Select Committee on International Development Minutes of Evidence

Memorandum submitted by the Department for International Development (continued)


  There is a complex reciprocal relationship between the spread of HIV/AIDS and political and social instability. The epidemic both fuels and is fuelled by poverty, conflict, social dislocation, food insecurity and disasters. For a region such as sub-Saharan Africa, parts of which are at present suffering disproportionately from civil and political unrest, the link with HIV/AIDS is an important human security issue. The UN Security Council recognised it as such when they discussed HIV/AIDS in January 2000.

HIV/AIDS as a cause and effect of political and social instability

  This memorandum has described the impacts on households and the workforce, and the emergence of many millions of additional orphans. The continuing growth in orphan numbers will result in increasing numbers of impoverished and disaffected adults. This is likely to aggravate existing social and political tensions, especially in areas where social cohesion is already fragile.

  This memorandum has described, above the way that the education sector is being undermined by the loss of teachers. In addition, in situations where children are taken out of education (to care for ill relatives or provide labour, or because of loss of household income), their access to an important set of socialising influences is reduced.

  Yet the education sector has a vital role to play in reducing these potential threats to social cohesion. Schools are places for learning about HIV/AIDS prevention, not only in providing access to the right information about the disease, but also in empowering young people, particularly girls. Literacy skills, increased awareness about human rights especially with respect to HIV/AIDS, may enable individuals to feel more confident in negotiating safer sex, or in seeking treatment and entitlements owed to them. Access to an effective education system is an important component in maintaining the social fabric of communities at any time—the role is reinforced in the face of HIV/AIDS.

Impact of HIV/AIDS on the Armed Forces, and vice versa

  Armed forces (militia, military and police) constitute a major population block—highly mobile, and frequently called upon to serve away from home, within their countries or abroad. Armed forces personnel operate in a risky environment—they are young people, often away from home for long periods they have multiple opportunities for engaging in risk behaviours such as casual sex or drug use to relieve stress and boredom. Sexually transmitted disease has always been a problem for armed forces and for civilians with whom they come in contact, and HIV is no exception. The statistics on HIV prevalence in some uniformed populations are alarming their governments—up to 40 per cent or more amongst soldiers in some countries.

  The impact of HIV/AIDS on the armed forces can pose a serious threat to security. Police and military capability is compromised through illness, loss of training input, loss of experience and skills, demoralisation, with the associate costs of additional recruitment and replacement training.

Conflict and disaster as a cause of the spread of HIV/AIDS

  Conditions associated with conflict and forced population displacement—poverty, social instability and powerlessness—can exacerbate HIV transmission. Military populations, refugees and internally displaced people may find themselves in high risk environments, particularly since they often live in, or interact with refugee camps. Evidence suggests that the level of risk in refugee population varies from situation to situation, and depends on factors such as level of physical well-being, the need for sex work as a survival strategy, the presence or absence of male household members, and the involvement of the armed forces. Women and children can be especially vulnerable due to the fact that they comprise up to 75 per cent of the world's refugee and IDP population.

  Key factors which exacerbate spread of the disease in situations of conflict and disaster include the following:

    —  sexual violence and abuse is a significant problem in many of these situations. The geographical location of refugee camps, the social structure in the camps, services and facilities and lack of police protection can all contribute to incidences of sexual violence.

    —  where conflict leads to breakdown in cultural and social structures, for example through loss of family or separation from family members, this puts severe stress on traditional coping mechanisms. People may engage in commercial or casual sex where, in more stable situations, they would not.

    —  lack of educational opportunities in refugee camps can mean that young people may engage in more risky behaviour such as drug and alcohol abuse and increased sexual activity. Orphans and unaccompanied children are an especially vulnerable group as they do not have the support and guidance of their parents.

    —  a lack of income and basic needs in conflict and disaster situations can contribute to increased sexual coercion and sexual bartering in exchange for goods and services.

    —  increased ill-health arising from conflict and disaster, combined in some situations with disruption in access to quality health care services, can contribute to the risk of HIV transmission. In particular, a breakdown in the ability to provide safe blood and a lack of sterile equipment to safely handle blood products increases the risk of transmission.


    Significantly, the success of various HIV/AIDS interventions has been shown to be directly proportional to the degree to which human rights are promoted and protected in the context of these interventions. These realities, demonstrated time and again over the course of the HIV/AIDS epidemic, make clear that the protection and promotion of human rights must be an integral component of all responses to the epidemic.31

  HIV/AIDS is one of many health problems and disabilities that attract discrimination, stigma, and the abuse of human rights. The people most at risk of HIV infection often belong to population groups whose rights may already not be respected. Several human rights agreements, while not specific to HIV/AIDS, nevertheless have much potential for offering protection. The quotation, above, comes from a UNAIDS guide written especially for nongovernmental organisations. It empowers them to use the United Nations human rights machinery to protect people with HIV/AIDS from discrimination and human rights abuses, in part by holding governments to account for their own actions or for the abuses that occur in their countries. This section draws mainly on that guide and on DFID's consultation document, "Human Rights for Poor People", published in February 2000.

  The IDC's call for memoranda did not explicitly mention the gender aspects of HIV/AIDS. Discrimination against women is reflected, however, in the fact that women may be more severely affected than men in mature epidemics in the worst affected countries. In addition to the severe personal consequences on women, this can have a developmental impact—for example if a woman is removed from a household or productive role because of her infection, her children receive a less sound or less well-resourced upbringing, or, in a more abstract way, if the ostracisation of a proportion of the population contributes to a loss in social cohesion. The human rights agreements and committees that are relevant to HIV/AIDS do include discrimination against women, and so it is a topic that is covered in this section. For more information on DFID's views on gender and HIV/AIDS, please see Annex 2.

Types of discrimination

  Stories of stigmatising treatment have abounded since AIDS first became recognised. People who have been known or suspected to be HIV-infected have been publicly humiliated and vilified, driven out of their homes and communities, sacked from their jobs, socially isolated, imprisoned, deported, beaten up, murdered, prevented from having normal burials. Some employers have tested prospective employees, hospitals and health workers have refused treatment to HIV-infected patients or given them particularly low standard of care, some insurance firms have refused cover, children have been banned from schools. Groups such as commercial sex workers, males who have sex with males, and injecting drug users have experienced discrimination as a result of their lifestyles, and this has been reinforced by fears about HIV/AIDS. As mentioned, discrimination against women contributes to the disproportionate ways in which HIV/AIDS affects them.

  There have also, of course, been examples of good practice, sometimes in the face of widespread discriminatory attitudes—many individuals and organisations and some large companies took a progressive approach in the early years of the epidemic, particularly in North America and Europe.

Participation, inclusion and obligation

  These are three principles that underlie DFID's and other organisations' emerging approach to human rights and development.

  A series of consultations with poor people in the late 1990s found, to no great surprise, that many considered themselves to lack influence over the decisions that affected their lives, including in countries with democratically elected governments. Participation is linked to access to information. In relation to HIV/AIDS, people infected or affected by the disease need to be able to influence the way that governments and organisations respond to it, and they need access to accurate, explicit information about it.

  A definition of social inclusion was agreed at the Social Development Summit in 1995, and has its basis in the Universal Declaration of Human Rights. A socially inclusive society is one in which all people are able to claim their rights. Groups that are particularly vulnerable to HIV infection and to the impact of AIDS are often excluded from society to a lesser or greater degree, including access to health care, work, shelter and employment. When infected or ill with AIDS, the exclusion increases.

  States have obligations under national legislation and international human rights law. Many of the human rights instruments (see below) contain provisions that are relevant to the protection of people from HIV/AIDS-related discrimination.

  DFID's review of the links between human rights and development identified the following lessons, all of which are relevant to HIV/AIDS as a development issue:

    —  there is a large gap between the aspirations contained in the principles of the Universal Declaration of Human Rights and the reality of the lives of many people in poorer countries;

    —  the progressive realisation of human rights requires resources and strategic planning for medium and long-term action;

    —  there are problems with relying solely on legal measures for the protection of human rights;

    —  there is no single prescription for effective citizens' participation;

    —  clear standard setting and the concrete definition of entitlements enables poor people to claim rights;

    —  claiming and respecting human rights is a political process;

    —  the voices of the excluded can be translated into concrete responses from government;

    —  there is increasing scope to translate human rights into national legislation and policy implementation;

    —  the promotion of human rights requires an understanding of the challenges facing governments in the South;

    —  non-state parties have responsibilities to protect human rights.

  This clearly places HIV/AIDS-related rights and obligations within the broader human rights and development agenda. Subject to the outcome of consultation on DFID's current document, we will be using these lessons as the basis for a rights-based approach to the elimination of poverty—including its HIV/AIDS-related aspects. This will, of necessity, require partnerships with NGOs and other organisations. An outline of the relevant human rights institutions and documents is set out below.

The relevant human rights instruments and machinery

  "Instruments" are the declarations, covenants, conventions and charters that constitute human rights law. The "machinery" is the array of commissions and committees that exist to promote them and to monitor states' obligations to apply them.

  The international instruments most useful in the protection of people infected or affected by HIV/AIDS include the following:

    —  Universal Declaration of Human Rights.

    —  International Covenant on Civil and Political Rights.

    —  International Covenant on Economic, Social and Cultural Rights.

    —  Convention on the Elimination of all Forms of Discrimination.

    —  Convention on the Elimination of all Forms of Discrimination against Women.

    —  Convention against Torture and other Cruel, Inhuman or Degrading Treatment.

    —  Convention on the Rights of the Child.

  Relevant regional charters include the following:

    —  African Charter on Human and People's Rights.

    —  American Convention on Human Rights.

    —  European Convention on Human Rights.

  Each of these instruments is overseen by a commission or committee. For example, the main body for discussion on progress related to human rights is the Commission on Human Rights, which meets annually. Its subsidiary body is the Sub-Commission on the Protection and Promotion of Minorities. Separate commissions and committees meet on women's rights, child rights, civil and political rights, economic, and social and cultural rights. The African Commission on Human and People's Rights supervises the implementation of the African Charter, and so on.

  A simple illustration of their use by individuals is when Mary Robinson, previously President of Ireland, now UN Commissioner for Human Rights, brought AIDS-related cases under the European Convention in the 1980s when she was a practising lawyer. Organisations with an interest in AIDS-related human rights abuses can influence the work of the various bodies by submitting reports, attending their meetings and by working closely with UN bodies that have mechanisms for monitoring compliance with human rights norms. While expertise on the pursuit of rights is growing among organisations, not only related to HIV/AIDS, there is still much potential for pressure to be brought to bear through the formal mechanisms.

  UNICEF, UNIFEM, UNDP have been active in promoting rights relevant to their fields of work. WHO's member states are bound by a World Health Assembly resolution on the avoidance of discrimination against people with HIV or AIDS. As with other organisations, the UN agencies could be more active in promoting the protection of AIDS-related and other rights, in the pursuit of effective social and economic development. DFID has realised that its own expertise in rights-based development needs to be strengthened—and hence the production of the consultation document, "Human Rights for Poor People". When finalised, this should underlie DFID's approach to development through the promotion and protection of rights in the field as well as through the formal mechanisms at global and regional levels.


  There has been a lot of good epidemiological work done by UNAIDS and others to establish trends in transmission rates, effects on different sections of the population and overall impacts on life expectancy. However, there has been little work so far to link this directly to impact on the international development targets. But even without explicit data, it is generally accepted that in countries with the highest infection rates, it is unlikely that the international development targets will be met. This is likely to include Zimbabwe, Zambia, Botswana and Namibia, where 20-26 per cent of people aged 15-49 are HIV positive, and Ethiopia, Kenya, Mozambique, South Africa and Tanzania, where 9-20 per cent of adults are infected. In countries outside of Africa, the impacts of HIV/AIDS may be very severe for certain sectors of the population such as commercial sex workers, men who have sex with men and injecting drug users.

  The most disturbing feature of the HIV/AIDS epidemic is its impact on life expectancy. In the 13 or so African countries with adult prevalence of 10 per cent or more, HIV/AIDS will erase 17 years of potential gains in life expectancy, meaning that instead of reaching 64 years, by 2010-2015 life expectancy in these countries will regress to an average of just 47 years; this represents a reversal of most development gains of the past 30 years. In contrast, South Asians, who in 1950 could barely expect to reach their 40th birthday, can expect to be living, by 2005, 22 years longer than their counterparts in southern Africa.

  In the most severely affected countries, child mortality is rising. In 1998, about 530,000 HIV-infected children were born in sub-Saharan Africa, about 90 per cent of the world total. By 2005-2010, infant mortality in South Africa will be 60 per cent higher than it would have been without HIV/AIDS. In Zambia and Zimbabwe, 25 per cent more infants are already dying than would be the case without HIV. By 2010, infant and child mortality rates in these countries will have doubled.

  The tendency for more women than men to be infected in mature epidemics has profound implications for the international development target on gender disparity in those countries. In addition, girls are more likely to be pulled out of education to care for sick relatives, further intensifying the disparity.

  The fact that the disease strikes people in their prime years has considerable implications for the economic well-being target. AIDS profoundly disrupts the economic and social bases of families. When a household loses its primary income earner or producer, its very survival may be threatened. It sells assets and uses savings to pay for health care and funerals. In sub-Saharan Africa, there has been a huge loss of skilled workers to HIV/AIDS. One large bank in Zambia lost most of its senior management to the disease. The World Bank now estimates that GDP in the most severely affected countries will be reduced by 1 percentage point per annum as a result of HIV/AIDS.

  There are around 7.8 million AIDS orphans in sub-Saharan Africa alone. As a proxy for the death of mothers, this is a clear indicator that the target for maternal mortality will not be met in many African countries. It is likely that the rate, in fact, will continue to get worse.

  The impact of the disease on the health sector in the most affected countries has grave consequences for the target on universal access to sexual and reproductive health services. Health systems in the most affected countries are being stretched beyond their limits as they not only deal with a growing number of AIDS patients and the loss of health personnel due to death and illness, but also cope with rising cases of tuberculosis, the most common opportunistic infection associated with HIV/AIDS. With the consequent competition for scarce resources, demands for spending on acute care is likely to take precedence unless health-service planning improves significantly and is able to allocate resources against well-defined priorities.



  The main priorities in HIV/AIDS are prevention of future cases and the care and support of the roughly 35 million people now estimated to be living with HIV infection. Further, many of the roughly 11 million AIDS orphans have special needs that are not being met through existing coping mechanisms, for example in education and socialisation. The impact on households needs special attention, for example where subsistence livelihoods are undermined to the point of pushing people into absolute poverty. This brings government departments and organisations firmly into the arenas of agricultural policy, micro-enterprise support including credit, and human resource protection and development in both the public and private sectors. The most urgent geographical area for action is sub-Saharan Africa, but South and South-east Asia and parts of Latin America and the Caribbean need attention too. A rights-based approach is essential.

  DFID is in the process of refining a cross-sectoral strategy that will help it to take HIV/AIDS into account in all its work. The strategy will provide guidance to DFID's managers on priority interventions and locations. It will help DFID to decide how best to allocate additional resources, not least to the problems arising from significantly increased illness and death among productive adults. The strategy will take account of the recommendations arising from the IDC's hearings on the impact of HIV/AIDS.

Priorities for Intervention

  DFID and other major supporters of HIV/AIDS programmes give highest priority to the prevention of future cases of HIV infection, especially among people whose risk behaviour is likely to infect others. This means concentrating on helping people with high risk behaviour, especially the young, to reduce the HIV-related risks they take or that they have imposed upon them. Only in this way will the rapidly increasing future burden of AIDS be reduced—one case prevented now among people who take the highest risks could reduce many-fold the number of people needing care in the future, as well as reducing the future social and economic impact. Of the HIV risks, the most important is unprotected sexual intercourse, especially among people who have multiple concurrent partners.

  People taking risks need access to supportive sexual health services, including clear, explicit information and advice; confidential testing and counselling; and condoms and treatment for sexually transmitted infections. For young people, those services need to be specially designed to be youth friendly. These services need to be targeted on the groups with the highest risks, such as sex workers and their clients—and, where they are growing up in high-risk environments, the young. Girls are particularly at risk—but prevention programmes need to be available to men as well. Where injecting drug users or males who have sex with males have high levels of partner exchange or share injecting equipment, they should also be priorities for risk reduction programmes.

  Future technologies hold out hope for increasingly effective prevention in the future. DFID is contributing to efforts to find a practical HIV vaccine, for example through the International AIDS Vaccine Initiative (IAVI—to which the UK's £14 million was the first bilateral donation); and for a microbicide that women can use to avoid infection.

  While the epidemiological and economic arguments might be to use scarce resources almost entirely for prevention, humanitarian realities dictate that the swelling numbers of people with HIV-related illnesses have a major claim on governments, civil society and international agencies. They will continue to do so, in vastly increasing numbers, over the coming decades and beyond. Care also creates opportunities for promoting HIV risk reduction. DFID will contribute to well-designed, high priority care efforts, concentrating in the countries and communities of greatest need. In many cases this will be linked to broader health service development and public sector reform initiatives.

  At present DFID is wary of the growing groundswell of demand for widespread access to antiretroviral drugs. While there are sound arguments in terms of equity, there are still concerns about practicalities such as affordability (even if there were to be a 95 per cent cut in prices), cost effectiveness and opportunity costs, the capacity of health systems to handle complex medical treatments, and the relative priority to be placed on drugs as one part of countries' HIV/AIDS strategies.

Collaborative Working

  DFID works co-operatively with governments, international agencies, and civil society including the voluntary and commercial sectors. The UK participates in the UNAIDS-led International Partnership against AIDS in Africa, both financially and through the organising sessions at international and national level. As the Partnership becomes more operational, DFID will continue to work towards action in countries that is collaborative and that takes place within the framework of nationally-agreed strategic plans. DFID will also contribute to making sure that the national plans do concentrate on the strategic priorities in prevention, care and multi-sectoral, impact mitigation.

  In terms of geographical focus, DFID will give greatest emphasis to sub-Saharan Africa. However, HIV/AIDS is a public health priority throughout the world. Even in the less-affected countries in Asia, for example, failure to act now will lead to hundreds of thousands of avoidable deaths. DFID is therefore working with others to identify the strategic priorities in Asia and elsewhere, and will place its support for HIV/AIDS activities in the context of overall need.

  A list of DFID-financed HIV/AIDS-related initiatives is at Annex 3. As DFID's multi-sectoral approach develops, we will be increasingly able to provide details of how initiatives in, for example, education, rural and urban livelihoods, and human rights promotion reflect the realities of HIV/AIDS prevention, care and impact mitigation. Most projects are at present in prevention. They reflect the highest priority that DFID has given to focusing on the risk-behaviour groups. As the new strategic approach is finalised and implemented, future lists are likely to demonstrate a greater focus on impact mitigation as part of DFID's over-arching approach to poverty elimination.

  The IDC requested information about other institutions' responses. We enclose in the package of material sent with this memorandum a new and comprehensive matrix of 19 UN agencies' priorities and a programme, including that of the World Bank and the other UNAIDS co-sponsors.


  This memorandum has tried to capture some of the diverse ways in which HIV/AIDS impacts on people's lives and livelihoods. This section lists, very briefly, some of the main points. As throughout the document, it focuses not so much on the infection or its subsequent array of diseases, but more on the way that rapid and significant increases in illness and death among adults affects survivors' lives and livelihoods. Our focus is on the worst-hit countries of sub-Saharan Africa, though, as described earlier in the paper, the impact on individuals and households can be as great in countries with lower levels of infection—and the greatest short-term impact, it seems, does occur at household level:

    —  at the most basic level, the impact is upon livelihoods. If coping can be defined as avoiding destitution, households try to do so by cutting into consumption, savings and assets. The poorer households have less of a cushion, and face destitution earlier. The implication for governments and development agencies is to reorient and intensify poverty reduction programmes targeted at the poorest—taking into account the impact of HIV/AIDS when allocating their resources.

    —  linked to households is the lowest level of economic production, including subsistence farming (or farm households that are partly subsistence, partly cash earning). Smallholder agriculture is the largest single sector in sub-Saharan Africa. Because they are, essentially, households, these enterprises face the loss of savings and assets—some adjust, some cannot adjust enough and land and housing are lost. The implications are for government departments to examine the needs of small farmers in the face of large scale reductions in the labour force and to adjust policies and practice accordingly. Impact varies across farming systems and their related local economies. There is a need for changes in extension advice, inputs, and marketing. Affordable credit is an essential, both as part of the support for economic growth and as a cushion against shock. This need is not AIDS-specific—but the extra burden of AIDS reinforces its utility as a part of anti-poverty programmes.

    —  at the level of larger enterprises, we have seen that they have been facing an increasing level of labour loss and the associated costs in terms of benefits payments and lost production. The threat is not only for productivity, but also for longer-term investment in the hardest hit countries and communities. Some firms have been facing up to this for a decade or so, others are late in getting engaged. The formation of AIDS-specific business coalitions is increasing, as are co-operative relations between the private and public sectors. Much needs to be done in this area, and much needs to be learned about the threats and how to reduce them.

    —  similarly, much is not yet understood about the macro-economic impact. It does appear that there will be negative impact, and that in some countries this will be very significant over a decade or two. There will be implications for pro-poor growth policies, which must increasingly take account of AIDS-related illness and death at the varying levels at which it occurs from country to country. This is beginning to be reflected in Poverty Reduction Strategy Papers, the HIPC process, and related plans.

    —  education, perhaps more directly than other sectors, is an investment in the future. In some countries more teachers are dying than entering the cadre. Ways to maintain the teacher presence in schools, and to keep pupils in education when their labour is needed in the home, need to be found. Schools and universities, as well as being sexual risk locations, are also useful places for sexual health promotion. They need to be protected.

    —  similarly, the health sector is being particularly badly hit in the worst-affected countries. Health worker attrition is eating into the workforce. Ways to replace lost workers and to maintain worker morale need to be found. A continued emphasis on health sector development and reform, aiming at improved quality both of care and work environment, is essential. As with education, the private productive sectors, and other institutions, the issue is fundamentally one of human resource development at a time that human resources are being reduced.

  There are clearly many implications for the way that DFID and the rest of the development community respond. From the health angle, prevention is clearly the top priority as infections prevented in an epidemic mean that many more cases of illness are avoided in the future—it is a pre-emptive form of impact reduction. There is also a growing population of people for whom care, even at a basic level, is essential. National governments and the donor community need to make sure there are enough resources to provide care as well as to prevent infections.

  Increasingly, however, agencies are becoming involved in impact mitigation work. This raises new challenges in understanding impact across all spheres of social and economic life. Within DFID we are examining the implications in education and in rural and urban livelihoods, including for example the transport industry, as well as in the health sector. We will expand this approach—we need to look more, for example, at how DFID's efforts in micro-enterprise development and micro-credit should adjust themselves to new needs. We need to find ways to engage with governments, especially in the worst affected countries, about how they can adjust their rural development policies including agricultural extension, and how they deal with their increasing human-resource development crises.

  Wherever feasible, DFID's work in these areas will be part of partnership responses. At the international level, UNAIDS is increasingly getting engaged in a multi-sectoral approach, and DFID is engaged with the secretariat, with UNAIDS co-sponsors, and with other agencies on these issues. The International Partnership against AIDS in Africa is, at present, a particular focus for bringing a multi-sectoral effort to bear in the most affected countries, involving governments and organisations at the international, regional and national levels.

Department for International Development

May 2000

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