EXECUTIVE SUMMARY
This paper examines the implications of the HIV epidemic for rural development policies and programmes in sub-Saharan Africa and, in particular: the inter-relationships between rural development and HIV/AIDS; and the broad policy and programming challenges that the epidemic poses for rural institutions. The proposed conceptual framework for the identification of key policy and programming issues for rural development raised by HIV is intended to provide guidance for the design and conduct of a set of four case studies to be carried out in Southern and Eastern Africa. The main objective of the case studies will be to help formal and informal rural institutions generate policy and programme responses to the HIV epidemic (in the areas of land tenure, agricultural research, training and extension, appropriate technology, credit, etc.) in each of the four countries.
The relationships between rural institutions and HIV/AIDS are bi-directional:
a) the epidemic may have an effect on rural institutions.
The effects of HIV/AIDS on formal rural institutions may: i) impoverish directly affected clients; ii) erode the capacity of rural institutions through losses in human resources; and iii) disrupt the smooth operation of rural institutions by severing key linkages in the organisational and/or production chain. The effects of HIV/AIDS on informal rural institutions may create a crisis of unprecedented proportions particularly among the extended family and kinship systems, with implications not only for the spread of HIV but also for the viability of rural institutions and of traditional social safety mechanisms (widow inheritance, child fosterage, etc).
b) the policies and programmes of rural institutions may have a positive or negative effect on the HIV epidemic (i.e. by enhancing mobility and strengthening urban-rural linkages, they may inadvertently facilitate HIV transmission; by improving support and social services, they may contain the spread and impact of the epidemic).
The following key points cross-cut the proposed conceptual framework on the implications of HIV/AIDS for rural development policy and programming:
1. The causes and consequences of the HIV epidemic are closely associated with wider challenges to development, such as poverty, food and livelihood insecurity, gender inequality. In effect, HIV/AIDS tends to exacerbate existing development problems through its catalytic effects and systemic impact.
2. In areas heavily affected by HIV/AIDS, the catalytic effects and systemic impact of the epidemic on rural development may:
a) amplify existing development problems to such an extent as to trigger structural changes (i.e. in adult and infant mortality); and/or
b) create new problems and challenges for rural development (child-headed households, the breakdown of informal rural institutions and thus of certain vital social safety net mechanisms).
3. Given that many problems arising from the epidemic are not specific to HIV/AIDS, policy and programme responses need not be HIV/AIDS-specific but must address the root causes and consequences of the wider challenges to rural development. In other words, a developmental rather than an AIDS-specific focus is critical to tackling the multi-sectoral complexity of the epidemic and its systemic impact and to ensuring the sustainability of both HIV/AIDS responses and rural development efforts.
4. The policy environment plays a key role in defining the parameters of susceptibility/vulnerability to HIV/AIDS and of the impact of the epidemic.
5. Gender, age and marital/family status play as decisive a role in determining susceptibility/vulnerability to HIV/AIDS and the potential impact of the epidemic as economic and cultural conditions. For this reason, the interplay between these factors needs to be considered at each stage of policy and programme development.
6. The policy and strategy recommendations put forth by the World Conference on Agrarian Reform and Rural Development and by the World Food Summit in particular provide a springboard from which to mainstream HIV/AIDS in rural development policies and programmes. In particular, WCARRD's focus on poverty alleviation and participation by rural people in the institutions that govern their lives as a basic human right, and the World Food Summit emphasis on food security and sustainable human development are not only prerequisites for the revitalisation of the rural economy, but also for effective responses to HIV/AIDS.
7. Rural development policies and programmes in support of poverty alleviation, food and livelihood security, the empowerment of rural women, etc. are, in effect, also HIV prevention and AIDS mitigation measures and vice versa.
8. While rural development programmes can be integrated with HIV/AIDS prevention and mitigation programmes, HIV/AIDS-specific policies and programmes have an important complementary role to play.
The proposed conceptual framework focuses on selected rural development focus areas, and in particular on:
Poverty alleviation: This section examines the broad inter-relationships between poverty and HIV, identifying gaps in knowledge (i.e. on household coping strategies), critical issues that are not currently being addressed (such as the consequences of HIV-related inter-generational poverty and of the increasing asset/land concentration and marginalisation of the poor) and alternative targeting criteria (such as adult death and/or household dependency ratios) for poverty alleviation programmes.
Food security and sustainable livelihoods: The dynamics of labour mobility/ migration and food security/sustainable livelihoods are critical dimensions of HIV transmission and impact. This section raises the issue of the sustainability of labour-intensive food production strategies, upon which food security policies and programmes are often based, given labour shortages arising from HIV/AIDS, drought, migration and other factors. The issues of labour shortage and livelihood insecurity and of food/livelihood security coping mechanisms of informal rural institutions to HIV/AIDS impact are also examined.
Empowerment of rural women: Gender inequality facilitates the spread of HIV and exacerbates its impact. This section examines: a) the gender-specific impact of young adult mortality; the gender (and age/marital status) differentiated effects of HIV on household income and expenditures; and c) the interface between formal and informal rural institutions, gender and HIV/AIDS as manifested in traditional social safety net mechanisms for women, such as widow inheritance, and the implications of the adverse effects of such practices for women.
Labour: The heterogeneity of labour is highlighted as a critical factor in the analysis of the impact of the epidemic. Human rights, production and productivity issues, employment and labour market issues resulting from the impact of HIV/AIDS are examined in terms of their policy and programme development implications. More specifically: the role of the workplace in HIV prevention; lost skills and experience; the substitutability of labour; losses in production and rising payroll costs are analysed in the context of HIV/AIDS.
Infrastructure: The implications of construction, maintenance and operation of rural infrastructure are examined in terms of their potential positive or negative contribution to the spread and impact of the epidemic. The impact of HIV/AIDS on rural housing, and thus on rural living conditions, is also examined.
Participatory, gender-sensitive and multi-sectoral rural development policies and programmes are essential elements of any response to HIV/AIDS. The need to develop capacity-building strategies to improve the planning capabilities of agricultural and rural development institutions and to help them cope with the loss in human resources and other effects of the epidemic is underscored. Rural institutional strengthening and capacity-building activities that will also assist the case studies to generate policy and programme responses may include one or several of the following components of the menu of options proposed below:
a) Rural development sector/sub-sector susceptibility/vulnerability assessment (why and how is a sector/sub-sector vulnerable to HIV/AIDS? which population/employee groups are most susceptible/ vulnerable? How do labour conditions facilitate HIV transmission? etc.)
b) Human resource needs/capacity assessment of public and private rural development institutions, to evaluate the degree to which their policies and programmes are aligned with the effects of the epidemic and with the implications of human resource losses.
c) Participatory training for rural institutions and their clients/target groups in: bottom-up, cross-sectoral, gender-sensitive planning; the implications of HIV/AIDS for rural development; and mechanisms that move field-based information on the bi-directional relationships between HIV and rural development up the planning ladder so as to influence how planners and policy-makers think, how they plan responses and set policies.
d) Policy/programme review (national and district level rural development policies and plans, etc) to take into account the dynamics and impact of the epidemic; to enhance multi-sectoral collaboration among rural development programmes; and to integrate rural development programmes with HIV/AIDS prevention and mitigation programmes.
e) Creating a mandate on HIV/AIDS and generating political commitment at the highest level for HIV/AIDS.
f) Setting up a Management Information System on HIV/AIDS in rural areas.
ACKNOWLEDGEMENTS
The author would like to thank Emmanuel Chengu, Rural Development Analysis Officer of FAO, for his thoughtful and insightful comments on the inter-relationships between HIV and rural institutions. Jacques du Guerny, Chief of FAO's Population Programme Service and AIDS focal point, provided valuable comments on the framework, outline and early drafts of the paper. Desmond Cohen of UNDP's HIV and Development Programme contributed many good ideas, particularly with regard to HIV, poverty and rural development, and indefatigably responded to all my questions. I am especially grateful for his sharing with me a draft of his paper on "Poverty and HIV/AIDS in sub-Saharan Africa," which I have used extensively. Guenter Hemrich, Agricultural Advisor to GTZ's Integrated Food Security Programme in Eastern Province, Kenya, provided invaluable input to the various stages of the paper, and particularly to the framework. The comments of Ms. Florence Egal (FAO ESNP), Ms. Silke Weigang (FAO SDRE), and Gabriel Rugalema, Institute of Social Studies (ISS), the Hague, are also much appreciated. Other valuable contributions were made by staff of FAO and UNDP and are gratefully acknowledged.
GLOSSARY OF TERMS AND ACRONYMS
AIDS: Acquired Immune Deficiency Syndrome; the last and most severe stage of the clinical spectrum of HIV-related diseases.
CBOs: Community-based organisations.
Cumulative HIV incidence: The total number of HIV infections that have occurred in a population over time.
Dependency ratio: Population aged less than 15 and over 64 (dependent population), divided by the population aged 15 to 64 (productive population).
HIV: Human Immunodeficiency Virus; a retrovirus that damages the human immune system thus permitting opportunistic infections to cause eventually fatal diseases. The causal agent for AIDS.
HIV prevalence: Total number of persons with HIV infection alive at any given moment in time.
IEC: Information, education and communication programmes.
IFAD: International Fund for Agricultural Development
Incidence: An epidemiological term which refers to the number of new cases of a disease occurring in a population during a given period of time, usually a year.
NGOs: Non-governmental organisations.
Opportunistic infections: The many parasitic, bacterial, viral and fungal infections which are able to cause disease once the immune system has been damaged. These are the most common clinical manifestations that establish the diagnosis of AIDS. They are characterised by an aggressive clinical course, they resist therapy and have a high rate of relapse.
PLWAs: People living with AIDS.
PRA: Participatory Rural Appraisal.
STDs: Sexually Transmitted Diseases
UNDP: United Nations Development Programme
WCARRD: World Conference on Agrarian Reform and Rural Development
AIDS
or acquired immunodeficiency syndrome, fatal disease caused by a rapidly mutating retrovirus that attacks the immune system and leaves the victim vulnerable to infections, malignancies, and neurological disorders. It was first recognized as a disease in 1981. The virus was isolated in 1983 and was ultimately named the human immunodeficiency virus (HIV). There are two forms of the HIV virus, HIV-1 and HIV-2. The majority of cases worldwide are caused by HIV-1. In 1999 an international team of genetic scientists reported that HIV-1 can be traced to a closely related strain of virus, called simian immunodeficiency virus (SIV), that infects a subspecies of chimpanzee (Pan troglodytes troglodytes) in W central Africa. Chimpanzees are hunted for meat in this region, and it is believed the virus may have passed from the blood of chimpanzees into humans through superficial wounds, probably in the early 1930s
ACTION OF THE VIRUS
In a process still imperfectly understood, HIV infects the CD4 cells (also called T4 or T-helper cells) of the body’s immune system, cells that are necessary to activate B-lymphocytes and induce the production of antibodies (see ). Although the body fights back, producing billions of lymphocytes daily to fight the billions of copies of the virus, the immune system is eventually overwhelmed, and the body is left vulnerable to opportunistic infections and cancers.
SIGNS AND SYMPTOMS
Some people develop flulike symptoms shortly after infection, but many have no symptoms. It may be a few months or many years before serious symptoms develop in adults; symptoms usually develop within the first two years of life in infants infected in the womb or at birth. Before serious symptoms occur, an infected person may experience fever, weight loss, diarrhea, fatigue, skin rashes, shingles (see ), , or memory problems. Infants may fail to develop normally.
The definition of AIDS has been refined as more knowledge has become available. In general it refers to that period in the infection when the CD4 count goes below 200 (from a normal count of 1,000) or when the characteristic opportunistic infections and cancers appear. The conditions associated with AIDS include malignancies such as , non-Hodgkin’s , primary lymphoma of the brain, and invasive carcinoma of the cervix. Opportunistic infections characteristic of or more virulent in AIDS include Pneumocystis carinii , , , and diarrheal diseases caused by or isospora. In addition, C is prevalent in intravenous drug users and hemophiliacs with AIDS, and an estimated 4 to 5 million people who have are coinfected with HIV, each disease hastening the progression of the other. Children may experience more serious forms of common childhood ailments such as tonsillitis and . These infections conspire to cause a wide range of symptoms (coughing, diarrhea, fever and night sweats, and headaches) and may lead to extreme weight loss, blindness, hallucinations, and dementia before death occurs.
TRANSMITION AND INCIDENCE
HIV is not transmitted by casual contact; transmission requires a direct exchange of body fluids, such as blood or blood products, breast milk, semen, or vaginal secretions, most commonly as a result of sexual activity or the sharing of needles among drug users. Such a transmission may also occur from mother to baby during pregnancy or at birth. Saliva, tears, urine, feces, and sweat do not appear to transmit the virus.
In 2001 it was estimated that 36 million people were infected with HIV worldwide, the great majority in Third World countries; nearly 22 million had died from AIDS. The disease in sub-Saharan Africa, which has been especially hard hit, in the main has been transmitted heterosexually and has been exacerbated by civil wars and refugee problems and less restrictive local mores with regard to sex. Some 25 million people were infected with HIV in this region. The estimated number of children orphaned by AIDS in sub-Saharan Africa was more than 10 million. The epidemic also has begun to manifest itself in Asia (especially in India, China, Myanmar, Thailand, and Cambodia) and Latin America.
In the United States, the demographics of AIDS have changed over time. In the 1980s it was seen mainly in homosexual and bisexual men and was one of the spurs to the , as activists lobbied for research and treatment monies and began education and prevention programs. Also in the early years, before careful screening of blood products was deemed necessary, the virus was contracted by an estimated 9,000 hemophiliacs (see ), and a small number of people were infected by surgical or emergency blood transfusions. Before long, however, the majority of new HIV infections were seen in drug users who contracted the disease from shared needles or unprotected sex. A large proportion of infected women are drug users or partners of drug users. Nearly a third of the infants born to HIV-infected women are infected with the virus. (Some of these infants test positive for AIDS only because of the mother’s antibodies and later test negative.)
TESTS AND TREATMENT
Various blood tests now are used to detect HIV. The most frequently used test for detecting antibodies to HIV-1 is enzyme immunoassay. If it indicates the presence of antibodies, the blood is more definitively tested with the Western blot method. A test that measures directly the viral genes in the blood is helpful in assessing the efficacy of treatments.
There is no cure for AIDS. Drugs such as , ddI, and 3TC have proved effective in delaying the onset of symptoms in certain subsets of infected individuals. The addition of a protease inhibitor such as saquinovir or amprenavir, to AZT and 3TC has proved very effective, but the drug combination does not eliminate the virus from the body. A recently approved drug not in the protease inhibitor group, efavirenz (Sustiva), must be taken with protease inhibitors or older AIDS medicines. Opportunistic infections are treated with various antibiotics and antivirals, and patients with malignancies may undergo chemotherapy. These measures may prolong life or improve the quality of life, but drugs for AIDS treatment may also produce painful or debilitating side effects.
Some 30 experimental AIDS vaccines have been developed and tested, but none has yet proved effective. The development of a successful vaccine against AIDS has been slowed because HIV mutates rapidly, causing it to become unrecognizable to the immune system, and because, unlike most viruses, HIV attacks and destroys essential components of the very immune system a vaccine is designed to stimulate. In 1998, however, authorization was given in the United States to begin the first full-scale testing of an AIDS vaccine, a process that was expected to take four years.
Governments and the pharmaceutical industry continue to be under pressure from AIDS activists and the public in general to find a cure for AIDS. Attempts at prevention through teaching “safe sex” (i.e., the relatively safer sex accomplished by the use of condoms), sexual abstinence in high-risk situations, and the dangers to drug users of sharing needles have been impeded by those who feel that such education gives license to promiscuity and immoral behaviors.
BIBLIOGRAPHY
See S. Sontag, AIDS and Its Metaphors (1989); S. Flanders, AIDS (1991); G. Corea, The Story of Women and AIDS (1992), publications of Gay Men’s Health Crisis, the National Institute of Allergy and Infectious Diseases, and the Centers for Disease Control and Prevention.
