Introduction

AIDS depends for its success on the failures of development. If the world was a fairer place, if opportunities for men and women were equal, if everyone was well nourished, good public services were the norm, and conflict was a rarity, then HIV (Human Immunodeficiency Virus) would not have spread to its current extent, nor would the impacts of AIDS (Acquired Immune Deficiency Syndrome) be as great. We now know that the spread of HIV and the effects of AIDS are closely linked to development problems such as poverty and gender inequality. Development and humanitarian agencies should be doing more to respond to the challenges posed by HIV/AIDS. This book suggests a way in which they can do so through their existing work without necessarily establishing special programmes of HIV prevention or AIDS care.

This book is a shorter, simplified version of AIDS on the Agenda (Holden 2003), a book which can be ordered from Oxfam GB, or downloaded for free from http://www.oxfam.org.uk/what_we_do/issues/hivaids/aidsagenda.htm. The ideas in the two books are the same; but this version, we hope, is accessible to a wider range of readers: those who actually do development and humanitarian work, in addition to those who manage it and fund it. Unlike AIDS on the Agenda, this book does not feature quotations and case studies; instead it presents general lessons learned – mainly from the experiences of non-government and community-based organisations (NGOs and CBOs) working in the parts of Africa that are worst affected by HIV/AIDS.

AIDS has changed the world. This book is about the changes that we need to make in order to do effective development and humanitarian work in a world of AIDS.

What this book contains

Part 1 presents the reasoning behind the idea of mainstreaming HIV/AIDS in existing development and humanitarian work, and Part 2 presents practical ideas for agencies that are seeking to mainstream HIV/AIDS into their work.

Part 1: The case for mainstreaming HIV/AIDS

Chapter 2 considers the two-way relationship between under-development and the causes and consequences of HIV/AIDS. It shows how the disease can make gender inequality worse, and claims that HIV/AIDS is a long-term development problem with no obvious solution.

Chapter 3 explores what mainstreaming means, by setting out the four main terms used in this book:

• AIDS work

• integrated AIDS work

• external (programmatic) mainstreaming of AIDS

• and internal (organisational) mainstreaming of AIDS.

It identifies similarities and differences between them, and gives practical examples of what the terms mean for development and humanitarian organisations.

Chapter 4 addresses the question 'Why mainstream HIV/AIDS?'. It considers some of the problems that may arise if development and humanitarian organisations fail to take AIDS into account in their ordinary work. It also responds to some objections to the idea of mainstreaming HIV/AIDS, and describes two problems which development organisations may meet when they do AIDS work.

Chapter 5 draws together all the elements of Part 1. It presents a 'web', showing four levels of influence on HIV transmission, and different kinds of response, both direct and indirect. Currently most of the global response to AIDS is direct; this chapter argues that all the influences need to be addressed and recommends that in AIDS-affected countries the indirect approach of mainstreaming should be the basic initial strategy for development and humanitarian agencies. Organisations with enough capacity, skills, and resources should ideally also engage in direct AIDS work; others might form partnerships with other agencies that are undertaking AIDS work.

Part 2: Ideas for mainstreaming HIV/AIDS

Chapter 6 provides some general strategies for initiating and sustaining mainstreaming, and proposes some guiding principles. Chapter 7 offers ideas for mainstreaming HIV/AIDS within the internal operations of development and humanitarian agencies, and Chapters 8 and 9 offer suggestions for external mainstreaming in development and humanitarian programmes respectively. Chapter 10 presents an overview of the issues and challenges involved in promoting and adopting the strategy of mainstreaming, and the book concludes with Chapter 11.

Using this book

If you are not sure about the basic facts of HIV/AIDS, you should first read Appendix I. It describes the ways in which HIV can be passed from one human to another, and the four stages through which someone who is infected with HIV passes: from initial infection to developing AIDS. The appendix also explains how patterns of HIV infection vary according to age, sex, ethnicity, wealth, and occupation.

You will find that most technical words or phrases are included in the book's glossary on pages ix–xii. Each of these words or phrases is shown in italics the first time that it is used in the main text.

Most readers will need to read Part 1 of the book before Part 2. However, if you are already convinced of the case for mainstreaming, you might read only Chapters 3 and 5 before going on to Part 2.

When you reach Part 2, you may want to prioritise reading Chapter 7, if you are particularly interested in ideas for mainstreaming HIV/AIDS within organisations; or Chapter 8, if you are mainly interested in development work; or Chapter 9, if your main concern is humanitarian work. Chapters 6 and 10 are relevant to all three types of mainstreaming.

Some of the ideas for mainstreaming in Part 2 are presented in more detail, with practical suggestions for implementation, in a series of Units published in AIDS on the Agenda. If you have access to the Internet, you may wish to download the Units, which are listed below, from http://www.oxfam.org.uk /what_we_do/issues/hivaids/aidsagenda.htm.

Unit 1 Researching the current internal impacts of AIDS

Unit 2 Predicting the internal impacts of AIDS

Unit 3 Assessing the impacts of AIDS education

Unit 4 Devising or adapting a workplace policy

Unit 5 Monitoring the internal impacts of AIDS and the effects of internal mainstreaming

Unit 6 Training for mainstreaming AIDS in development work

Unit 7 Undertaking community research for mainstreaming AIDS in development work

Unit 8 Adapting organisational systems

Unit 9 Training for mainstreaming AIDS in humanitarian work

Unit 10 Undertaking community research for mainstreaming AIDS in humanitarian work

HIV/AIDS and under-development

Introduction

This chapter explores the two-way relationship between the causes and consequences of HIV/AIDS and factors of under-development. It examines how HIV/AIDS can make women's position in poor communities even more difficult than it already is, and argues that HIV/AIDS is a long-term problem of under-development for which there is no obvious solution. This fact points to the need for development and humanitarian agencies to address it through their on-going core programmes.

AIDS as a development issue

Since HIV was first identified at the beginning of the 1980s, HIV/AIDS has been understood and addressed in two main ways, which still predominate today. First, it has been treated as a purely medical problem, with a scientific focus on the biological effects of the virus, and developing ways to tackle it through medical interventions. Second, it has been treated as a behavioural problem which can be solved by individuals acting on information; the result is a focus on AIDS-education campaigns.

Although both of those approaches are essential – HIV/AIDS is both a medical and a behavioural issue – this book approaches the problem as one of development – or, more accurately, of under-development. AIDS has not affected all nations or all types of people equally. More than 90 per cent of HIV-positive people live in developing nations, and sub-Saharan Africa alone is thought to account for about two thirds of the global total of cases. The worst-affected region in the world, Southern Africa, is home to about two per cent of the world's population – but thirty per cent of all the people in the world who are living with HIV/AIDS live in Southern Africa. HIV flourishes where the conditions of under-development – poverty, disempowerment, gender inequality, and poor public services – make societies susceptible to HIV infection and undermine efforts to prevent its transmission. Furthermore, those same factors of under-development make societies vulnerable to the impacts of AIDS.

Figure 2.1 illustrates a model of the causes and consequences of HIV/ AIDS. On the causes side are the main factors which make individuals, groups, and whole populations more susceptible to HIV infection. In addition to these, other factors include labour migration, economic globalisation, and environmental damage. On the consequences side are some of the impacts of HIV infection and AIDS, as they affect households, communities, and nations. These effects are more severe where vulnerability to the impacts of AIDS is high; for example, where there are few means of support for individuals who fall sick and for families that become impoverished. The important thing to note is that the two sides of the model reinforce each other: high susceptibility leads to higher levels of HIV infection, which leads to AIDS; and where people are vulnerable to the impacts of AIDS, its consequences cause increased susceptibility, and so on.

Causes of susceptibility to HIV infection

We shall first consider the causes side of the model.

• Poverty can create susceptibility to HIV infection in many different ways.

In terms of biology, malnourishment and other infections weaken the body's immune system. Poverty also causes higher susceptibility to HIV infection because poor people are less able to afford health care, and so they are less likely to be in good health, less likely to get treatment for sexually transmitted infections (STIs), and less likely to buy and use condoms.

In general, poverty also has an important effect on how people think and act: it tends to displace long-term concerns such as the possibility of developing AIDS in the future. Poor people cannot afford to take long-term measures to protect their lives: they are too busy trying to survive in the short term. If they have few ways of earning a living, they may have to rely on selling sexual services; poor girls and women, in particular, may obtain cash, goods, protection, and favours, either via commercial sex work or through informal sexual exchange with varying degrees of commitment. When migrating to find work, young women may typically find themselves in employment which increases their susceptibility to HIV infection, such as working as house maids or bar girls. And men who migrate to find work are often separated from their homes and families for long periods, which may lead them to take casual sexual partners. Poor working conditions and living conditions can undermine people's health too, as experienced, for example, by the large numbers of migrant miners in Southern Africa.

• Gender inequality is another factor which increases susceptibility to HIV infection. Women and girls are made more susceptible if social norms dictate that they should submit to their partners' demands to have sex. Following the 'ABC' of HIV prevention ('Abstain, Be faithful, use Condoms') is all the more difficult in situations where women are likely to be punished with violence if they attempt to refuse sex or propose using condoms. In general, where girls and women have less control over their lives than men and boys do, and are disadvantaged in terms of education, income, and opportunities, they are less likely to be able to protect themselves from HIV infection. This susceptibility is partly linked to poverty; for example, where women's rights to inheritance and divorce are not respected, they are likely to become impoverished when widowed, or on leaving a relationship.

• Poor public services can increase susceptibility to HIV infection within a population. This may happen directly, when patients are accidentally infected with HIV through receiving contaminated blood in a transfusion, or when staff use surgical equipment which is not sterile or use unsterilised needles when giving injections. Such modes of transmission are far more likely in impoverished settings where blood for transfusions is not screened for safety, and health-care workers lack sterile equipment and are not trained in preventing the spread of HIV. Poor public services can increase susceptibility to HIV infection in indirect ways too. For example, where education services are inadequate and literacy rates, particularly among girls and women, are low, efforts to prevent infection are generally less effective, and there is greater inequality between men and women. And where treatment for STIs is not available, or not affordable, untreated infections leave those who suffer from them (and their sexual partners) more susceptible to HIV transmission.

• Finally, when considering the main causes of susceptibility to HIV infection, one must include the role of crises such as armed conflict or environmental disasters. In such situations the whole of the affected population may be more susceptible to infection with HIV as a result of impoverishment, displacement, loss of assets, and disruption to social-support networks. However, women and girls tend to suffer disproportionately, because they are more likely than men to be subject to rape and sexual violence, and they are more likely to resort to using their one portable asset – their bodies – in order that they and their dependants may survive. And where a crisis causes population movements, susceptibility may be further increased if populations with low levels of HIV prevalence encounter populations, or groups such as the armed forces, who are experiencing higher levels of prevalence.

Consequences of HIV infection

Until more research has been conducted into the consequences of HIV and AIDS, the impacts of AIDS are best understood at the levels of the individual and household. Analysts have identified sequences of reactions among AIDS-affected households in various settings; Table 2.1 illustrates a sequence of three phases.

How severe will the impacts of AIDS be? That depends on the level of vulnerability of the household and community. For each household, key factors which determine vulnerability include

• access to resources

• household size and composition

• access to assistance from extended families

• and the ability of the community to provide support.

A household with enough resources in the form of labour, savings, and other assets will certainly feel the impact of a death from AIDS, but may be able to survive by using strategies from only the first stage of Table 2.1, and so recover from the shock. Poor households with fewer resources and fewer options are more vulnerable; they may reach the third stage, which is permanent impoverishment.

The vulnerability of households to the impacts of AIDS is also affected by the wider context, including the level of public services and support that is available from the State. In particular, people are less vulnerable where health care is available and is free or inexpensive, allowing HIV-positive people and their family members to get treatment even when AIDS is impoverishing them. This is all the more true where HIV-positive people have access to antiretroviral therapies which help them to live and work for longer. However, in the cycle of causes and consequences, the delivery of all services – from government, non-government organisations, and the private sector – may be affected by sickness and death among staff. Of particular note, as Chapter 4 will discuss, are the pressures that AIDS places on the health service, and the way in which a decline in education services can damage the prospects for future development. In addition, AIDS can threaten people's food security, and may make recovery from food shortages more difficult to achieve.