HIV & AIDS

One of the greatest challenges facing the Southern African Development Community (SADC) and the Member States as they move toward greater integration is the adverse effects of the HIV and AIDS epidemic on social, political and economic development. The region has the highest levels of HIV prevalence globally. Many countries are now grappling with the severe impact of the mature HIV and AIDS epidemics, and the related epidemic of tuberculosis (TB) that together are reversing the hard won development gains of the past few years. Factors that contribute to the spread of HIV include (among others):

• Extreme poverty and income inequalities
• High mobility and migrant labour between rural and urban areas, within countries and between Member States
• Gender dynamics and gender-based violence
• Illiteracy
• Stigma and discrimination
• Alcohol abuse
• Emergency situations such as civil conflict, war and displacement
• Multiple sexual partners
• Low rates of male circumcision
• Cultural determinants, such as cleansing

The HIV and AIDS epidemic is an obstacle to the Millennium Development Goal of eradicating poverty by undermining economic development and by exacerbating poverty. SADC recognises the epidemic’s impact on the development of the region and is committed to facilitating solutions.

Trends in the SADC Region

The SADC region remains the area most affected by the HIV epidemic. According to the UNAIDS 2010 Global Report, out of the total number of people living with HIV worldwide in 2009, 34% resided in ten SADC countries.

In line with the SADC HIV and AIDS Strategic Framework the region continues to implement a number of interventions. These include: condom promotion and distribution; behaviour change communication; HIV Testing and Counselling; Safe Medical Circumcision; mainstreaming HIV and AIDS across all sectors; Prevention of Mother to Child Transmission (PMTCT); treatment and home-based care.

Although SADC Member States are implementing HIV prevention interventions, the HIV burden is still heavy with the region being home to an estimated 13.4 million people living with HIV.

Prevalence rates vary considerably between SADC countries, between just less than 1% to nearly 40%. Urban populations are more affected than rural populations. Over the entire SADC region 53% of those living with HIV and AIDS are women. In some countries, young women and girls account for more than 80% of those in their age groups living with HIV and AIDS and gender is an important consideration. An estimated 92% of infections occur through heterosexual transmission. Consequently the most affected are the sexually active adults in the 20 to 39 year age group, the so-called producers and providers.  Vertical transmission from mother to child accounts for 7% of total infections and childhood HIV infection is now the underlying factor in the majority of childhood illnesses in the highly-affected Member States.

Tuberculosis is experiencing resurgence as a result of HIV and AIDS. It is estimated that 40% of people with HIV are co-infected with TB, which is now the leading cause of death among people living with HIV and AIDS in the region.

Impact of HIV and AIDS

Impacts from HIV and AIDS are felt on various scales, from households, to nations, to entire regions.  High levels of adult deaths are leading to increasing numbers of orphans. More than 5.5 million children aged 0-17 years are estimated to have been orphaned by AIDS by the end of 2003. As much as 20% of children in some countries have lost one or both of their parents to AIDS.

Households impacted by HIV and AIDS are likely to experience decreased or complete loss of income, disintegration of the household, increased school dropouts (especially amongst girls), disproportionate increases in household workload on girls and elderly women; all of which increases vulnerability to further infections.

Various economic sectors are impacted by the HIV and AIDS epidemic:

• The Private Sector has experienced a loss of productivity due to illness, absenteeism to care for sick family members and to attend funerals, and loss of skilled and experienced workers. The private sector is also increasing expenditures on health, disability, pension and death benefits, which contributes to decreased profit margins.
• Health Care - workers are at the frontline of responding to the HIV and AIDS pandemic. Nurses and midwives (mostly female) not only have to treat ever increasing numbers of patients with inadequate resources, but themselves are more vulnerable to infection than ever before. Rural facilities do not have the infrastructure or institutional capacity for protective practices to be adhered to at all times.  The strain of the work and low pay is leading many nurses to seek better work outside the region.
• The Mining sector is overwhelmingly staffed by migrant men between the ages of 18 and 49 with lower levels of education. The danger and risk involved with daily work can mean that workers have a different perspective of risk to HIV infection. The willingness of these workers to engage in risky sexual behaviour is encouraged by separation from family, higher income in relation to surrounding communities and the presence of brothels. Once infected, they risk spreading HIV to their other communities once returning home. Costs incurred by the Mining Sector increase in order to cover medical benefits and insurance premiums. 
• The Agricultural workforce is mainly young people between 15 and 49 years of age; approximately 70% of which are women. The same age group is the hardest hit by the HIV and AIDS epidemic. A diminished workforce may lead to food insecurity. Food insecurity may lead some to transactional intergenerational sex and sex work in order to survive. Malnutrition diminishes the capacity of both the immune system and antiretroviral treatments for slowing the progression of HIV to AIDS. Along with AIDS-related illnesses and deaths, household income decreases, assets are sold, and medical costs increase. Children are likely then pulled from school to assist with household activities.
• The Education sector drives the development of human resources and is essential for addressing socio-economic development challenges. HIV and AIDS impact the education system by limiting enrolments, the supply of education and the quality of education.  HIV and AIDS-affected households may be unable to pay for school fees and uniforms. Children may be required to provide care to sick family members or siblings. Stigma experienced by affected children may result in fewer children able to complete their education. Orphaned children may be unable to attend school. There is a strong correlation between lower levels of education and increased risk of HIV infection of girls. Educators are at risk of HIV infection owing to separation from families for employment and the expectations of ‘sexual bonuses’. Teacher absenteeism due to HIV related illness or to caring for family reduces quality of education.
• Tourism may facilitate the spread of HIV both in countries of destination as well as countries of origin as some travellers engage in unsafe sex (willingly or otherwise). The combination of high HIV and AIDS rates with a perceived lack of health care may undermine tourism to the region. Higher rates of HIV and AIDS in the tourism sector staff mean that productivity decreases or is lost to illness. Staff morale is also affected by stigma and discrimination. Sector costs increase in order to cover medical benefits and insurance premiums.
• Transport is of crucial importance for economic development since it facilitates economic growth and trade by connecting producers, suppliers and markets. HIV prevalence however, is higher among transport workers and in communities along transportation routes than in the general population. Illnesses and deaths due to AIDS threaten the sustainability of economic development by diminishing the transportation workforce.

The SADC Region as a Focus of the Global Response

The status of HIV and AIDS as a global epidemic has stimulated a global response. Many programmes are addressing the pandemic in the SADC region. The Southern Africa Regional Program on Access to Medicines and Diagnostics (SARPAM), sponsored by UK Aid, promotes “a more efficient and competitive market for essential medicines in the SADC Region.” The program supports the SADC Pharmaceutical Programme, access to medicines information, facilitates understanding of intellectual property, and helps build SADC Member State capacity for pharmaceutical policy reform. UNAIDS, co-sponsored by 10 UN agencies, aims to prevent HIV infections, prevent discrimination and prevent AIDS-related deaths. The World Health Organization provides evidence-based technical support to efforts by Member States in supplying treatment and prevention. There are numerous non-profit organizations working on improving HIV and AIDS issues in the SADC region as well.

SADC Response to the Epidemic: The SADC HIV and AIDS Strategic Framework

Responses to HIV and AIDS in the SADC region commenced in the mid-eighties; following reports of the first AIDS cases. The nature and severity of HIV and AIDS has necessitated a response at both national and regional levels. Political commitment to address HIV and AIDS is high. Most Member States have developed national policies on HIV and AIDS or National Strategic Plans.

The commitment of SADC Member States to combat HIV and AIDS is further reflected in the establishment of the HIV and AIDS Unit at the SADC Secretariat. The SADC HIV and AIDS Strategic Framework is an intervention developed and aimed at intensifying measures and actions to address the devastating and pervasive impact of the HIV and AIDS pandemic in a comprehensive and complementary way. The plan has since been updated and HIV and AIDS is a standing item on the agenda of the SADC Summit of Heads of State and Government.

This Strategic Framework is a multi-dimensional response to the HIV and AIDS pandemic by the region, with interventions aligned to the Regional Indicative Strategic Development Plan (RISDP).

The Goal of the Strategic Framework is to:

Decrease the number of people living with and affected by HIV and AIDS in the SADC region, so as to ensure that HIV and AIDS is no longer a threat to public health and to the sustained socio-economic development of Member States.

The Vision of the Strategic Framework is to:

significantly reduce levels of HIV and AIDS within SADC.

The Main Objectives of the Strategic Framework are to:

• Reduce the incidence of new infections among the most vulnerable populations within Member States.
• Mitigate socio-economic impact of HIV and AIDS.
• Review, develop and harmonise policies and legislation relating to HIV prevention, care and support, and treatment within SADC.
• Mobilise and coordinate resources for  a multi-sectoral response to HIV and AIDS in the SADC region.
• Monitor the implementation of the SADC framework and regional continental and global commitments ensuring that gender is fully mainstreamed.

National programmes are beginning to show signs of a positive impact, especially on prevention among youth. All SADC Member States are addressing HIV and AIDS through multi-sectoral national responses. Most have adopted responses that address key areas such as better enabling interventions, prevention of HIV infection, care, treatment and support for those infected and affected, and mitigating the socio-economic impact of the epidemic. A number of Member States have increased national budgetary contributions to HIV and AIDS. Further assistance has been provided to some SADC Member States through international development programs and funds. Outstanding issues that need to be addressed include:

• Achieving the target of reducing HIV prevalence in young populations by 25%.
• Developing and implementing comprehensive programmes of care, support and treatment including addressing resource constraints such as a poor healthcare infrastructure and issues of stigma and discrimination.
• Mitigating the socio-economic impact, especially in providing support for orphans and other vulnerable children by developing and implementing strategies for social support, such as shelter, schooling, nutrition, health and social services.
• Developing and implementing (mainstreaming HIV) work-place policies, strategies and programmes on HIV and AIDS, to sustain human resources in key sectors such as education and agriculture.

At the regional level, the Strategic Framework has advocated for a multi-sectoral response driven by the individual Sectoral Coordinating Units located in different Member States. The Health Sector Coordinating Unit was mandated to provide overall coordination of the regional response. SADC has facilitated the sharing of experiences and best practices amongst Member States in the areas of program delivery, research and policy, capacity building and development of standards. The commitment of political leadership is clearly demonstrated by the prioritisation of HIV and AIDS. Major interventions undertaken include facilitation of best practices, programme delivery, research and policy development, capacity building and development of standards. Additionally, the Regional Indicative Strategic Development Plan (RISDP), recognizes that combating HIV and AIDS is integral and essential to poverty reduction in the region. The plan outlines areas for intervention along with strategies to achieve specific target reductions in infections.

Long term Response and Coordination depends on the development and implementation of evidenced-based HIV and AIDS interventions. The establishment of mechanisms for exchange of technical information from both scientific and behavioural research findings among SADC Member States is a key output for the SADC Secretariat and is clearly articulated in the HIV and AIDS Business Plan (2005-2009).

By the end of 2003 there were more than 10,000 HIV and AIDS research projects that were either in progress or had been completed. Since then, there have been concerns for the need to develop coordinated research to improve the HIV and AIDS response in the region. Some common challenges are faced by research in most of the SADC Countries. These include difficulties in coordinating research efforts, utilizing and sharing of research findings, weak financial and institutional capacity and a lack of clearly defined research programmes at the regional and country levels. An objective of SADC’s HIV and AIDS Research Agenda is to help coordinate research in Member States to objectively identify and better understand the key drivers, trends, determinants, and dynamics of the HIV epidemic in the region.

The future direction of SADC will see intensification in interventions addressing the pandemic guided by the SADC Strategic Framework and Programme of Action and the Maseru Declaration on the Combating of HIV and AIDS in the SADC Region. These two documents provide a clear policy direction and political commitment in combating the pandemic in the region.

Relevant Protocols and Declarations

The Health Protocol

Article 9 of the SADC Health Protocol addresses communicable disease control and Articles 10 through 12 look specifically at HIV and AIDS, malaria and TB. Article 10 requires that Member States shall:

1. Co-operate to harmonise, and where appropriate, standardise policies in the areas of.
2. Case definitions for diseases
3. Notification systems
4. Treatment and management of major communicable diseases.co-operate in the establishment of regional reference laboratories and in sharing technical expertise in order to ensure high immunisation rates to reduce, eliminate, and where possible eradicate communicable diseases.
5. share information related to outbreaks and epidemics of communicable diseases within the Region and work together in epidemic control and management.

Declaration on HIV and AIDS

The Declaration recognises commitments made thus far, recognises that the pandemic can be curbed, that collaboration on various socio-economic improvements can combat poverty, and that upholding human rights combats stigma; and thus commits to the following areas requiring urgent attention and action:

1. HIV and AIDS prevention and social mobilisation
2. Improving care, access to counselling and testing services, treatment and support
3. Accelerating development and mitigating the impact of HIV and AIDS
4. Intensifying resource mobilization
5. Strengthening institutional, monitoring and evaluation mechanisms

Addressing gender imbalances is a strategy that cross-cuts many of these areas of focus, as is policy harmonisation to decrease inefficient efforts.

Protocol on Gender and Development

Articles 26 and 27 of the SADC Protocol on Gender and Development mandate Member States to address gender-specific health care needs related to HIV and AIDS. Universal access to HIV and AIDS treatment for all who have been infected (men, women, girls and boys) is required. Particular attention must be paid to the vulnerability of girl children and to harmful practices and biological factors that result in women being the majority of those infected. Specifically, legislation, programmes, policies and services for the following are required:

Reduce the maternal mortality by 75% by 2015;

• Develop and implement policies and programmes to address the mental, sexual and reproductive health needs of women and men.
• Ensure the provision of hygiene and sanitary facilities and nutritional needs of women, including women in prison.
• Allocate resources and psychological support for care givers (the majority of whom are women) and promote the involvement of men in health care by 2015.