VULNERABILITY AND HIV/AIDS

PROF. TIM QUINLAN

HEARD

(Health Economics and HIV/AIDS Research Division)

UNIVERSITY OF NATAL

DEFINITIONS (COMMON USEAGE IN HIV/AIDS RESEARCH)

RISK - Probability of infection.

e.g. Biological : women more than men; Age : ‘youth’ (15-24 yrs old)

Occupational categories: sex workers; truckers

SUSCEPTIBILITY - infected

Risk plus Context (living conditions, lifestyles and behaviour)

Why some people have a higher chance of being infected than others

(e.g. not all sex workers are equally at risk of being infected)

VULNERABILITY -affected

- how & why HIV/AIDS affects many people’s lives and livelihoods

including those not infected;

- why some are not able to cope;

- why & how changes in lifestyle and behaviour (susceptibility indic.)

Purpose: Identify conditions that contribute to the spread of HIV/AIDS; where to focus interventions.

BACKGROUND

SERO-PREVALENCE &

DEMOGRAPHY

Ante-natal clinic prevalence (%)

0

5

10

15

20

25

1990

13

Ante-natal clinic prevalence %

0

5

10

15

20

25

1990 1991 1992 1993

14

Ante-natal clinic prevalence (%)

0

5

10

15

20

25

1990 1991 1992 1993 1994 1995 1996 1997 1998

15

Ante-natal clinic prevalence (%)

0

5

10

15

20

25

1990 1991 1992 1993 1994 1995 1996 1997 1998

South Africa

Thailand

16

A model of futureAIDS and non-AIDS Deaths

0

200000

400000

600000

800000

1000000

1200000

1995 2000 2005 2010 2015

year

num

ber

of d

eath

s

Other deaths AIDS Deaths

Number of people living with HIV/AIDS in sub-Saharan Africa, 1980-2001

0

5

10

15

20

25

30

1980 1983 1986 1989 1992 1995 1998 2001

Mill

ion

s

Source: UNAIDS, 2002

0

10

20

30

40

50

6019

85

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

Mil

lio

ns

Tota

l po

pu

lati

on

0

1

2

3

4

5

6

7

8

9

Mil

lio

ns

Nu

mb

ers

HIV

, AID

S s

ick

and

HIV

dea

ths

Totalpopulation

Total HIV

TotalnumberAIDS sick

CumulativeHIVdeaths

Numbers infected, sick and dead, ASSA2000

By 2010, orphans will account for 15-25% of all children in 12 countries in SSA

0 5 10 15 20 25

Lesotho

Swaziland

Botswana

Zimbabwe

Mozambique

Zambia

Namibia

Malawi

Rwanda

South Africa

Burundi

Central African RepublicNon-AIDS

AIDS

AGGREGATE EMPIRICAL EVIDENCE ON DEMOGRAPHIC IMPACTS

• Survival from HIV sero-conversion is about 8 years

• Risk of infection is greater for women than men

• Age is a significant factor

• Different patterns (mortality rates; socio-economic impacts) due to variation in maturity of each national epidemic

• Current AIDS impacts represent incidence rate of about 10 years ago

• Surveys in Tanzania and South Africa suggest that mortality patterns are unique to Africa.

SOCIO-ECONOMIC IMPLICATIONS

IMPACT AND VULNERABILITY

MORTALITY

MORBIDITY

Smaller local pop. Slower national pop. growth

Change in age structure

INDIVIDUAL

FIRM/SECTOR

GOVERNMENT

MACROECONOMY

HOUSEHOLD

LABOURMARKET

HIV/AIDSHIV/AIDS

Channels of Economic Impact

Individual level

• Incubation period – 5-8 years from infection until the onset of

AIDS– very little economic impact during this time

• AIDS– Period of escalating illness – Ability to work is reduced– While the cost of care increases

What makes women more vulnerable to infection?

Biological:• Larger exposed mucosal surface.• Semen has a higher concentration of HIV • Young girls mucosal surface is immature.• STD infections are asymptomatic.• Semen stays in the vagina.

SOCIO-ECONOMIC FACTORS:

• Women are economically dependent on men

• Burden of care falls on women

• Girls may be withdrawn from school

• ‘Revival’ of ‘traditional’ social norms about subordinate role of women challenges

‘empowerment’ and ‘emancipation’ interventions

What makes women more vulnerable?

Household Impacts

• Due to the sexual nature of transmission often more than one household member is infected.

• Infections are concentrated among the primary carers and earners

• Double impact of reduced income and increased costs of care

Rural household responses to being infected/affected by HIV/AIDS

FOOD SECURITY INCOME LABOR

Eat cheaper foods Diversify income Reallocate labor – e.g.children leave school

Reduce consumption Migrate Work extra hours

Borrow (from informalsector/relatives)

Hire labor & draftanimals

Call in social &familial obligations

(send children torelatives) Sell assets (dissaving) Decrease cultivated

areasEat wild foods Use savings or

investments (dissaving)Call in social &

familial obligations(ask relatives to help)

Beg Beg Diversify income

Effect of HIV on Household Security

Vulnerability Line

Household with weaker safety net

Early stages Frequent hospital visits

BedriddenDeath /Burial

Care for orphans

Household with stronger safety net

INDICATORS & INTERCONNECTIONS

• Morbidity and mortality: determinants of socio-economic impacts on families and households (variation in income levels, likely to suffer severe poverty; household dissolution and child migration)

• Gender and the position of the deceased family member in the household are significant indicators of HIV/AIDS effect on household economic and social viability

• Illness and death of mother an indicator of child mortality (under 5-mortality increasing)

• Extended effects of HIV/AIDS are highlighted in the impacts on organisations: (e.g. Loss of experience and skills, Lower productivity; higher absenteeism and leave rates)

Company costsProgression of HIV/AIDS

in the WorkforceEconomic Impact on the Company

Morbidity begins

Employee becomes infected

Employee leaves workforce (resigns or dies)

Company hires replacement employee

No costs to company at this stage

Morbidity-related costs are incurred(e.g. absenteeism, individual & workforce productivity, management resources, medical care & insurance)

Termination-related costs are incurred(e.g. payouts from pension or provident fund, funeral expenses, loss of morale, experience, & work-unit cohesion)

Turnover costs are incurred (e.g. recruiting, training, reduced productivity)

Timeline

Year 0

Year 1-5

Year 6or 7

Year 7 or 8

Government Finance

• Increased demand on government services

– Health

– Welfare

– Poverty reduction etc etc

• Although demand will increase the level of spending on services will be determined by policy decisions

• Decreased Tax Base

– AIDS effects most economically active

– Government has less resources at its disposal

ANALYTICAL FRAMEWORKS FOR ASSESSING THE IMPLICATIONS OF

HIV/AIDS

Medical interventions for HIV-AIDS

ImmunisationMicrobicidesAnti-

retroviraltreatment

Individual Behaviour

Support

Incapacity & absenteeism inprivate sector &

civil service

cure

s exte

nds

reduces

Viral mutation

redu

ce prevent

Increaces?decreases?

prev

ents

Sex industry interventions

Healthy lifestyle

Condom use

increaces

sustains

impr

ove

AIDS education & awareness

caus

es

redu

ces

prod

uctiv

ity

more orphans

Mores & customs (multiple sets of these) Education

Diet &nutrition

affect

Migrant & mobile workers

Stable & settled workers

brings better

Govtpolicies

Funding for health care, infrastructure, sanitation

scarce educators die

challenges

& influences provides skilled people

Red

uces

de

man

d

sustains

creates vacancies

inhibits

support Drain on

Shareholderexpectations

& values

drive

risk taking &risk avoidance

Role of women

NGOinvolvement

Circumcision

Notions of masculinity

Social cohesion

Spiritual & political authority

Religion challenges

& influences

Beliefs

Above average survivors:chaste & faithful,

long term thinkers,tertiary educated,

non-migrant families,settled LT employees,high income, cohesive

& candid societies, grandparents

Aboveaverage survivors

Above average mortality:unemployed, orphans,soldiers, sex workers,

hazardous occupations, migrants, temps, contract

workers, newly prosperous, young women,

uncircumcised men, & partners of all the above

Population stops

growing, and ages

Businesssector

involvement

Autonomy of HIV in Complex Societies - A systems model of the S’n Africa AIDS epidemic

TreatingSTD’s

HIVEpidemic

(prevalence)

HIV Transmission

LatencyPeriod

(avg 8 yrs)

AIDS related Disease & Deaths

(death rate)

Motherto child

treatment

ham

pers

prev

ents

Treatingopportunistic

diseases

Africantraditionalhealers

promiscuity

incr

eass

Economicorganisation

Personal responsibility

Self-confidence

Chastity,Fidelity

reduces

Business sector involvement

Migration & mobility

Impr

oves

wea

kens

changes

Tension of two worlds

Life force,procreation,

sex urge

Drives

affects

affects uptake of

AIDS testing & counselling

impr

oves

Promote / hamper

increase

s

Leadershipin society

Bus

ines

s se

ctor

invo

lvem

ent

reduces

Promote / hamper

G i v e s r i s e t o

Global competition &

economy

Weather & climate

change

Jobs

Economy

Cost of hiring &

retraining

affe

ctaffe

ct

affect

skilledworkers

die

Who dies & who survives:

(population. Demographics &

particularities)

values, profits, patents, prices, research

Determinesnature of

influ

ence

s

create

provides

prov

ides

prov

ides

promotes

increases

create

incr

ease

s

perceptions of risk Hazardous

occupations

crea

te

affects

Housing & land Urbanisation

affect

Safety, crime & war

I n f l u e n c e

Cost to individuals & households : medication, care, burial,

& orphans

reduces

affects

extends

Epidemic Curves, HIV

27Aug01 - Report I: Epidem’gy & Lit. p. 27

T1 T2 Time

Numbers

A1

A2

HIV prevalence

A

B

Epidemic Curves, HIV and AIDS

27Aug01 -Report I: Epidem’gy & Lit. p. 27

T1 T2 Time

Numbers

A1

A2

HIV prevalence

AIDS - cumulative

B1

A

B

Epidemic Curves, HIV, AIDS & Impact

27Aug01 -Report I: Epidem’gy & Lit. p. 27

T1 T2 Time

Numbers

A1

A2

HIV prevalence

B1

A

B

AIDS - cumulative

Impact

HIV Epidemic – Where we should respond

Determinants

STD treatment

Blood safety

Anti-retroviral therapy during pregnancy

Provision of condoms

Behaviour change communication

Change beliefs, attitudes, ‘mindsets’

Condom promotion and marketing

Micro-environment

Social Policy

Economic Policy

Legal Reform

Employment legislation

Macro-environment

Social policy – redistribution

Legal Reform

Human Rights

Taxation

Debt relief

Terms of Trade

Interventions

Sexual behaviour

Biomedical

A Virtuous Circle

HIV Prevention

Treatment and care

Pre-empts need for treatment

Mitigation of Impact

Reduces risk, strengthens communities

Makes communities less vulnerable

Pre-empts need for future mitigation

Makes communities less susceptible

Pre-empts need for future mitigation

Strengthens systems for delivery of care

42

STRATEGIC PLANNING APPROACHES

(RESEARCH) (MANAGEMENT)

(Research)

Reactive Creative

‘Multi-sectoral (work out how to achieve vision: Response’ define objectives; pool resources

collaboration) = ‘integration’

HOW? TO WHAT END? VISION

STRATEGICPLANS

RE-THINK APPROACHTheory; Methodology; Criticalthinking; Values/Philosophy

IMPACTASSESSMENT

(Research)

INTERVENTION(e.g. PR; monitoring –derivefrom approach;)

Participatory exercises

INTEGRATEDSTRATEGIC PLANS