AIDS and Poverty

Poor people in rural Africa have received little assistance in the last decade, and a great deal of what has been provided has been directed to emergency situations in the form of short-term consumption support. The process of building durable institutions and material assets in rural society has been sidelined by short-term, crisis-driven issues – at least as far as the productive framework for the poor is concerned.

Many of what pass for “natural” and “exogenous” disasters among the poor in rural Africa are neither totally natural nor exogenous. Drought, for example, is natural, famine is not – the difference is not only relief, but the capacity of rural society to organize its own production and distribution systems to handle what are often regular challenges: to manage water better, to develop more drought-resistant cropping systems, to establish better storage and marketing systems. Similarly, HIV/AIDS is a disease, but the epidemic reflects social facts – migration, the powerlessness of rural women. Behind most crises, poverty is at work – and the crises create more poverty. Hence the seemingly endless succession of crises, which reveal themselves not as natural and inevitable events, but as what happens when poor societies encounter major problems.

The region has the most HIV/AIDS-afflicted populations in the world. Over the last two decades, civil strife has at one time or another threatened the lives and livelihoods of the rural poor on a major scale in many parts of the region – as have occasional periods of major international hostility. Together, these represent a formidable obstacle to development and to the real and sustainable reduction of poverty – for it is the rural poor who are their principal victims. Conflict and HIV/AIDS can and should be addressed by rural development strategy. It can and must address the causes of conflict – and post-conflict transition from relief to development in rural communities and among the rural poor (including community reconciliation). The social dimensions of the causes and effects of the HIV/AIDS epidemic – and the role of rural development in containing them – are just beginning to be widely appreciated. It must become a priority issue in rural development, through special programmes and through inclusion in normal activities oriented towards empowering the rural poor. It will be an area, perhaps more than any other, that will require broad partnerships to articulate a comprehensive response to a complex, multisectoral crisis.

IFAD is very much involved in responding to crises. But it is not a relief agency. It is oriented towards reducing the causes of crisis, and towards building future resilience even in the recovery period. This may never be a total solution, but it makes crises less dramatic and more manageable. It is a part of the solution that should be made stronger if a significant part of the region’s population is to make a sustainable exit from poverty.

Initially, HIV/AIDS was perceived as a public health issue. In 1991, it was projected that by the end of the decade, nine million people in sub-Saharan Africa would be infected with HIV and five million would die. This was a three-fold underestimation: today, it is estimated that more than 34 million people in sub-Saharan Africa have become infected with HIV and 11 million have died of AIDS. The magnitude of the epidemic and its systemic impact are affecting each and every economic sector: industry, transport, tourism, education, and health, as well as agriculture and rural development. A number of countries in the region have declared HIV/AIDS a national disaster.

The eastern and southern Africa region is the epicentre of the HIV epidemic and has the fastest-growing HIV infection rates in the world:

In 14 countries in the region, adult HIV/AIDS prevalence rates range from 11 to 36%.
In seven countries, all in the southern cone of the continent, at least one adult in five is living with HIV/AIDS.
South Africa, with a total of 4.2 million infected people, has the largest number of people living with HIV/AIDS in the world.
In a number of countries, such as Botswana, Zambia and Zimbabwe, over one third of 15-year-olds may die of AIDS.

Caring for AIDS Orphans in Uganda
IFAD/Belgian Survival Fund Joint Programme (BSF.JP)

When her husband died of AIDS in 1982, Regina Nankabirwa could not afford rent for a house large enough for her and her eight children in the southwestern Ugandan town of Masaka.Without a husband or income, she was forced to move into a small house in the village of Kitante. Here, she had more land and could grow food to feed her family. She decided to open a small retail shop to generate some income.

Over the next fifteen years, AIDS devastated Ms Nankabirwa’s family. She lost brothers and sisters to the disease, and in the tradition of African extended families, she took in all of their children.There are now eighteen living under her roof in Kitante.

Fortunately, she has help. Thanks to UWESO, she is able to provide for all those in her care. Supported by IFAD/BSF.JP, UWESO is a non-profit organization launched in 1986 by Janet Kataha Museveni, wife of the country’s president.The goal of UWESO can best be summarized by the group’s mission state-ment: “To improve the quality of life of needy orphans by empowering local communities to meet the social, moral and economic needs of these children.” UWESO now has 36 branches working in 15 dis-tricts throughout Uganda. In the Masaka area alone, the organization is helping 1 036 households with a total of 7 404 orphans.

The statistics on orphans in Uganda are staggering. There are currently 1.9 million, nearly 10% of the country’s population. Most have lost one or both parents to AIDS. Families with five or six children of their own are now looking after as many as twenty. UWESO has stepped in to provide help for large house-holds such as Ms Nankabirwa’s, filling a gap left by the breakdown of the traditional family structure.

Ms Nankabirwa joined UWESO in 1997 and received a loan of 100 000 Ugandan shillings (USD 67) to start her business. She has since repaid that loan and two others, and she has just secured her fourth loan from UWESO, this time totaling UGX 200 000.
“With UWESO’s help,” says Ms Nankabirwa,“I increased the size of my store and opened a small restaurant.” Most of the vegetables she serves in the restaurant are grown on the land beside her house.

With her profits from the shop and restaurant, Ms Nankabirwa has recently bought two cows and three goats. “The business is doing well,” she says. “Soon, I hope to secure a small piece of land and put up some apartments to rent. My daughter Harriet will run this business.” Harriet, who is 24, already works for her mother in the restaurant and store. She is evidently a shrewd businesswoman, who can regularly be seen haggling over prices with merchants who have come to sell items to the shop.
UWESO has developed a unique approach to helping people like Harriet and her mother. The orga-nization’s strategy is to alleviate poverty by giving women the money and training they need to start a successful small business. “It is microfinance with a difference,” says UWESO Executive Director Pelucy Ntambirweki. “Banks do not deal with grandmothers and widows.They bombard them with paperwork and want them to write and sign things. We designed savings and credit programmes that work for families in these situations, and we have taught them how to manage, how to use a loan and how to save.”

UWESO’s methods and message are expanding. Membership in the organization has grown to 10 000 volunteers. More than 100 000 orphans across the country have received some form of aid from direct UWESO involvement. This includes help to finance schooling for young orphans and vocational training for adolescents.

However, according to Mrs Ntambirweki, there remains much to do. “We have helped 100 000 children,” she emphasizes, “but despite all of our efforts, that is still only 5% of those in need.”

In eastern and southern Africa, it is no longer isolated households that are being affected by the epidemic. Virtually all households are being affected by young-adult morbidity and mortality, either directly or indirectly. Households are directly affected by HIV/AIDS when: (i) one or more household members are living with HIV/AIDS; (ii) they have recently lost a young adult to AIDS; or (iii) they are giving foster care to one or more orphans. Households indirectly affected by HIV/AIDS assist sick relatives with labour, food, cash or other contributions on an intermittent or continuous basis, help neighbours with occasional labour, or fulfil their obligations towards the community with contributions to funerals.

Nearly 13 million children have been orphaned by the epidemic in sub-Saharan Africa. In Uganda alone, a country with a population of 21 million, 1.7 million children are AIDS orphans. The social cost of the epidemic in terms of human suffering, orphanhood and dislocation is incalculable. Further, HIV/AIDS is eroding the social fabric of African societies by unravelling socio-economic safety nets, exacerbating gender inequities and fragmenting or dissolving a growing number of households. The strength and resilience of African rural society has been based on its communities and families rather than on formal public institutions. The impact of HIV/AIDS on public institutions is serious. Its impact on people’s own institutions for managing their lives and coping with challenges is disastrous – striking at the heart of the emotional, moral and social identity of the rural poor.

It now seems probable that the impact of HIV/AIDS is particularly severe on small-holder agriculture. Smallholder agriculture south of the Sahara relies almost exclusively on family labour – the most important productive resource poor people have. HIV/AIDS-induced morbidity and mortality can constitute a serious threat to small holder agriculture through their adverse effects on household demography, productive capacity and food and livelihood security.

At the household level, HIV/AIDS increases the vulnerability of rural families and communities to food and livelihood insecurity, and pushes many of them to impoverishment through:

the loss of young adult on and off-farm labour, leading to a decline in production;
a decline in income (and particularly disposable cash), leading to a decrease in food consumption, the removal of children from school and poorer health status;
an erosion of the household asset base (through depletion of savings and the forced disposal of productive assets such as land, livestock, etc.);
a dramatic rise in expenditures (for medical treatment and transport, funeral costs, etc.);
an increase in the household dependency ratio due to a rise in the number of dependants relying on a smaller number of productive family members;
the loss of agricultural knowledge, practices and skills (including farm management and marketing skills), and social capital (such as kinship duties and responsibilities, sociocultural norms, etc.); and
the disruption of traditional social-security mechanisms.

The HIV/AIDS epidemic is disastrous from the rural livelihood perspective, as well as from the human one.

The impact of the HIV/AIDS epidemic upon rural poverty and the inability of many rural households to rise to the challenge of economic and political transition are unquestionable.

It is perhaps in the rural areas of eastern and southern Africa that the impact is worst. Here, dependency upon household labour is greatest, household assets are lowest, and public services are weakest. The area also receives few resources in the fight against HIV/AIDS compared to urban areas. This is a mistake. The constant circulation of people between rural and urban areas means that HIV/AIDS cannot be contained even in the cities if rates of infection in the rural areas are not reduced. The response of rural development agencies has been slow and certainly inadequate. In part, this reflects the tardy emergence of an understanding of the social dynamics of the epidemic.

ABC Africa: A film by ABBAS KIAROSTAMI

HIV-AIDS is found almost everywhere, but principally in Africa. In Africa it is found everywhere, but principally in the countryside. It affects all classes, but principally the poor. As Director Kiarostami observes in the film ABC Africa, HIV-AIDS is not transmitted by mosquito bite: it is a social disease. The deadliest of all. It is a complex disease, medically. It is a disease for which there is no known cure - and for which existing treatments are economically and organizationally beyond the reach of most of those who suffer from it. Especially in Africa where hundreds of millions of people live below the recognized ''lines'' of the most extreme poverty.

The social causes of the epidemic and its effects are much better understood. As a social disease it reflects social conditions: the fragility of rural economies and the lack of social power of women. It reflects the high levels of migration of men, impelled by the crisis of agriculture and rural development. It reflects the spread of prostitution as a means of survival. And it reflects the fact that it is poor women in rural society who have the least social power to control their own sexuality.
The social consequences of HIV-AIDS are also well understood. For those who directly suffer from it - and from the much greater number who do not suffer from it, but whose lives are taking new and more threatening shapes. Deepening rural poverty as families sell their possessions and their tools to care for the sick and compensate for lost income. Disorganization of families. Intolerable strains on families and communities. And a crisis in the care and education of the young. The effects on the future development of Africa and the fight against rural poverty are incalculable.

None of this is inevitable. While the race for better treatment and, ultimately, cure continues, the epidemic can be reduced through attacking some of the most important social bases of vulnerability: the local and global crisis of the African peasant economy; the position of women and girl children in rural society. Prevention can work, and it can reduce the medical burden dramatically. Mitigation can work. Communities and families can be effectively helped to regain their strength to deal with the challenge of millions of orphans and loss of the young and able-bodied. The answer to the social challenge of HIV-AIDS in rural Africa is something that can be based only in the initiative and optimism of Africans themselves. That is what is shown in ABC Africa : a willingness to engage and struggle. Among women, among children and among men. While we spend billions on the medical solution we should also be thinking about the social problem and the social solution. And about re-engaging in assistance to social and economic development in rural Africa - without which the prospects for improving the lives of the majority of the poor and controlling HIV-AIDS continentally and globally are dim, indeed.

The dynamics of the epidemic in rural areas are increasingly clearly seen in terms of social factors – many of which express rural poverty. This is not to suggest that HIV/AIDS is, somehow, a social product that will disappear with social change. It is to suggest that the spread of HIV/AIDS in rural areas is very much affected by rural poverty – in its institutional, productive and gender dimensions. In effect, it appears that the relationship between HIV/AIDS and rural poverty is bidirectional:

Poverty creates an environment of risk and is a key factor in HIV transmission.
The experience of HIV/AIDS by poor individuals, households and communities is likely to lead to an intensification of poverty, push some non-poor into poverty and some of the very poor into destitution.

The Nyeri Dry Area Smallholder and Community Services Development Project (Kenya). The main objectives of this project, which was financed by an IFAD loan and Belgian Survival Fund Grant during 1991-1999, were to reduce mortality and morbidity and improve the overall well-being of the rural poor in the Keinei District of Kenya. Activities focus on health and sanitation, agricultural and irrigation development, institutional support and group development and participation. Activities targeting HIV/AIDS were implemented under the health, nutrition and sanitation component of the social services development, through which district and community health workers were trained in home-based care and counselling of people living with HIV/AIDS.

Rural Financial Services Programme (Tanzania). The main goal of this programme, which was approved by IFAD in 2000, is the sustainable increase in income, assets and food security of rural poor households. This will be achieved by enhancing the capacity of the rural poor to mobilize savings and invest in income-generating activities by developing viable rural financial systems. The programme will be offering insurance coverage to the beneficiaries through a fund, which will cover loan defaulting for a variety of reasons, including incapacitation/death as a result of HIV/AIDS. Beneficiaries are required to pay 50 percent of the insurance premium, and the programme will contribute the remaining 50 percent towards the insurance Fund.

Empowering the Poor and Containing the Epidemic

HIV/AIDS is an extremely complex phenomenon, and the best response might well be a simple, lasting and cheap medical cure. No such cure exists, and in its absence the emphasis must be on prevention (minimizing incidence) and mitigation (minimizing social and economic impact). Rural development assistance has a role to play on both sides. On the side of prevention, poor communities have to be knowledge-empowered, and poor households and individuals have to have livelihood options outside the high-risk areas. On the side of mitigation, specific solutions to sustainable livelihoods for affected individuals and households must be found – both as part of the general poverty-reduction effort and as a means of breaking the poverty-AIDS-poverty cycle. And women in particular have to be given the basis for choice.

For IFAD, engagement is essential. For many there can be no sustainable exit from rural poverty while the epidemic continues. For very many, the epidemic is making the rural poverty situation much worse. The reduction in rural poverty will diminish the virulence of the epidemic.

IFAD works in the areas of community-level knowledge and decision-making systems. It works on opening economic opportunities for marginal groups. And it is very much engaged in gender issues. IFAD has experience in supporting the coping capacity of rural communities through the Uganda Women’s Efforts to Save Orphans (UWESO) project in Uganda, which started as an NGO-assistance operation and evolved into community-level self-help support among women. The experience gained is helping IFAD develop more HIV/AIDS-sensitive rural programmes. More and better work on HIV/AIDS will mean more support to these community-level coping mechanisms – specifically targeted to at-risk areas and groups.

IFAD’s loan resources have been invested in areas where there is a clear and identifiable return to smallholder development. Working on a targeted basis with vulnerable communities, households and families on basic security issues (rather than development) is unlikely to offer the same economic returns. Mobilization of a significant grant component for governments and communities might be essential for comprehensive action in this area, which certainly will not solve the HIV/AIDS problem, but is one part of the response – a response that is only beginning to receive attention as the medical model gives way to a more balanced approach recognizing the important social elements of prevention and mitigation.

Partnership in the Fight Against HIV/AIDS

Recognizing that any effective response to HIV/AIDS must involve partnerships between a broad coalition of actors based upon comparative advantages, IFAD initiated the establishment of a co-operation framework with the UNAIDS Secretariat. UNAIDS' mission is to lead, strengthen and support an expanded response to the HIV/AIDS epidemic, provide care and support for those infected by the disease, reduce the vulnerability of individuals and communities to HIV/AIDS and alleviate the socio-economic and human impact of the epidemic.
Areas identified for collaboration include:

identifying and promoting the best practices for the prevention and mitigation of HIV/AIDS in rural communities;
exchanging information on HIV/AIDS-related projects in the rural and agricultural development sector; and
providing technical assistance by UNAIDS to IFAD in the areas of impact alleviation and reduction of vulnerability to HIV/AIDS.

This is the beginning of a series of partnerships that IFAD will be fostering with various actors, and particularly with civil society organizations, in order to assure a joint effort towards HIV/AIDS prevention and the mitigation of its impact on the livelihoods - and lives - of the poor.