development in the same way. AIDS has shifted the parameters on which development is based, and this must be incorporated into the way we 'do' and talk about development. Although HIV prevention work is crucial in order to curb the spread of infection, we also need to look beyond infection to address, and deal with, the impact of the epidemic. AIDS poses the major development challenge today.