4
The Burden of HIV/AIDS: Implications for African States and Societies

Key Findings

  • The burden of HIV/AIDS has profound implications for four sectors of African society: development, health, the state, and academia.

  • These impacts confronting many African states and societies pose challenges to their management of their epidemics now and into the future.

  • The mosaic of African nations is significantly heterogeneous in the extent of the HIV/AIDS burden and its implications.

In 2009, an estimated 1.8 million new HIV infections occurred in Africa (UNAIDS, 2010), accounting for 69 percent of new infections worldwide; in the same year, 370,000 children began their lives with HIV, which is a decrease from the previous year when 390,000 African children were infected through mother-to-child transmission (UNAIDS, 2010; UNAIDS and WHO, 2009). Between December 2008 and December 2009, 961,000 patients in Africa began receiving antiretroviral therapy (ART), bringing the total receiving treatment to 3,911,000, just 36 percent of those in need of treatment in Africa according to the 2010 guidelines of the World Health Organization (WHO) (WHO et al., 2010). In 2009, 1.3 million Africans lost their lives as a result of AIDS1 (UNAIDS, 2010). Also in

1

This number could be an underestimation as official death certificates often do not cite AIDS as the cause of death.



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4 The Burden of HIV/AIDS: Implications for African States and Societies Key Findings • The burden of HIV/AIDS has profound implications for four sectors of African society: development, health, the state, and academia. • These impacts confronting many African states and societies pose challenges to their management of their epidemics now and into the future. • The mosaic of African nations is significantly heterogeneous in the extent of the HIV/AIDS burden and its implications. In 2009, an estimated 1.8 million new HIV infections occurred in Africa (UNAIDS, 2010), accounting for 69 percent of new infections worldwide; in the same year, 370,000 children began their lives with HIV, which is a decrease from the previous year when 390,000 African children were infected through mother- to-child transmission (UNAIDS, 2010; UNAIDS and WHO, 2009). Between December 2008 and December 2009, 961,000 patients in Africa began receiving antiretroviral therapy (ART), bringing the total receiving treatment to 3,911,000, just 36 percent of those in need of treatment in Africa according to the 2010 guidelines of the World Health Organization (WHO) (WHO et al., 2010). In 2009, 1.3 million Africans lost their lives as a result of AIDS1 (UNAIDS, 2010). Also in 1 This number could be an underestimation as official death certificates often do not cite AIDS as the cause of death. 70

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71 IMPLICATIONS FOR AFRICAN STATES AND SOCIETIES 2009, an estimated 14.8 million children in Africa were estimated to have lost one or both parents to become “AIDS orphans” (UNAIDS, 2010). Beyond this devas- tating human toll, the high HIV/AIDS burden has compromised the achievement of key Millennium Development Goals in Africa (World Bank and International Monetary Fund, 2008), and many agree that HIV/AIDS has a negative effect on total gross domestic product (GDP) in the most affected countries (Haacker, 2009). Many of the very countries experiencing these declines in GDP growth due to HIV/AIDS are among those that require the most dramatic increases in health care spending to meet their treatment goals (Over, 2004). The committee was charged with studying the implications of the HIV/AIDS burden for African governments and institutions. This chapter details these impli- cations and some of the major issues confronting many African states and soci - eties in managing their epidemics in the future. Given that the epidemics across Africa range from highly concentrated to highly generalized (Wilson and Challa, 2009), the committee recognizes that significant heterogeneity exists in the extent of the burden of HIV/AIDS and its implications. While all subregions of Africa require continued, long-term commitments that are responsive to the profile of the epidemic in individual countries, this chapter, like the report generally, focuses on the southern African epicenter of the pandemic (Wilson and Challa, 2009). The chapter explores the implications of the projected HIV incidence and overall HIV/AIDS burden (described in Chapter 2 and Appendix A) for four sectors of African society: development, health, the state, and academia. IMPLICATIONS FOR DEVELOPMENT The negative impact of HIV/AIDS on development outcomes in Africa, especially in high-prevalence countries, is well documented. High rates of HIV- related sickness and premature adult deaths compromise household stability and investment in children; stress extended family and broader social networks; and diminish labor supply and productivity while increasing costs for households, public institutions, and private-sector companies. These observations are gener- ally undisputed. There is, however, less consensus on how these effects translate into overall impact on the welfare and well-being of nations and populations. Debate focuses not only on the long-term effects of the epidemic on economic growth, but also on whether the classic measure of economic performance (GDP per capita) suitably captures the full range of effects of HIV/AIDS on the overall well-being of populations in high-burden countries. Improved availability of treatment has certainly altered the landscape. However, few micro- or macro-level studies to date have considered the development and socioeconomic impacts of HIV/AIDS assuming different treatment access scenarios. This section reviews findings on the disease’s adverse effects on well-being from the household to the national level and presents results of recent studies examining the influence of treatment on mitigating these effects.

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72 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA Household-Level Impacts HIV/AIDS infects and kills young and middle-aged adults preferentially, the age group that comprises household heads, mothers and fathers of young children and adolescents, caregivers for the old and sick, transmitters of agricultural and livelihood knowledge and skills, and custodians of social safety nets (Commission on HIV/AIDS and Governance in Africa, 2008). The epidemic’s adverse effects on African countries’ long-term development thus begin in the household with an assault on the health of an adult member, and appreciating household-level impacts is essential to formulating an effective response to the epidemic. Sickness and possible death draw down the household’s existing financial reserves and compromise the sick member’s income-earning and food-producing potential. This erosion of household resilience undermines the care of and financial invest - ment in children. In highly affected countries, placing children’s futures at risk potentially weakens long-term development prospects. A Poverty Trigger Findings from Booysen’s (2004a) study of income mobility and poverty in poor HIV/AIDS-affected households in South Africa reveal these starting-point dynamics. Comparing outcomes in a cohort of HIV/AIDS-affected households with outcomes in a control group, Booysen demonstrates an association between HIV/AIDS-related morbidity and mortality and downward income mobility in affected households. Households at the lowest end of the income distribution, which are more likely to be in a state of chronic poverty prior to HIV/AIDS stressors, show the least variation in mobility, whereas households at the upper end of the income distribution show the greatest mobility, downward. Addition - ally, the intensity of income mobility increases with the level of illness and death experienced by the household. Booysen concludes from the study that in addi - tion to conventional determinants of poverty, effects of HIV/AIDS-related mor- bidity and mortality on income mobility push households into chronic poverty. Greener’s (2004) analysis of household income and expenditure data in Botswana supports Booysen’s findings. “Income shocks” stemming from the AIDS-related death of an adult household member produce almost all observed changes in household-level poverty status. Many of the poorest are women, who often head the poorest households in Africa (Mbirimtengerenji, 2007). The characteristics of the poor are well known, as are some of the causal factors, such as early marriage, that contribute to a “culture of poverty”—the fact that the children of a poor community often become the poor of the succeeding generations. Another group—children on the streets—have extremely low welfare; receive much less education than other children; and are more exposed to health risks, prostitution, drug abuse, HIV infection, and crime (Ahmed et al., 2007). Street children and children orphaned

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73 IMPLICATIONS FOR AFRICAN STATES AND SOCIETIES by AIDS are more vulnerable than others to the risks leading to HIV infection and perpetual poverty, with little to no access to health care. Food Security The dynamic described above applies also to households whose livelihood depends on agricultural production. A study by de Waal and Whiteside (2003) postulates that HIV/AIDS has exacerbated the food shortage in southern Africa. This hypothesis is based on several observations: that household food shortages in southern Africa are widespread, including in areas not affected by drought; that the decline into household impoverishment is rapid compared with what was seen in earlier droughts; and that household vulnerability continues after the return of good rains. Some empirical evidence from the region bears out this hypothesis. Studies from several countries in the region have linked declines in house - hold food production to adult HIV infection (Arrehag et al., 2006). Government studies from Swaziland report particularly dramatic declines in food production and in agricultural land use (Naysmith et al., 2009). Findings from Kenya do not show declines in land use, but they do show changes in land use patterns, including stopping cultivation of labor-intensive crops and reducing farming management practices (Nguthi and Niehof, 2008). Vulnerability varies depending on household composition, as well as on the gender and stage of disease of the infected adult household head. Some research reports greater negative impact from the loss of labor of an adult male household head, while others suggest that impacts on household food security are more severe if adult females are infected (Gill, 2010). Appreciating the extended-family dynamic linking rural food pro - ducers to urban income-earning laborers, Crush and colleagues (2006) point out that HIV/AIDS impacts food security beyond agricultural households, extending into a wider system of family exchanges of food and cash remittances. Whether the negative effects of HIV/AIDS on household food security pro- duce negative effects at the community level has been questioned (Frayne, 2006). Conversely, others criticize studies’ household-level focus, arguing that the effects of HIV/AIDS on food security are broader and need to be framed explicitly within complex social and political−economic systems (Ansell et al., 2009). In this view, the negative impacts of HIV/AIDS can be fully understood only when considered within preexisting social, political, and economic structures that in themselves create inequality, poverty, and hunger. Ansell and colleagues (2009) contend that limiting the focus of analysis to the household level masks these structural determinants of social inequality of which HIV/AIDS is but one contributing part.

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74 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA Family Coping to Support Orphaned and Vulnerable Children The ways in which HIV/AIDS-induced food and income vulnerabilities affect children are critically important for understanding the long-term impact of the epidemic in Africa. A review of the literature on HIV/AIDS-affected house - holds’ coping strategies by Drimie and Casale (2009) is useful in this regard. In response to increased health care costs and income reductions, families often adopt “erosive” coping strategies, such as taking children out of school, dimin - ishing food intake, or selling and slaughtering animals prematurely. Households without health insurance or savings are especially at risk of adopting erosive coping measures. Meant to respond to the immediate stressor, such strategies jeopardize future livelihood options for the household and undermine children’s education and future livelihood potential. Orphaned children are at greatest risk of a compromised future. Data from southern Africa consistently and unambiguously confirm that all forms of orphanhood—loss of a mother, loss of a father, and loss of both—have increased substantially in recent decades (Hosegood, 2009; Meintjes et al., 2010). Evidence from South Africa shows that in number and percentage, the greatest increase is among “double orphans”—children who have lost both parents (Meintjes et al., 2010). Advanced HIV/AIDS epidemics in these countries are associated with this rise in orphanhood. Of interest is what happens to these children and who cares for them once orphaned. While significant attention and HIV/AIDS-dedicated resources target child-only households, reviews of demographic evidence from southern Africa generally (Hosegood, 2009) and South Africa specifically (Meintjes et al., 2010) indicate no substantive increases in such households. The majority of orphaned children have one surviving parent, and most are living with that parent. More - over, contrary to common scholarly and popular depictions alike of disintegrated extended families in Africa unable to care for a growing number of AIDS orphans, Mathambo and Gibbs (2009) argue that families are coping along a continuum of caring abilities, although it has been observed that a large number of orphaned children are being cared for by frail, elderly grandmothers who often need to be cared for themselves and lack adequate support systems (de-Graft Aikins et al., 2010). At the same time, recent work by Akwara and colleagues (2010) suggests that orphanhood and coresidence with a chronically ill or HIV-positive adult may not be the best indicator of children’s vulnerability. Based on surveys from 36 African countries, their data show that a parent’s AIDS-related death or chronic illness could not consistently be tied to hunger, lower school attendance, or first sexual experience at an early age. What the authors did find reliably linked to vulnerability was the level of wealth in the child’s household. Accordingly, they recommend looking beyond the usual measures of vulnerability and suggest that measures of vulnerability be calibrated to account for each country’s unique conditions.

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75 IMPLICATIONS FOR AFRICAN STATES AND SOCIETIES Care Options for Orphans and Vulnerable Children Although recent data are scarce as to who is caring for orphaned African children, it appears that throughout Africa, household-based care is dominant (Subbarao and Coury, 2004). Most orphans reside in foster care within family lines. Foster care and adoption by nonrelatives are uncommon, in part because of a variety of cultural beliefs and taboos. Institutional care for orphans also is quite limited, although it appears to be growing in some countries. According to a recent Save the Children report from Liberia, there are 11 times more orphan - ages now than 20 years ago. In Zimbabwe, 24 new care institutions for children were built between 1994 and 2004, and the number of children in residential care doubled. In Ghana, the number of such homes increased from 10 in 1996 to more than 140 in 2009 (Csáky, 2009). One reason for the relatively limited number of institutionalized care facili - ties for orphans is the cost of running them. The cost per child per year ranges from US $5,403 (with donated food) in Rwanda to $1,350 in Eritrea and $698 in Burundi. Placing just 1 percent of the 508,000 Burundian orphans in such insti - tutions would cost $3.5 million each year. For most African countries, this cost per child rules out institutions as the preferred option for scaling up of orphan care (Csáky, 2009). A 2001 study comparing the cost-effectiveness of six models of orphan care in South Africa found that formal institutional care is the least cost-effective model, while informal models, such as community-based care and informal fostering, are relatively more cost-effective, although they fail to meet minimum standards of care (Desmond and Gow, 2001). Other studies have reached similar conclusions (Owiti, 2004; Subbarao and Coury, 2004). Given the diverse cultural and socioeconomic settings in Africa and the complex needs of orphans and vulnerable children, most countries are adopting a cost-effective care model that considers multiple levels of care. In Malawi, for example, the National Orphans Task Force has developed a guideline for orphan care in which community-based programs are at the forefront of interventions, followed by foster care; institutional care is the last-resort option, as a temporary measure (Subbarao and Coury, 2004). Policy Implications with a Long-Term Perspective According to Booysen (2004a), dedicated resources that target HIV/AIDS- affected households with broad-based medical, educational, and social security systems could potentially prevent these households from declining into chronic poverty. The stakes of such policies are potentially very high for African coun - tries’ long-term economic development. Bell and colleagues (2004) contend that “AIDS does much more . . . than destroy the existing abilities and capacities––the human capital––embodied in its victims; it also weakens the mechanism in which human capital is formed in the next generation and beyond.” Children deprived

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76 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA of adequate childrearing and education will transfer their capacity and knowl - edge gaps to their own children, thereby transmitting and amplifying the HIV/ AIDS-generated poverty trap in generations to come. Using projections from two high-prevalence countries, Bell and colleagues conclude that without aggressive and expensive policies to preserve the development and transfer of human capital in overlapping generations, highly affected countries risk progressive collapse of their economies. A recent review of studies in Tanzania and Uganda (Seeley et al., 2010) confirms lasting negative impacts on household poverty and on children, but does not confirm large societal impacts of the order predicted by Bell and colleagues (2004). Nevertheless, the latter authors’ focus on the injurious effects of HIV/AIDS from generation to generation rightly underscores the epidemic’s significance for Africa’s future. Economic Performance HIV is sexually transmitted, debilitating, and fatal. Most of the sickness and death caused by the infection is in adults of (re)productive age. Even scholars who doubt the pertinence of disease for economic growth concede that these facts about HIV/AIDS compel special consideration in macroeconomic analyses for countries with generalized and severe epidemics (Acemoglu and Johnson, 2007). Alongside orphaning with its lasting effects, HIV/AIDS-related adult morbidity and premature death affect economic development in several direct and indirect ways. Labor and Productivity The disease’s impacts on labor and productivity are immediately relevant. In a study of HIV/AIDS and private-sector companies in Africa, Feeley and col- leagues (2009) describe a variety of costs to businesses. Employee absenteeism and impaired function due to HIV/AIDS represent tangible costs to companies operating in highly affected communities. Both lead to lower productivity, the cost of which is felt most strongly by firms relying on skilled labor and having invested in worker training. Other costs to companies take the form of increased employee benefits (whether for treatment or for benefits to families in the event of death), costs of recruiting new staff, and increased management time spent on HIV/AIDS-related issues of infected employees. In the pre-ART era, empirical reviews of these extra costs to companies—the “AIDS tax”—showed them to account for 0.5 to 10.8 percent of total compensation costs, depending on the HIV/AIDS burden in the community and the workforce (Feeley et al., 2009). Although a 1−2 percent “AIDS tax” is more common, companies aware of these costs often seek ways to mitigate, cut, or shift these extra expenses (Barks- Ruggles et al., 2001; Reddy and Swanepoel, 2006; Rosen et al., 2007). Following the initiation of ART, some loss of productivity may result from

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77 IMPLICATIONS FOR AFRICAN STATES AND SOCIETIES the treatment itself, whether because of toxicities (side effects) of the antiretro - viral (ARV) drugs or the queuing time required to obtain services in the public sector (queues at public clinics can last for many hours, and current ART guide - lines typically require many clinic visits, especially in the first year) (Rosen et al., 2007). On the other hand, some data suggest that—using worker absenteeism as a proxy for productivity—ART is effective in restoring the productivity of infected workers over time (Habyarimana et al., 2010; Rosen et al., 2010). Within the private sector, reduced labor performance combined with increased labor costs may discourage business investment in communities with severe epidemics (Arbache, 2009). A vicious cycle may ensue, whereby the disease negatively impacts labor supply and performance, leading to negative impacts on capital investment, leading to a decline in employment. As household incomes decline, a high burden of HIV/AIDS can ultimately lead to negative market impacts (Feeley et al., 2009). Economic Growth While the economic impact of HIV/AIDS on households is well established, so is their remarkable ability to cope. Although potentially consequential for an individual entrepreneur, high morbidity and mortality among the labor force do not necessarily slow the overall macroeconomic growth of an economy as long as new firms arise to replace those hurt by the epidemic, and new healthy, equally productive employees are hired to replace those lost to illness and death. Many African economies suffer from extreme unemployment and underemploy- ment of their labor forces, so firms may be able to replace lost workers at a low cost. Given that enterprise surveys in Africa typically find turnover rates among unskilled workers of around 11 percent per year in the absence of HIV/AIDS, a very high HIV prevalence is required to substantially increase annual hiring costs. Thus, the question of whether a high prevalence of HIV infection reduces per capita economic growth remains pertinent. Early analyses of the economic impact of the HIV/AIDS epidemic down- played its consequences for GDP (Lovász and Schipp, 2009). Researchers drew these conclusions largely because of the way they assessed GDP (per capita GDP = GDP/total population), which takes into account the size of the popula- tion. With this formula, when the growth rate of the population declined along with GDP, a minimal economic impact of HIV/AIDS was found. Many of these studies were conducted at a time when the morbidity and mortality from HIV had not been fully realized. Newer analysis approaches take into account more recent data and use advanced modeling techniques. Using these approaches, several authors have found statistically significant negative effects of HIV prevalence on the growth of per capita GDP. One of the most methodologically sophisticated of these efforts is a recent study by McDonald and Roberts (2006), who found the negative effects of HIV/AIDS on economic growth in Africa to be statistically

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78 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA significant. In their model, using data from the pretreatment era, poor health and loss of life reduce social and economic capital. In the Africa sample, an average reduction of 0.59 percent in income per capita results from a 1 percent increase in HIV prevalence (McDonald and Roberts, 2006). In contrast to reports reviewed by Feeley and colleagues (2009), the findings of McDonald and Roberts show that surplus labor supplies in poor countries do not diminish the negative effects of HIV/AIDS on economic growth. Slower growth reduces the tax base, while every new HIV/AIDS-related illness episode, death, and vulnerable child has financial implications for the public health and social sectors (Arbache, 2009; Haacker, 2006). Lovász and Schipp (2009) also found a significant negative effect of the HIV/AIDS epidemic on the growth rate of per capita GDP in Africa. Their study—looking at the impact of the epidemic on the pace of economic growth in 41 countries—reports that the economic impact of HIV is not uniform across countries or even within countries. The economies of countries with low HIV prevalence appear able to absorb the shock of the epidemic and maintain rela - tively normal economic relationships. By contrast, the economies of countries with high prevalence, particularly in southern Africa, experience severe and sig - nificant difficulties due to the epidemic (Lovász and Schipp, 2009). A crucial point that should not be lost in technical discussions of per capita GDP is that HIV/AIDS has a disastrous impact on the social and economic well- being of heavily impacted nations and on their development. The epidemic is reducing the stock of skills, experience, and human capital and, in turn, driving up costs and decreasing productivity (Nkomo, 2010). It is diverting resources away from savings and investment, interrupting generational transfers of knowledge, weakening the education system, and threatening food and human security. All these factors have a long-lasting effect on social and economic development and make it difficult for southern Africa to attain the Millennium Development Goals of eradicating poverty and achieving sustainable development. Influence of Treatment on Household and Economic Well-Being Whether for assessing ART’s effect on preventing orphanhood and vulner- ability in children or on averting affronts to African economies, understanding the influence of treatment on the socioeconomic impacts of HIV/AIDS has now become imperative. One of the first studies of this kind examines the impact of treatment on labor supply in a rural region of western Kenya (Thirumurthy et al., 2008). Within 6 months of treatment initiation, adult labor supply and participation among HIV/AIDS patients increased dramatically. Simultaneously, labor participation of children in the patient’s household, especially that of boys, decreased significantly. The effects of the latter finding are larger and impact more household members in households with multiple patients (Thirumurthy et al., 2008).

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79 IMPLICATIONS FOR AFRICAN STATES AND SOCIETIES A review of studies of the economic and quality-of-life outcomes of HIV/ AIDS treatment in developing countries reports similar trends (Beard et al., 2009). Such studies consistently show improvements in physical health after treatment, as well as improvements in subjective well-being and outcomes related to depression, dementia, and anxiety. Other benefits reported in studies reviewed by Beard and colleagues include significant declines in absenteeism after 1 year of ART, coupled with increased work performance. These effects are found across different sectors. Other household-level benefits are reported as well. With increased ability to work among HIV-infected adults, child labor participation declined and school attendance increased. The first 6 months of treatment was also associated with increased consumption of nutritious foods in the household and with a decline in wasting among children under age 5—from 12 percent at baseline to 5 percent after the adult caretaker had been on ART for 5 months. In South Africa, Booysen (2004b) investigated the role of social grants in mitigating the socioeconomic impact of HIV/AIDS at the household level (Booysen, 2004b). He concluded that social grants play an important role in alleviating poverty (bringing very poor people closer to the poverty line) in HIV- affected households, more so than in eradicating poverty (lifting people out of poverty). However, Booysen notes that the magnitude of the epidemic in South Africa also necessitates consideration of the fiscal affordability and sustainability of such a system in the longer term. IMPLICATIONS FOR THE HEALTH SECTOR The concept of the burden of HIV/AIDS is more meaningful if grounded in concrete consequences and resource demands (Parikh and Veenstra, 2008). Nowhere are the consequences of HIV/AIDS and the resulting resource impli - cations more evident than in the health sector. The health sector has long been key in the response to HIV/AIDS, but its role has become more central with the relatively recent addition of clinic-based prevention, treatment, and care services. Provision of treatment and care is pivotal to managing generalized and severe HIV/AIDS epidemics, and for many African countries, funding commitments for WHO’s 3 by 5 Initiative in 2003 represent a turning point in this regard. Financial resources in and of themselves do not make for success, however. Management and institutional capacity demands on the health sector are both substantial and evolving within a changing context of more treatment and care. The injection of resources for HIV/AIDS care, while providing tremendous opportunity to respond more effectively to the epidemic, also presents critical dilemmas con - cerning the sustainability of service provision over time and the future direction of HIV/AIDS policies and programs. This section reviews some of the challenges and possible trade-offs faced by the health sector in African countries in planning and managing responses to the epidemic.

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80 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA Supply and Demand, Costs and Benefits Changes in the supply and demand of health care are one macro-level expres- sion of a shifting HIV/AIDS burden. Early in the global scale-up of treatment and care, Over (2004) described how HIV-related disease both increases demand for and reduces the supply of health sector outputs. The result is health care scarcity, leading to higher costs and national spending for health. Dedicated funding to increase access to HIV/AIDS treatment and care introduces another dynamic. As the supply of HIV/AIDS-related treatment and care increases, so, too, does demand for the new services. While increased supply and demand of HIV/AIDS treatment and care are partially offset by declining demand for treat - ment of opportunistic infections, they also can cause declines in supply in other health areas (Over, 2004). The provision of complex lifelong treatment to an ever-expanding number of patients will only continue to create extra demand for health care resources, driving up provider incomes and the price of all health care. On the other hand, evidence from Brazil, where an early response to HIV/ AIDS included universal access to ART for medically eligible patients, suggests that aggressively “fighting HIV/AIDS is good business” (Teixeira et al., 2004). As has been seen in wealthier contexts (Gebo et al., 2005; Krentz et al., 2006; Sherer et al., 2002), putting more HIV-infected people on ART in Brazil dramati - cally reduced deaths and HIV/AIDS-related hospital admissions (Candiani et al., 2007; Teixeira et al., 2004), saving the country’s public health sector close to $2 billion between 1997 and 2003 (Teixeira et al., 2004). Reductions in opportu - nistic infections also were seen with the introduction of ART, suggesting similar potential benefits in African settings (Badri et al., 2002; Jerene et al., 2006). Some scholars question the applicability of Brazil’s experience with cost savings for those African countries most challenged by HIV/AIDS (Over, 2004), while others argue that treating more people sooner results in net savings regardless of setting (Ford et al., 2009). Empirical evidence for both arguments is lacking, however. While the cost/benefit debate continues, there is no question as to the clinical benefits of earlier treatment, as reflected in WHO’s recent recommendation to ini- tiate ART earlier at a CD4 threshold of 350 cells/mL for all HIV-positive patients regardless of symptoms (WHO, 2009). In addition to the clinical benefits for individual patients, many experts believe that treating more people earlier also has a prevention benefit (see the discussion below and in Chapter 2), although this benefit is still under debate (Cohen and Gay, 2010; Mastro and Cohen, 2010; World Bank and USAID, 2010). Moreover, treating key coinfections decreases viral load, which has been shown to slow HIV progression; even small changes in viral load could translate into population-level benefits in lowering the risk of HIV transmission (Lingappa et al., 2010; Modjarrad and Vermund, 2010).

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95 IMPLICATIONS FOR AFRICAN STATES AND SOCIETIES Attempts are being made, however, to assist in improving and expanding medical education in Africa (NIH, 2010; SAMSS, 2010). Training for HIV/AIDS Professional Support Staff In addition to doctors and nurses, the HIV health workforce includes clinical officers, pharmacists, laboratory technicians, epidemiologists, phlebotomists, counselors, program managers, statisticians, data clerks, ancillary staff, and com- munity health workers. The function of each category of health worker depends on the local model of care delivery and is influenced by tradition, legislation, and local regulations. Variation in health worker roles can be an obstacle to adapting generalized training tools and curricula to a specific setting (McCarthy et al., 2006). Another category of health worker needed to respond to the HIV/AIDS epidemic in Africa consists of professional epidemiologists and other public health workers needed to manage and optimize health systems and the public’s health. Unfortunately, there are critical gaps in advanced public health education in Africa (IJsselmuiden et al., 2007). On the continent as a whole, there are 29 countries without graduate public health training and 11 countries with only one such institution or program. Training is provided mainly by small units that lack the critical mass needed to expand the field of public health into the multisectoral effort it should be. The greatest shortages occur in lusophone and francophone Africa and in the one Spanish-speaking country (Equatorial Guinea). There are only 493 full-time faculty in public health for the entire continent (854 if part- time staff are counted as well). The overwhelming shortage of academic staff in public health in Africa is clear. While there is no clarity about an optimal number, fewer than 500 full-time academic staff distributed in small groups across Africa are unlikely to provide the public health leadership needed for nearly a billion people (IJsselmuiden et al., 2007). Training for Less Specialized Workers To respond to their human resource needs, African nations may be using or considering a health systems model that encourages the health workforce to share roles and responsibilities with other, less trained workers who can perform an aspect of HIV/AIDS care through task sharing (see Chapter 5). In May 2005, Family Health International’s Zambia Prevention, Care and Treatment Partnership began training and placing community volunteers as lay counselors to comple - ment the efforts of health workers in providing HIV counseling and help reduce their burden, using the national HIV counseling and testing curricula (Sanjana et al., 2009). This national training package includes a 2-week classroom compo - nent followed by a 4-week supervised practicum component. Utilizing a training

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96 PREPARING FOR THE FUTURE OF HIV/AIDS IN AFRICA system already in place in Africa could be a way of training less specialized workers in needed areas of HIV/AIDS prevention and treatment. Technical and Vocational Education and Training (TVET) Technical and vocational skills development has existed since the 1960s as a way of easing the problem of unemployment among primary school dropouts. In the last decade, such training has been gaining momentum in Africa, in large part as a result of evidence for its transformative role in East Asia and its con- tinuing importance in Organisation for Economic Co-operation and Development countries (African Economic Outlook, 2010b). Students enrolled in formal TVET programs in Africa typically receive 3−6 years of training beyond primary school, depending on the country and the model. A recent survey conducted by the African Union on the state of TVET in 18 African countries suggests a number of priority areas for such training in Africa (African Union, 2007). The agricultural sector is of the highest priority, followed by public health and water resources, energy and environmental management, information and communication tech - nologies, construction and maintenance, and good governance. Although TVET could play a role in scaling up the supply of unskilled workers, enrollment in TVET programs in Africa remains marginal to poor. This low enrollment signals stagnation and overall inadequate public training capacity. Formal TVET is seriously underfunded, and obsolete equipment and weak mana - gerial capacity affect the quality of programs. In addition, gender inequalities in TVET reflect the lower enrollment rates of women in secondary education gener- ally (African Economic Outlook, 2010a). The delivery of quality TVET depends in large part on the competence of teachers (African Union, 2007). Partnering with and learning from successful TVET programs in other African and non-African nations and utilizing twinning relationships as described in Chapter 5 could take advantage of a system already in place to develop the numbers and types of workers needed to respond to the challenges of scaling up HIV/AIDS services in Africa. RECOMMENDATIONS Recommendation 4-1: Develop 10-year country roadmaps. In parallel with the U.S. strategic planning called for in Recommendation 3-2, individual national HIV/AIDS coordinating bodies in Africa should develop, articu- late, and update national 10-year roadmaps for combating HIV/AIDS. Each roadmap should take into account the implications of long-term projections of the national HIV/AIDS burden for institutions, communities, and resource requirements. As part of their roadmap, African governments should:

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97 IMPLICATIONS FOR AFRICAN STATES AND SOCIETIES • nvest sufficiently in HIV/AIDS prevention, following globally i accepted best prevention practices; • isclose national and subnational prevention outcomes and impacts and d how they vary geographically and over time; and • erform yearly evaluations to determine success as measured by p change in HIV incidence data, as discussed in Recommendation 2-1. Recommendation 4-2: Develop and promote more efficient models of HIV/ AIDS care and treatment. African countries should invest in, evaluate, and apply more efficient models of HIV/AIDS care and treatment and promote those models through South−South learning exchanges. Recommendation 4-32: Establish a governance contract. African countries should establish a negotiated contract with U.S. agencies that includes pro - grammatic targets and delineates each partner’s responsibilities and expecta - tions within a shared-responsibility approach. African governments should fully maintain the role and function of leadership and stewardship for poli - cies and program implementation in their countries’ health sector. REFERENCES Acemoglu, D., and S. Johnson. 2007. Disease and development: The effect of life expectancy on economic growth. Journal of Political Economy 115(6):925-983. African Economic Outlook. 2010a. Access to technical and vocational education in Africa . http://www.africaneconomicoutlook.org/en/in-depth/developing-technical-and-vocational- skills-in-africa-2008/the-rationale-for-technical-and-vocational-skills-development/ taking-stock-of-technical-and-vocational-skills-development/access-to-technical-and- vocational-education-in-africa/ (accessed October 29, 2010). ———. 2010b. Brief history of the evolution of technical and vocational skills in national and interna- tional agendas. http://www.africaneconomicoutlook.org/en/in-depth/developing-technical-and- vocational-skills-in-africa-2008/the-rationale-for-technical-and-vocational-skills-development/ brief-history-of-the-evolution-of-technical-and-vocational-skills-in-national-and-international- agendas/ (accessed October 29, 2010). African Union. 2007. Strategy to revitalize technical and vocational education and training (TVET) in Africa. Paper read at meeting of the Bureau of the Conference of Ministers of Education of the African Union (COMEDAF II+), Addis Ababa, Ethiopia. Afrique Avenir. 2010. World Bank donates mobile labs to Benin to fight HIV/AIDS. http://www. afriqueavenir.org/en/2010/08/18/world-bank-donates-mobile-labs-to-benin-to-fight-hivaids/ (ac- cessed August 26, 2010). Ahmed, A. U., R. V. Hill, L. C. Smith, D. M. Wiesmann, T. Frankenberger, K. Gulati, W. Quabili, and Y. Yohannes. 2007. The world’s most deprived: Characteristics and causes of extreme poverty and hunger. Washington, DC: International Food Policy Research Institute (IFPRI). 2 See counterpart Recommendation 3-1 directed to the U.S. Office of the Global AIDS Coordinator.

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