Vulnerability of IFAD Target Groups to HIV Infection and the Impact of AIDS

35. In addition to the impact of HIV/AIDS on households as outlined in the previous section, IFAD field work in Uganda and Zambia revealed its specific impact on project beneficiaries including: (a) inability of contact farmers and community leaders to attend training activities due to caring responsibilities. As an agricultural extensionist in Zambia asked: "Who do you train when farmers spend all their time attending funerals or looking after sick people?"; (b) loss of trained beneficiaries, which is also the loss of their knowledge, experience and labour, undermining the adoption of agricultural technologies and innovations; and (c) exploitation of destitute children, often AIDS orphans, as child labourers in tea plantations or as child domestic workers (Box 6).

36. IFAD-funded projects target the resource-poor, who are also likely to be vulnerable to HIV/AIDS. Poverty (and particularly food and livelihood insecurity), migration, gender inequality, and poor health are co-factors of vulnerability to HIV/AIDS. Addressing target groups’ vulnerability, therefore, is a question not only of preventing the spread of HIV and changing risk behaviour, but also of addressing the co-factors of vulnerability to HIV infection. This is precisely where IFAD’s comparative advantage lies: by focusing on enhancing livelihoods and empowering poor rural families, IFAD-supported projects can effectively reduce their vulnerability to HIV/AIDS.

Vulnerability of IFAD/Counterpart Staff (and Their Families) to HIV Infection and the Impact of AIDS

37. IFAD project staff, counterparts and their families are at least as vulnerable to HIV infection as the average adult population in a given country. Levels of knowledge of HIV/AIDS may vary considerably among IFAD project staff. Professionals are likely to be better informed than support staff, but often assumptions about HIV/AIDS awareness are wrong.⁴³ Moreover, project staff directly affected by HIV/AIDS may lack access to essential services such as testing, counselling and treatment, and may be discriminated against.

38. Some project staff are exposed to high-risk situations by virtue of their work. Mobile professional and support staff who need to travel to carry out their duties (such as managers and professionals who frequently attend seminars, workshops and in-service training, and drivers who spend much of their time travelling to project areas) are often separated from their families. In addition, project staff may have their duty stations away from their home base and live apart from their families over a prolonged period of time.

39. Fieldwork undertaken in connection with this paper confirmed staff vulnerability to the impact of AIDS. For instance, some 95% of the district officers responsible for the implementation of a district development support programme in three districts of Uganda, and about 70% of the district agricultural extension staff of a programme in Zambia, were looking after orphans. These added responsibilities weigh heavily on government project staff, whose salaries are generally low compared to the cost of living.

Reduced Project Implementation Capacity

40. HIV/AIDS can affect project implementation capacity on three levels:

(a) Service delivery may diminish as sickness and death increase. Contributing factors include:

• reduced staff productivity (loss of human resources, absenteeism due to illness and funeral attendance, staff demoralization and HIV/AIDS-related on-the-job fatigue). In one Ugandan agricultural extension office, four out of 22 staff had died in the last 12 months, three of these from AIDS;
• increased staff turnover;
• increased project expenditures due to costs related to HIV/AIDS absenteeism, medical and burial costs, recruitment and training costs, among others. In some Ugandan districts, the administration has a budget component for staff medical and burial expenses, including the purchase of coffins. However, given the increased demand, the budget is grossly insufficient and cannot be accessed by extension staff in the sub-counties;
• increased workloads of project staff. Project staff in Uganda reported that AIDS had increased their workloads since they now needed to train new community workers and contact farmers: the ones they had already trained were either ill or dead; and
• lost knowledge, skills and expertise among staff:⁴⁴ The loss of well-trained and experienced staff can have a significant impact on project implementation capacity as junior staff may not have the expertise needed to meet the demands of the project.

(b) Project staff may not be able to address the impact of HIV/AIDS in their professional capacity. For instance, agricultural extension workers may need to deal with problems related to the impact of AIDS on the farm household economy that falls outside their technical expertise (e.g. abandonment of key agricultural practices and changes in cropping patterns). Or they may not know how to confront problems such as labour shortages among previously labour-abundant communities, land tenure problems and child-headed households.

(c) HIV/AIDS may reduce district revenue bases and thus IFAD counterpart funding. In Uganda, it is reported that the scale of HIV/AIDS-related deaths among the male population has led to a reduction in both the number of taxpayers and the taxes paid by survivors (who have a lower production capacity because of income and time spent caring for the sick). This is threatening the district tax base and IFAD counterpart funding.

41. These effects erode human capacity, disrupt project operations, delay implementation and undermine targets. As an agricultural extensionist in Zambia summed up, "The loss of any key person in the farm extension chain leaves a vacuum in project activities. These often have to come to a standstill until replacements are made, which is usually not easy." In the long term, HIV/AIDS may even undermine the sustainability of IFAD-supported projects.

Are IFAD Project Objectives, Strategies and Interventions Still Relevant?

42. Project objectives are defined on the basis of target group problem analysis. In areas heavily affected by HIV/AIDS, the constraints of some of the target groups may be changing. For example, as mentioned above, following the death of their husbands, many women are dispossessed of their land and other property, which reverts to the male relatives of the deceased. These women and their dependent children are often left without any means to support themselves – in addition to the AIDS stigma that they often bear. Thus, as a result of the impact of AIDS, land tenure may emerge as a key problem, even though it may not have been addressed as such during project design.

43. Similarly, in areas heavily affected by AIDS mortality, project objectives based on long-held assumptions about labour abundance or about the profitability of certain crops may need to be carefully reviewed. Project objectives should reflect the changing needs and interests of the poor, including the ultra-poor (a growing number of whom are now affected by HIV/AIDS), and particularly women, orphans and the elderly.

44. While HIV/AIDS can impact on IFAD-supported projects directly and indirectly, the reverse can also be the case: projects can inadvertently increase the risk of HIV infection and exacerbate the impact of AIDS by, for example:

• displacing farmers and stimulating labour migration through the construction of large-scale infrastructure (dams, roads, irrigation schemes) and the stimulation of trade, tourism and employment opportunities;
• inadvertently encouraging migration, by increasing the economic potential of a particular area;
• increasing cash incomes, part of which may then be spent on alcohol, casual sex or drugs; and
• exacerbating gender disparities.

45. Thus, a project objective, such as increasing the economic potential of a particular area, if pursued in isolation from the socio-cultural and socio-economic environment, can become a co-factor of vulnerability to HIV/AIDS. To give one example, the IFAD-supported Vegetable Oil Development Project (VODP) in Uganda includes a component for road improvement and a regular ferry service to Bugala Island. These measures are expected to "bring much-needed economic opportunities to the people of the island, including trade, tourism and job/employment opportunities."⁴⁵ However, these very factors may also contribute to the spread of the HIV epidemic unless HIV prevention measures are built into project activities.

46. In conclusion, the fact that IFAD-supported projects may inadvertently contribute to fuelling the epidemic demonstrates the need to factor into project design the potential adverse demographic and socio-economic effects brought about by economic development and build in appropriate HIV prevention mechanisms.

B. Identifying Mitigation Responses to HIV/AIDS

47. Effective responses to HIV/AIDS require an in-depth understanding of the phases and dynamics of HIV/AIDS prevalence and impact. This section proposes an HIV/AIDS vulnerability and mitigation matrix (Table 2) and provides a detailed commentary on the factors underlying it. The matrix is intended to help identify project areas vulnerable to HIV/AIDS and determine the focus of response required at each epidemic stage. The tool has purposely been kept simple for easy use and needs to be refined. Moreover, parameters to the proposed indicators need to be established and agreed upon. At this stage, the purpose of the matrix is to underscore the need for dynamic, rather than static, responses to HIV epidemics and to link responses to epidemic dynamics.

Table 2: HIV/AIDS Vulnerability and Mitigation Matrix

48. Since HIV/AIDS is a long-wave disaster, measures to reduce its spread and impact are required before, during and after the peak of the epidemic. Before an HIV epidemic makes its impact felt, response measures need to focus on:

(a) HIV prevention. A two-pronged approach can be adopted to reduce the risk of HIV infection among project staff, partner institutions and target groups: (i) information, education and communication (IEC); and (ii) measures designed to reduce vulnerability to HIV infection, such as poverty alleviation programmes, including support to livelihoods, food security and nutrition. Since IEC HIV prevention measures have always been sharply distinguished from other mitigation measures, this paper will use the term distinctly from mitigation.

(b) preparedness. Measures taken in advance to develop operational capabilities that will facilitate a rapid response to the crisis could include: (i) projecting future epidemic impact in a project area; (ii) planning for the future impact of AIDS; (iii) building the capacity of governments, NGOs and communities to deal with current impact, and project and plan for future impact; (iv) preparing operational response action plans; and (v) earmarking funds. In the case of agriculture and rural development, measures may also include the development of an early warning system, using farming systems vulnerability mapping to plan for labour shortages and livelihood systems vulnerability; and mapping to identify vulnerable livelihoods and livelihood options appropriate in the context of HIV/AIDS.⁴⁶

49. During the course of an HIV epidemic, response measures will need to focus on:

(a) Reducing vulnerability to the impact of AIDS. Measures could include, in addition to the poverty alleviation programmes mentioned above, nutrition monitoring, education and nutrition programmes.

(b) Alleviating impact. Immediate measures to alleviate suffering and reduce economic losses in HIV/AIDS-affected areas could include: (i) access to financial services adapted to the conditions imposed by young adult morbidity and mortality; (ii) provision of agricultural inputs (such as seeds and tools); (iii) formal or informal education for orphans; (iv) temporary relief for needy foster families; and (v) promotion of labour-saving agricultural and household technologies to offset labour shortages and facilitate food production. Measures could also include care and support for persons living with HIV/AIDS, and for their families, through nutrition education, counselling, the provision of essential drugs for target groups in collaboration with health ministries,⁴⁷ and, in some cases, the provision of food assistance to the very ill through partnerships with other organizations such as the World Food Programme (WFP).

50. After an HIV epidemic has peaked, measures will need to focus on rehabilitation to help restore livelihoods and rebuild or re-establish basic services in the medium term. Socio-economic safety nets stretched to the breaking point may need to be substituted with other mechanisms. Rehabilitation measures could include credit and training programmes for households fostering orphans; apprenticeship programmes for adolescent orphans; training in agricultural skills for orphans; and the rehabilitation of agricultural extension services to address the felt needs of farmers, including those directly affected by the epidemic. As discussed later, IFAD has been engaged in such rehabilitation work through its Uganda Women's Effort to Save Orphans (UWESO) project.

51. To measure vulnerability to HIV/AIDS and define the focus of AIDS mitigation responses, project staff and others need to understand the five stages of the epidemic from initial HIV infection to AIDS, as summarized in Box 7.

52. Households with persons living with the first, second or third stage of HIV infection will not be affected by labour shortages since infected members will be able to work and should be encouraged to do so. However, plans should be made at this time for the loss of labour, income and knowledge that households will inevitably face in the future. Nutrition interventions are as critical in these early stages as they are later on to help prolong life and avert the most severe impact of the disease on families. Households with members in the fourth or fifth stages of the disease will divert much of their labour to caring for and supporting these persons, who will only be able to undertake light work intermittently. Care and support measures are of critical importance at this stage. Household expenditures on medical treatment and related expenses will be high, and measures to alleviate the impact of AIDS on households will be needed. After AIDS victims die, impact alleviation measures will still be required in the short term and rehabilitation support in the medium term.

53. The spatial and temporal specificities of the HIV epidemic are key dimensions of impact dynamics and are reflected in what may be called the ‘leopard skin’ effect. In terms of spatial specificity, HIV prevalence rates can vary significantly not only from country to country but also from district to district, and sometimes even within districts. Some examples of factors contributing to the patchiness of HIV infection are the distance of a community from a major road network, a port or an urban centre; population displacement; and labour migration.

54. In terms of the temporal specificity of the epidemic, HIV/AIDS prevalence rates and impact levels may not always overlap. As shown in Table 2, countries with high HIV/AIDS prevalence rates can have low or high impact levels depending on the phase of the epidemic. For example, Ethiopia has high HIV/AIDS prevalence (large numbers of people in the first to third stages of the disease) and a low impact level. Zambia, on the other hand, has both high HIV/AIDS prevalence and a high impact level. Most of Angola currently has low HIV/AIDS adult prevalence rates and low impact levels and will thus require a different set of responses from that needed in many areas of Uganda and the United Republic of Tanzania, which have declining HIV/AIDS prevalence but face great challenges rebuilding their societies after two decades of severe AIDS impact levels. Countries and areas within countries with high HIV/AIDS prevalence will experience high impact with time, unless a concerted effort is made to stem the spread and mitigate the impact of the epidemic.

55. Even within a single country, HIV epidemics may be at different levels of maturity in different areas. For example, in Kenya, adult HIV/AIDS prevalence rates range from 6 to 35%⁴⁸, while impact levels also differ significantly. Differences in prevalence and impact levels need to be taken into account when designing response measures.

56. The ‘leopard skin’ effect has important implications for policy and programming: strategies and initiatives aimed at addressing HIV/AIDS cannot be designed at national level, nor can they be based on national averages of adult HIV/AIDS prevalence. Decentralization processes currently under way in some East and Southern African countries may greatly facilitate district-specific HIV/AIDS-related interventions and are thus good entry points for the identification of response categories.

57. The prevalence of HIV/AIDS among adults is a key factor of vulnerability to the epidemic. HIV/AIDS adult prevalence estimates are available for each country in East and Southern Africa, and in some cases estimates are also available by district and by urban versus non-urban area from UNAIDS, the United States Bureau of the Census, and sometimes from donors (for example, in Kabarole, Uganda, a sentinel surveillance site was set up with German Technical Cooperation (GTZ) assistance to measure adult HIV/AIDS prevalence rates for urban and rural areas in the district).

58. Although an essential indicator, adult HIV/AIDS prevalence alone cannot determine the vulnerability of a given area, whereas the epidemic impact level is critical in determining vulnerability levels and response priorities. The matrix defines epidemic impact level on the basis of four indicators:

(a) Percentage of single and double orphans. Data for single orphans (children who have lost one parent) are available for most countries, but, in many instances, data are also available for double orphans (children who have lost both parents) by district or province.⁴⁹ For Uganda, such figures have been available by district for more than a decade: in Masaka, for instance, the total number of orphans according to the 1991 census was 70 800 (8.2% of the population), of which 8 800 were double orphans.⁵⁰ Kumi District had the highest proportion of orphans in Uganda, with 19 900 single and 1600 double orphans.⁵¹ This indicator captures possibly the most devastating impact of the epidemic on current and future generations (unless other factors, such as civil strife and war, have substantially increased the number of orphans).

(b) Percentage of households fostering orphans. In Zambia and Uganda, according to some estimates, more than 20% of households are fostering at least one orphan. This indicator can help identify the scale of the burden that HIV/AIDS places on social safety nets and help focus responses on strengthening such safety nets.

(c) Percentage of household income spent on health-related expenditures. A survey in Rakai District, Uganda, in 1995 showed that medical expenditures for the terminally ill AIDS patient were USD 40 per month, when average monthly household income was only USD 18.⁵² Given the unprecedented costs created by HIV/AIDS, this indicator is a good measure of the cost burden borne by households.

(d) Percentage of households with access to health care. This indicator can help identify both the extent of vulnerability of households and communities to disease, and the status of health services in a given area.

59. The availability of data on the above indicators varies considerably among and within countries. Where such data are not available, participatory rural appraisal (PRA) exercises, baseline surveys, household surveys and other such tools can generate this information, which can then feed directly into project design. However, a concerted effort is also needed to define thresholds for these indicators (low/high HIV/AIDS adult prevalence rates and low/high AIDS impact levels). UNAIDS, the United States Bureau of the Census and the UNAIDS Reference Group on Epidemiology can help standardize these indicators.

60. It should be underscored that the matrix presented in Table 2 only highlights the focus of potential project activities. In practice, a mix of different activities will be necessary for each epidemic phase, depending on other social, cultural, economic and livelihood-related factors. Further, although the distinction among various response phases (HIV prevention, preparedness, impact vulnerability reduction, impact alleviation and rehabilitation) is artificial, it can be useful for conceptual and programming purposes. Finally, while this matrix can be used for comparative purposes at national level, it is more relevant at district level, given the spatial and temporal specificity of HIV epidemics within countries.

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C. Sector-Specific HIV/AIDS Impact and Implications for Response

61. This section⁵³ provides examples of the impact of HIV/AIDS on the agriculture sector and explores implications for IFAD-supported projects. The examples show that HIV/AIDS affects every technical area that IFAD is involved in and that a ‘HIV and development lens’ needs to be applied across sectors. It should be emphasized, however, that a multisectoral approach is essential for arresting the spread and mitigating the impact of the epidemic and that sector-specific responses can only be effective within a multisectoral framework of response.

Crop Production and Post-Harvest Protection Projects/Components

62. AIDS mortality and morbidity trigger labour shortages that may force farm households to shift from cash to subsistence crops when food security is being threatened. Cash crops requiring an extended investment period may not be suitable for families who need quick returns to cover immediate medical, funeral or orphan-related expenses. Similarly, labour-intensive crops or those needing purchased inputs may be unsuitable given labour and/or cash shortages. Thus, projects with crop production components will need to factor into their strategies both labour shortages and the need for low-input, low-risk, early-maturing and disease-resistant crop varieties. This may require, among other things, an evaluation of the appropriateness of the crops being promoted for households experiencing severe labour shortages and income loss.

63. The VODP in Uganda, for instance, is promoting some crops that are more suitable in the HIV context than others. Sunflower production is particularly suitable, as it is not labour-intensive, requires little weeding and is early maturing (3.3 months). Palm oil, instead, is likely to be unsuitable given that it is, at least initially, labour-intensive, and no income can be derived from it until four years after planting.⁵⁴ When projects operate in high HIV/AIDS prevalence areas, they will need to review whether and how they can accommodate the constraints encountered by households affected by HIV/AIDS and work with them to find appropriate solutions.

64. Post-harvest components of agricultural projects may also be adversely affected by the epidemic. In areas where it is the men who usually construct storage for the crops, the women may not know how to carry out the task when their husbands die, thereby leaving the crops unprotected and losing a substantial part of their production. Similarly, when a woman farmer switches from cash crops to subsistence crops after the death of her husband, she may be unable to determine what type of storage is needed for the new crops. Projects with post-harvest components should monitor such trends and offer training in post-harvest skills as needed.

Livestock Projects/Components

65. HIV/AIDS can compromise the viability of livestock projects or components in a number of ways: (a) family members may have to sell their animals to finance medical care for AIDS patients; (b) families may not be able to afford veterinary care for their livestock; (c) if the person in charge of the livestock dies, family members may be unable to manage due to the loss of skills and experience; (d) in some areas of heavily affected countries, the price of livestock has fallen steeply either because of animal diseases or because animals are being sold off to meet HIV/AIDS-related expenses. Livestock projects or components may therefore need to monitor HIV/AIDS impact levels, addressing in particular the following key issues: What are the effects of increased human medical/funeral costs on livestock production? How are livestock management and production affected by the reduced capacity of the rural workforce? What are the impacts of the inheritance system on livestock? How is livestock production affected by the loss of skills in the sector?⁵⁵

Irrigation Projects/Components

66. While HIV/AIDS affects irrigation projects through its impact on labour for civil works programmes or on the staffing of water users’ associations, what is perhaps more important to point out is how such projects can increase vulnerability to HIV infection. IFAD’s new Lower Usuthu Smallholder Irrigation Project (LUSIP) in Swaziland recognizes that the increase in the incidence of HIV and other STIs is often associated with the construction process of infrastructure such as dams, where large number of workers are isolated from their families for long periods of time, creating a market for commercial sex workers. To avert this situation, the project has adopted a community-based approach with an intensive and targeted information, education and behavioural modification component, together with condom distribution. To the extent possible, it intends to identify and target special at-risk groups in the host area before the influx of construction workers from outside and reach construction workers before they arrive on site.⁵⁶ In addition, the project will promote nutrition activities (e.g. nutritional gardens and nutrition education) to improve the nutritional status of rural households and enhance their resilience to disease.

Financial Services Programmes/Components

67. The viability of agricultural credit schemes may be at risk as a result of HIV/AIDS. First, increased mortality may raise the number of defaults. Second, AIDS-affected families may be forced to liquidate their assets in order to repay the loans; or they may have their assets seized, thereby ending up worse off than before they incurred the loan. Third, families may have to spend part or all of their credit to finance medical care for family members suffering from AIDS. One way to find out whether HIV/AIDS has affected credit schemes in a particular area is to inquire if the demand for loans is increasing; and if so, why. An example of a potential response⁵⁷ to increased young mortality can be found in the IFAD-supported Rural Financial Services Programme (RFSP) in the United Republic of Tanzania, which will offer its clients insurance coverage through a fund. This fund will cover loan defaulting for a variety of reasons, including non-repayment due to AIDS-related incapacitation or death. Insured clients will pay 50% of insurance premiums, and RFSP the other 50%.

Area Development Programmes

68. In Africa, people develop AIDS faster than in other parts of the world as a result of poor overall health conditions and health care, both in terms of dispensaries and extension services. The World Health Organization estimates that between 30 and 50% of adults in developing countries have latent tuberculosis infection, and HIV infection is the strongest known factor for the development of active tuberculosis. In addition, STIs greatly facilitate both the acquisition and transmission of HIV. STI and AIDS control rely heavily on the extent and quality of health care provision and health care systems in individual countries. Supporting primary health care can thus be an effective measure for HIV prevention, AIDS care and vulnerability reduction.

69. IFAD area development programmes are usually multisectoral and have primary health care components or health, nutrition and sanitation programmes. Its recently completed Nyeri Dry Area Smallholder and Community Services Development Project (NDAP), which aimed at reducing morbidity and mortality and improving the well-being of the rural poor in Kieni District in Kenya, had a health, nutrition and sanitation component. Through this component, district and community health workers were trained in home-based care and counselling of people living with HIV/AIDS. Such components could be further expanded to include STI control, tuberculosis treatment and HIV prevention.

Research, Extension and Training Projects/Components

70. Agricultural research projects/components may need to investigate the effects of AIDS on farmers' supply response to changes in labour inputs. They may also need to identify the special needs of farm households with high dependency ratios, particularly those headed by young widows with small children, by the elderly or by orphans. Strategies for labour substitution should be devised; situation-specific technical advice on farming and home economics issues is also likely to be needed. Further, agricultural extension staff may need to advise households on the importance of good nutrition in delaying the onset of AIDS and on improving the quality of life of AIDS patients. Ministries of agriculture in a number of countries in the region have prepared field manuals that can be used for this purpose. Nutrition education and communication strategies should have specific dietary recommendations (e.g. the need for increased protein intake, caloric intake and micronutrients) and take into account local food sources and production systems. ⁵⁸

71. The growing demands on extension services arise at a time of increased illness and death among agricultural extension staff and some disruption of extension services. Project training components should take account of both the higher demand for training of skilled labour and the need to train more individuals than required to compensate for increased mortality. The cost-effectiveness of training programmes may decline substantially due to higher turnover. In addition to adaptations to replacement and retraining strategies, training curricula may also need to be revised to include IEC components on HIV prevention, care and support, and technical training on the implications of HIV/AIDS for specific project activities.

Post-Conflict Reconstruction and Rehabilitation Projects

72. These are projects supporting returnee populations that have been exposed to high-risk situations (insecurity, camp life and separation from family, for example). In some countries, such as the United Republic of Tanzania, it has been estimated that 33% of young adults in refugee camps are HIV-positive.⁵⁹ Therefore, refugee populations may require both impact alleviation and rehabilitation measures. Projects supporting returnees in high HIV/AIDS prevalence areas will need to place greater emphasis on primary health care (including STI control and tuberculosis treatment, etc.), on awareness-raising of the target group using communication strategies specifically designed for returnees, and on restoring livelihoods.

43/ See Bota, Malindi, and Nyekanyeka, 1998; and Hemrich, 1997.