IFAD strategy paper on HIV/AIDS for East and Southern Africa
Section II - Why Should IFAD be Concerned about HIV/AIDS?
A. Update on
HIV/AIDS Prevalence in East and Southern Africa
9. With the fastest-growing HIV infection rates in the world, the East and Southern Africa region is currently at the epicentre of the HIV epidemic:
- In 14 countries of the region, adult HIV/AIDS prevalence rates range from 11 to 36% (Figure 2).
- In seven countries (all in the southern cone of the continent), at least one adult in five is living with HIV/AIDS.4
- South Africa, with a total of 4.2 million infected people, has the largest number of people living with HIV/AIDS in the world.5
- In a number of countries, such as Botswana, Zambia and Zimbabwe, over one third of the people who are now aged 15 may eventually die of AIDS.6
10. The vast majority of persons living with HIV are
not aware of their serostatus, especially in the worst-affected countries.7
And since anti-retroviral drugs are prohibitively expensive, even those
who have tested sero-positive are unlikely to be treated. Without treatment,
infected adults in Africa have an average of 17 episodes of illness from
HIV infection to death by AIDS, requiring more than 280 days of care.8
11. Just as HIV/AIDS is no longer just a health issue, it is also not
solely an urban phenomenon. In many countries in East and Southern Africa,
rural HIV prevalence rates are approaching the traditionally higher
urban rates. Thus, in Botswana, South Africa, Swaziland and Zimbabwe,
there is little difference in HIV infection rates between rural and urban
areas.9 Moreover, since many countries in
the region are predominantly rural, in absolute numbers more people
are living with HIV/AIDS in rural areas than in urban areas. In addition,
persons living with HIV/AIDS often return to their village of origin when
they fall ill, which not only places considerable strain on their rural
kin (in terms of food, patient care and medical and funeral expenses)
but also increases the latter's risk of infection. Rural communities are
also particularly vulnerable to the adverse effects of HIV/AIDS because
of their limited access to HIV/AIDS information, and the scarcity of social
support, health services and employment opportunities.
Figure 2 - Estimated Percent age of Adults (15-49 years) Living with HIV/AIDS, end-1999
Source: Haddad and Gillespie, 2001.
B. The Impact of HIV/AIDS on Agriculture and Rural Development
12. Given that agriculture is the largest sector in most
sub-Saharan African economies, accounting for a significant portion of
production and employing a majority of workers, HIV/AIDS has far-reaching
implications for agricultural investment programmes. This is especially
the case in a number of East and Southern Africa countries, where evidence
suggests that the HIV epidemic is disproportionately affecting agriculture
relative to other sectors (such as industry and services).10
13. Various studies have shown that the impact of HIV/AIDS is most severe on smallholder agriculture, which, particularly south of the Sahara, relies almost exclusively on family labour - the most important productive resource that poor people have. HIV/AIDS-induced morbidity and mortality can constitute a serious threat to smallholder agriculture through its adverse effects on household demography, productive capacity and food and livelihood security.
Figure 3: Estimated Millions of People Living with HIV/AIDS, end-1999
Source: Haddad and Gillespie, 2001.
14. At the household level, HIV/AIDS increases the vulnerability of rural
families and communities to food and livelihood insecurity (Box
3), and pushes many of them to impoverishment through:
- loss of young adult on- and off-farm labour, leading to a decline in production;
- decline in income (and particularly disposable cash), leading to decreased food consumption, increased drop-out among schoolchildren and poorer health status;
- erosion of the household asset base (through depletion of savings and the forced disposal of productive assets such as land and livestock);
- dramatic rise in expenditures (for medical treatment and transport, funeral costs);
- increase in the household dependency ratio due to a higher number of dependants relying on a smaller number of productive family members;
- loss of agricultural knowledge, practices and skills (including farm management and marketing skills) and social capital (such as kinship duties and responsibilities, socio-cultural norms); and
- disruption of traditional social security mechanisms. A study in Zimbabwe found that nearly 25% of rural households are fostering at least one child who is not the biological child of either parent.11 Similarly, in the Bukoba District of the United Republic of Tanzania, 21% of households are providing for an orphan.12 There is evidence that in some instances extended families are unable to cope with this added burden.
studies in Southern Africa indicate that households will be vulnerable to HIV/AIDS if they are:
- unable to secure non-farm incomes;
- unable to meet high-peak seasonal labour demands;
- highly dependent on women and girl's labour;
- dependent on inorganic fertilizers and credit; and
- unable to substitute labour by labour-saving technologies or by switching from labour-intensive to less-labour-intensive crops.
The impact of HIV/AIDS on rural households will manifest itself in changes in food production and consumption per capita and in the amount and balance of time allocated to agricultural and non-agricultural activities.
Source: Loewenson and Whiteside, 1997.
15. At the sectoral level, HIV/AIDS-induced morbidity and mortality result in:
- Decimation of skilled and unskilled agricultural labour. According to the Food and Agriculture Organization of the United Nations (FAO), AIDS has taken the lives of about seven million agricultural workers in sub-Saharan Africa to date and could claim an additional 16 million (up to 26% of the agricultural labour force) by 2020 (Figure 4). Changes in the age structure of the agricultural labour force will obviously affect the sector, but what their precise impact will be is unclear.
- Reduced smallholder crop and livestock production. HIV/AIDS may severely undermine smallholder production and thus exacerbate food insecurity. Or it may contribute to rendering food-self-sufficient areas food-insecure. In Zimbabwe, for instance, before the recent political turmoil, agricultural output from communal areas fell by a staggering 50%, largely due to HIV/AIDS, according to a 1997 report.13 Maize, cotton and sunflower yields were particularly affected. In maize production, there was a decline of 54% of the harvested quantity and a drop of 61% in marketed output. The amount of land planted to cotton decreased by about 34% and marketed output by 47%; while groundnut and sunflower production experienced an average decline of 40%.14 In Uganda, parts of the rural districts of Rakai and Masaka, traditionally self-sufficient in food, are now becoming food-deficit areas, mainly as a result of HIV/AIDS.15
- Adverse effects on commercial agriculture. In Kenya, one study found that the commercial agricultural sector is facing "a severe social and economic crisis" because of the impact of AIDS.16 In one Kenyan sugar-estate, managers reported that the cost of AIDS amounted to 8 000 labour days lost due to illness between 1995 and 1997, lower efficiency (a 50% drop in the ratio of processed sugar recovered from raw cane between 1993 and 1997) and higher overtime costs. Direct cash costs related to HIV/AIDS included a fivefold rise in spending on funerals (1989-97) and a more than tenfold rise in health costs during the same period.
- Loss of indigenous farming methods, inter-generational knowledge, and specialized skills and practices. In East Africa, farming practices essential to the survival of the coffee-banana farming system, such as mulching, weeding and pruning, are being neglected or abandoned in high HIV/AIDS prevalence areas.17 Evidence from two districts of Kenya further suggests that the transfer of agricultural knowledge from parents to children is being severely undermined. This is reflected in the low level of agricultural knowledge among orphan-headed households.18
- Capacity erosion and disruption in service delivery of formal and informal rural institutions due to the scale of staff morbidity and mortality. For example, at least 16% of the staff in Malawi's Ministry of Agriculture and Irrigation are living with HIV/AIDS, while 58% of all staff deaths in Kenya's Ministry of Agriculture were reportedly due to AIDS.19
Figure 4: AIDS Impact on the Agricultural Labour Force in East and Southern Africa, 1985-2020
Source: Slide presentation at FAO, Rome, for World AIDS Day, December 2000.
16. A distinguishing characteristic of the impact of HIV/AIDS on smallholder agriculture is that it can be so gradual that it is undetectable. As one HIV/AIDS expert has argued, "Even if [rural] families are selling cows to pay hospital bills, [one] will hardly see tens of thousands of cows being auctioned at the market….Unlike in famine situations, buying and selling of assets in the case of AIDS is very subtle, done within villages or even among relatives and the volume is small."20 Moreover, HIV infection rates in rural areas are hard to measure and are prone to under-reporting or misdiagnosis because of the poor health infrastructure, restricted access to health facilities and inadequate surveillance mechanisms. For these reasons, HIV epidemics in rural areas remain, to some extent, silent and invisible - an unknown entity for policy-makers, donors and development planners.
C. The Linkages between HIV/AIDS, Poverty and Gender
Poverty: The Driving Force of HIV Epidemics
17. Poverty alleviation has been the main focus of IFAD's work since it began operations in 1977. This goal became even more urgent following the United Nations Millennium Summit in September 2000, where a commitment was made to halve extreme poverty by 2015. In ways that are still imperfectly understood, HIV/AIDS poses a formidable challenge to IFAD's efforts in support of this goal in East and Southern Africa, as is summarized below.
18. The relationship between poverty and HIV/AIDS is bi-directional:
- Poverty is a key factor in HIV transmission. In effect, all factors that predispose people to HIV infection are aggravated by poverty, which "creates an environment of risk".21 Poverty can also accelerate the onset of AIDS and tends to increase the impact of the epidemic.
- HIV/AIDS is likely to push some non-poor into poverty;
deepen the poverty of already poor individuals, households and communities;
and drive the very poor into destitution. Thus, HIV/AIDS can impoverish
people in such a way as to intensify the epidemic itself.22
19. AIDS is often characterized as a "disease of poverty" (Box 4). The World Bank notes that (a) most people with HIV/AIDS are poor; (b) HIV/AIDS has a greater economic impact on poor households than on better-off ones because it forces them to draw on their assets to cushion the shock of illness and death; and (c) households with fewer assets are likely to have more difficulty coping than households with more assets.23
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It indirectly exacerbates HIV transmission by increasing migrant labour, family break-up, landlessness, overcrowding and homelessness. This places people at greater risk of having multiple casual partners. Poor people, particularly if they are struggling with daily survival, are less likely to take seriously an infection that is fatal years hence. The incubation period of AIDS is likely to be shortened by poor standards of nutrition, repeated infections and lack of access to medical care. Therefore, AIDS victims who are poor are likely to die faster than those who are better off. Poverty tends to affect women the most, with girls the first to be withdrawn from school and women increasingly marginalized from formal employment. Women's economic dependence on men in marriage or in less formal commercial sexual relations is thereby increased. Educating and empowering women is strongly linked with effective family planning, improved primary health care and consequently lower rates of HIV transmission. Poverty makes HIV/AIDS education difficult because of high levels of illiteracy and poor access to mass media and to health and education services. Poorly educated women are unlikely to be able to protect themselves from infected husbands. They tend to have little health information and little power to control any aspect of sexual relations. Even if they know they are at risk from their husbands, economic necessity may force them to acquiesce in an unsafe sexual relationship. Source: Adapted from Jackson, 1992. |
20. Poverty and inequity combined are fuelling the epidemic further. Studies have shown the strong association between a country's developmental status and HIV/AIDS prevalence. Countries ranked high on the Human Development Index24 tend to have low HIV/AIDS prevalence.25
21. To date, the response to the epidemic has been focused on 'risk behaviour'. This focus has overshadowed the key role that poverty plays in fuelling the epidemic. In fact, poverty is at the crux of HIV/AIDS vulnerability and impact. Risk behaviour itself is largely determined by the socio-economic environment and by the pressures that poverty exerts on rural men and women.
22. Further, HIV/AIDS is changing the profile and dynamics of rural poverty through its demographic and socio-economic impacts, which may:
- create inter-generational poverty by impoverishing surviving orphans (often forcing them out of school, thus limiting their livelihood options), fragmenting or dissolving households and depleting the fragile asset base of the poor;
- alter the age structure and composition of the poor, by decimating the young adult population while impoverishing an increasing number of children and elderly people;
- result in irreversible coping mechanisms for the poorest. What is unique about AIDS is that it inflicts a shock from which many households are unable to recover. In particular, the erosion of the household asset base tends to be permanent;
- intensify discrimination and marginalization of poor people living with HIV/AIDS and of their families. This is especially the case with women, often perceived as being responsible for transmitting the HIV virus;
- increase the prevalence of poor woman-headed households (young widows with small children and grandmothers looking after grandchildren) and thus the feminization of poverty and agriculture;
- exacerbate unequal asset distribution (land, livestock, etc.), leading to landlessness and destocking. Once land and livestock are sold, the recovery potential of these households is severely diminished. Destitution is the culmination of this process of asset depletion; and
- intensify poverty-driven labour migration as a coping strategy,
thereby increasing the risk of HIV infection among the survivors.26
23. These impacts are of direct relevance to IFAD's work as they may undermine the Fund's poverty alleviation strategies and agricultural investment projects. Given that smallholder agriculture is the subsector most severely affected by HIV/AIDS, the Fund's contribution to the international goal of halving extreme poverty by 2015 through improvements in smallholder production is under serious threat. For this reason, an analysis of the interface between HIV/AIDS and poverty (with emphasis on smallholders) and its implications for IFAD's work should be an integral part of IFAD's poverty situation analyses, and an important design and implementation consideration in its agricultural investment projects.
Gender: A Key Determinant of Vulnerability to HIV/AIDS and Coping Capacity
24. Gender determines vulnerability to HIV infection and to the impact of AIDS, and it is also likely that it is instrumental in determining the coping capacity of the survivors. This has important implications for IFAD's mandate, which is to seek to empower poor rural men and women. For, as argued in IFAD's 2001 Regional Assessment and Strategy for East and Southern Africa: "Any drive to include the poor in the development process that fails to address the specific problems of inclusion of poor women is likely to have a limited impact: addressing gender relations is an essential aspect of all development activities."27
25. Women are biologically more vulnerable to HIV infection than men are and are infected at a younger age. The risk of becoming infected with HIV during unprotected vaginal intercourse is between two and four times higher for women than for men. Women are also more vulnerable to other sexually transmitted infections, and an untreated STI in either partner multiplies the risk of HIV transmission by 300-400%.28 With regard to age of infection, average prevalence rates of HIV infection in teenage girls can be up to five times higher than those in teenage boys. This discrepancy is due both to their biological vulnerability and to age-mixing between young women and older men (who have more sexual experience and are thus more likely to expose girls to HIV). This partly explains why more women than men are infected with the HIV virus in sub-Saharan Africa, with an estimated 12 women living with HIV for every ten men according to the Joint United Nations Programme on HIV/AIDS (UNAIDS).29 This trend has far-reaching implications, first, because young age groups account for a larger proportion of the population and, second, because persons infected with HIV at a young age tend to survive longer than they would have had they been older.
26. HIV/AIDS exacerbates the social, economic and cultural inequalities that define women's status in society. Inequalities, such as economic need, lack of employment opportunities and poor access to education, health services and information, make women more vulnerable to HIV infection and the impact of AIDS than men. "Low income, income inequality, and low status of women are all fairly highly associated with high levels of HIV infection", the World Bank has argued.30 In rural areas, women tend to be even more disadvantaged because of their reduced access to productive resources and support services. Further, as mentioned, women are often blamed for transmitting HIV.
27. AIDS has a disproportionate impact on the lives of women survivors in relation to men survivors. Upon the death of their spouse, women often lose their house, land, livestock, plough and other resources. In Zambia, for example, IFAD found: "Not only did the death of a spouse reduce household productivity and livelihood options, but also the impact was exacerbated when associated with property grabbing by the deceased's relatives. Relatives typically dismantled the home, taking bricks, iron sheets and furniture, as well as productive assets, such as a husband's sewing machine, a gun used for killing bushmeat, hoes and cattle."31
28. Further, the burden of caring for people living with HIV/AIDS and for orphans falls largely on women. Yet, little information is available on the quantitative impact of AIDS on women's work time, entitlements, income and savings, and especially on how this affects women within households and woman-headed households in terms of their economic security and social status.32
29. The gender of the ill or deceased person can determine both quantitatively and qualitatively the loss a household suffers. Thus, it has been argued that the illness and/or death of a woman has "a particularly dramatic impact on the family"33 in that it threatens household food security, especially when households depend primarily on women's labour for food production, animal tending, crop planting and harvesting. According to the same source, when women fall ill while their husbands are working in urban areas, the overall socialization and education of their children and the management of the household may be seriously affected.34 Moreover, studies have shown that children's nutritional status is more closely related to the mother's work and income than to the father's.35 A survey conducted in 2000 in two districts in Zimbabwe found that 65% of households where a woman had died had ceased to exist.36
30. Gender also influences the ability of survivors to cope with the shock inflicted by AIDS (Box 5). Although our understanding of the influence of gender on the coping processes of survivors is currently inadequate, male survivors may be in a better position to cope with HIV/AIDS than are women survivors. A World Bank study in Kagera, the United Republic of Tanzania, where more women than men had died of AIDS,37 found that a significant proportion of men survivors coped adequately with the impact of AIDS. A FAO study in Uganda found that men survivors tended to remarry within one year of their spouses' death.38 Another FAO study underscored the difficulties women survivors and their families had coping with the loss of a breadwinner, parent and household head. They had, for instance, been forced to shift from a matooke (banana) and groundnut farming system to a cassava/sweet potato farming system. The result was a less nutritious and varied diet and a reduction in the area cultivated.3931. Socio-cultural norms also increase women's vulnerability to HIV, particularly norms that condone men's preference for unprotected sex and deny women (unmarried as well as married) the power to decide on sexual practice.40 For example, among the Shona people in Zimbabwe, as in many other societies of sub-Saharan Africa, a woman is considered a 'minor', and as long as she is unmarried, her father has full rights over her. When she marries, these rights are transferred to her husband through the bride price. This payment is meant to compensate for the loss of labour the woman's father sustains when she marries. The bride also gives the husband full rights over all the children from the marriage. Consequently, once a wife and mother, a woman may be reluctant to divorce her husband - even if he is unfaithful to her and she runs the risk of contracting HIV - as this could mean losing her children.
32. Cultural and sexual practices similarly increase women's vulnerability
to HIV infection. Some practices likely to facilitate HIV transmission
are: (a) ritual cleansing (where the surviving spouse is 'cleansed' and
freed of the dead person's spirit through sexual intercourse with a family
member of the deceased); (b) widow inheritance (a practice, which traditionally
was a social safety net for women, that allows a brother or close male
relative to inherit the widow); and (c) heirship for chieftaincy (where
a woman from each family in the community has sexual intercourse with
the chief, thus giving all families the opportunity to produce his heir).42
33. To conclude, women's predominant role and presence in most rural areas in East and Southern Africa, combined with their disproportionate vulnerability to HIV infection and to the impact of AIDS, make it even more urgent that IFAD step up its support to address gender relations as a source of marginalization, poverty and development underperformance. In particular, the Fund can enhance rural men and women's understanding of the gender-differentiated vulnerability and burden of HIV/AIDS and address their implications through its projects.
8/ World Bank estimate, cited in DFID, 1998.
9/ See Fransen and Whiteside, 1997.
10/ See, for example, Forsythe and Rau , 1996.
11/ G. Foster and C. Makufa, "The Families, Orphans and Children Under Stress Programme", 1998; cited in Mutangadura, 2000.
20/ Personal communication, Gabriel Rugalema, Institute for Social Studies, 16 July 2000, cited in Topouzis, 2000.
21/ Paul Farmer cited in Collins and Rau, 2000.
22/ Collins and. Rau, 2000 , p. 7.
23/ World Bank, 1999a, Chapter 4.
24/ The HDI, published by the United Nations Development Programme (UNDP), is a composite index constructed from four variables: life expectancy at birth, adult literacy rate, mean years of schooling, and an adjusted measure of per capita economic production.
26/ Topouzis, 1998. Migration and mobility are often associated with increased risk of HIV infection.
32/ Loewenson and Whiteside, 1997, p. 34.
33/ Forsythe and Rau , 1996, p. 29.
35/ Devereux and Eele, 1991, cited in ibid.
37/ Personal communication, Mead Over, World Bank, at the UNAIDS Reference Group on Economics Meeting, held in February 2001 in Cuernavaca, Mexico.
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