Abstract. The now two decade long history of the HIV/AIDS epidemic has seen significant strides made in the way the virus is tested, prevented and treated. However, the epidemic has grown rapidly and continues its rampant spread, hitting areas such as Sub-Saharan Africa with particular force. With death tolls in many areas reaching astonishing numbers and new infections every day, the impact of HIV/AIDS may now threaten national security in some countries. This paper will discuss the ways in which HIV/AIDS could potentially devastate governments, economies and the very fabric of societies. It will also identify political and social challenges faced by the global effort fighting the HIV/AIDS epidemic.
15 September 2004
Research sponsored by DARPA Grant DAAD19-02-1-0288, P00001
The first cases of the virus now known as AIDS were identified in the U.S. in 1981. As the recently discovered infection began to grow into a full-blown epidemic, the international scientific community rushed to identify the virus and to find ways of stopping it. Although no cure has yet been found, many advances have been made in the way HIV/AIDS is identified and treated. In wealthy, developed countries most of those suffering from acute AIDS have access to effective Anti-Retroviral Drugs (ARVs) and AIDS related deaths have decreased significantly since the peak years of the early 1990s. However, the problem of HIV infection persists even for resource-rich countries, such as the U.S., as socially marginalized populations face the greatest risk of contracting HIV and are among those least likely to be able to afford treatment. For example, homosexuals and needle-users continue to be the groups with highest seroprevalence in the U.S. Stigmatized and often discriminated against, these sectors of the population are at greatest risk of contracting HIV/AIDS and are also most likely to remain untested and untreated, therefore threatening to spread the epidemic further. HIV is also problematic for people of color living in the U.S., with disproportionate rates of infection occurring most notably among African-American males, who make up only 8% of the U.S. population yet account for almost 50% of all new AIDS cases (7). A similar phenomenon is occurring globally, in which the most marginalized countries (poverty-stricken, powerless, largely non-European, etc.) are those hardest hit by the AIDS pandemic, and are threatened with devastating results that are just beginning to be recognized.
HIV security risks and socio-economic impacts
According to UNAIDS, there were more than 40 million people living with HIV/AIDS as of 2003. There were 5 million new infections that year and 3 million AIDS deaths. 26.6 million of those infected lived in Sub-Saharan Africa (SSA), and the region accounted for 2.3 million AIDS deaths in 2003 (14). In some SSA nations, HIV prevalence has reached astonishing levels of almost 40% (14), and the region as a whole does not show signs of progress in alleviating the epidemic’s widening devastation. Currently there is concern for many other areas of the globe, Asia in particular, as other regions begin to show signs of a mounting epidemic similar to what was seen in the early years of the crisis in SSA.
That Sub-Saharan Africa is the hardest-hit region is not surprising, as HIV/AIDS thrives on conditions such as poverty, migration, economic instability and low levels of literacy, all of which can be found in heavy doses in many parts of SSA. Information about HIV/AIDS is difficult to disseminate among populations with high rates of mobility and low rates of education and literacy, and it is more difficult to distribute prevention facts and supplies. Distribution programs like those, as well as those that provide necessary testing and treatment are also few and far between, as countries in SSA simply lack the resources to fund them. Furthermore, AIDS works in tragically cyclical patterns. In a region where 200 million are undernourished and there is only one doctor for every 40,000 people (4), the scourge of HIV/AIDS has the tragic effect of exacerbating the very conditions that facilitate its rapid spread, leaving in its wake a path of devastation with no signs of relief.
AIDS threatens to mitigate any progress made by developing countries already struggling to improve and maintain the economic and social conditions in their nations. As death tolls rise, the reality of the major security threat the virus poses is beginning to be realized. As evidenced in the staggering number of deaths in SSA alone, sheer loss of life in many areas is enough to severely strain the livelihood of whole communities, if not entire nations. By 2010, for example, South Africa, Mozambique, Botswana and Swaziland are expected to see negative population growth, largely as a result of AIDS (16).
HIV/AIDS has the added negative result of affecting adults in their prime most often. As the sector of the population most sexually active, those aged 15-49 are obviously at a greater risk of infection than others. Unfortunately, adults are also those most likely to have children and families, to be working for a living or otherwise providing for themselves and others, and to be playing key roles in economic production and in the functioning of societies in general. Life expectancy rates have declined in many of the areas hardest hit by the AIDS epidemic, and there is reason for despair as estimates for the future do not show signs of a turnaround. The U.S. Census Bureau estimates that, in 2002, seven countries had seen their life expectancies reduced by over 10 years. Estimates for the future predict that by the year 2010 Botswana, Namibia and Swaziland will see life expectancies dwindle to a mere 27-33 years of age, a stark contrast to the estimated 68-74 year life expectancies these countries could have anticipated without the effect of HIV/AIDS (16).
Major losses in adult populations have potentially dire consequences for all sectors of society. Schools, key to education and literacy, as well as important avenues for sex education and AIDS awareness among young people, are vulnerable to the effects of HIV/AIDS. Schools may experience severe losses in staff and resources as more adults pass away as a result of AIDS and as government funds are allocated more and more towards the care of AIDS patients. In Zambia, for example, 30% of teachers are HIV positive (3). And a study carried out in Swaziland estimated that the country would need to train 13,000 new teachers by 2011 as a result of AIDS; without the effects of the epidemic only 5,093 new teachers would be needed (3).
Similar losses of available employees could potentially be expected in all business and economic sectors, affecting hospitals, courthouses, jails, and police forces. And not only is there the sheer loss in numbers to be contended with, but as businesses and other institutions lose staff they also may see a decline in morale, leading to further reductions in productivity. Additionally, the costs of medical care during illness and the increased costs of pensions and funeral services as a result of heavy AIDS related death tolls further strain businesses. Because of these additional costs, those living with HIV/AIDS may face discrimination in the workplace as companies terminate or refuse to hire people on the basis of their HIV status.
Governments are also threatened by the cost of the epidemic. A report published by The Economic Commission for Africa states: “In 2001, the Government of the Kingdom of Swaziland commissioned an assessment on three of its smallest Central Agencies, namely the Ministry of Finance, The Ministry of Economic Planning and Development and the Ministry of Public Service and Information (Government of Swaziland, 1999). This study showed that the three agencies will lose 32% of the work force to HIV/AIDS over the next twenty years and that the agencies will need to replace an additional 1.6% of the staff complement each year over the same period to maintain staffing levels (3).” In Malawi, the Ministry of Education saw losses as high as 58% by 2000 (3). Furthermore, difficult decisions lie ahead for many governments as more and more funding is required to handle the HIV crisis, financial assistance from international commissions and organizations may fall short of helping all of those in need, and tax bases are drained due to AIDS related deaths among adult populations.
Militaries may also fall victim to reduced funding, and some militaries have already been affected by loss of available servicemen and women due to AIDS. It is estimated that seroprevalance among soldiers in SSA is 2-5 times higher than that of the general population, even in peacetime (8). In Uganda, where Aids awareness programs are provided to troops, and soldiers are regularly tested, a 2001 survey revealed seroprevelance of 23% (8). South Africa and Angola, not having the same kind of prevention measures in place, have estimated military prevalence rates of 40% and 60%, respectively (8).
Additionally, as more adults are made ill or pass away, more children are forced to quit going to school, become involved in child labor (including high-risk activities such as sex work), and are orphaned. As of 2002 13.2 million children had lost one or both parents in SSA, largely due to the effect of AIDS (13). Orphans can strain extended families as well as state and national budgets as families and agencies step forward to care and provide for them. Also, those living in poverty become more numerous as children are left with nothing and must provide for themselves and siblings, and possibly even care for those made ill by HIV. Growing numbers of poor people of course contributes to and exacerbates those conditions in which the spread of the epidemic is most widely seen.
As children lose their parents, the threat of widening inequality also becomes imminent. As orphans and children with sick parents stop attending school, they may have difficulty in securing employment. Thus, even as job availability increases as a result of AIDS deaths, there is some question as to how many qualified candidates will be available to fill those positions, and young people affected by HIV/AIDS within their family may not be able to benefit. Additionally, widespread infection among adults, whether within a family or among the community at large, can deter young people from seeking education or otherwise planning for a future that may seem uncertain or hopeless.
It is difficult to ascertain how much of an impact HIV/AIDS has had and will continue to have on socio-economic conditions, yet the pandemic’s devastating potential is clear. AIDS cases begin with HIV infection and experience a prolonged latency prior to the onset of acute AIDS and beginning symptoms. Thus, people may be infected for years before even realizing that they are HIV positive. This is a large part of the reason why the spread of HIV/AIDS has happened so quickly and has been so rampant. In some SSA countries, for instance, infection rates have multiplied by as much as five times in less than a decade (3). Much of the pandemic’s impact has been felt at the family level, and as such has been difficult to quantify. The death toll due to AIDS is expected to continue to rise, and is predicted to peak at the end of the decade (3). The true impact of HIV/AIDS on societies and economies, therefore, has yet to be fully realized. Awareness of this threat continues to grow, however, and greater understanding will be instrumental in planning and policy-making efforts designed to mitigate the effects of HIV/AIDS on social and economic structures. The following pages attempt to identify challenges to the battle against HIV/AIDS and its subsequent security risks, and also describe steps that have already been taken and their relative success.
Years after his terms in office, former U.S. President Ronald Reagan continued to be criticized for his inaction in the face of a growing AIDS epidemic, an epidemic which first emerged during his presidency. His choice to ignore the epidemic for such a long time is thought to have been influenced, in a large part, by the fact that HIV/AIDS occurred mainly among gay men, especially in the first years after its initial identification. At the least Reagan has been accused of apathy in the face of an epidemic with devastating global effects, and, at the worst has been held responsible for the deaths of millions. Difficult (almost impossible) as it may be to predict what the outcome may have been with a more concerted effort on the part of the Reagan administration, recent successes have shown the efficacy of a quick response from high levels of government.
Uganda has been one of the only SSA nations to actually see declining infection rates. With a marketing strategy promoting condom use in place as early as 1990, AIDS awareness programs instituted for military personnel since 1989, and a Uganda AIDS Commission established in 1992 (8), Uganda started earlier than most other SSA nations to recognize and take action against the epidemic. As a result, Uganda’s seroprevalance had dropped to 6% as of 2003, a significant improvement over the 18% reported in 1993 (8). Political commitment has been widely recognized as one of the most important factors in the uncertain future of HIV/AIDS and its global effect. Uganda’s policies and subsequent success support this assertion.
In South Africa, President Thabo Mbeki has been criticized for his lack of political commitment. As the leader of one of the countries hardest hit by the epidemic, Mbeki’s early public comments concerning HIV/AIDS are marked more by skepticism of the virus’ cause, impact and treatment than a recognition of a need for action. Today South Africa’s prevalence rates remain some of the highest in the world at over 20% (16). Greater efforts have been made recently as a new plan has been introduced, promising to offer treatment to all South Africans living with AIDS, yet progress has been slow and mired in political red tape.
Leadership in many countries has been slow to even admit the existence of HIV/AIDS among their people, let alone take action to fight the spread of infection and care for those suffering from its effects. This kind of political inaction alone has potentially dire consequences, yet political commitment is required not only from within countries hardest hit by HIV/AIDS, but is desperately needed from nations with the kind of substantial resources required to truly turn around the growing crisis. Assistance has been assembled from some of the most wealthy countries in the world as well as from international and private organizations, and this can only serve as a positive support for the fight against AIDS. Yet there is some question as to whether certain nations are doing all that they can and whether the ways in which they choose to contribute are the most effective ways possible.
For example, the leadership of the U.S. has faced some criticism towards its response to the AIDS crisis. Promised funding has been slow to materialize and is granted with specific stipulations about the way it is to be spent. U.S. funding is allocated towards prevention efforts utilizing the ABC program, which stands for “Abstinence, Be faithful, and as appropriate, correct and consistent use of Condoms”(9). This program has been successful in some areas, including Uganda, yet does not accurately identify the needs of other nations or the particular nature of the epidemic in different areas. Abstinence is not as viable an option for regions that have high infection rates due to widespread needle use or prostitution, and the de-emphasized role of condom distribution in The President’s Emergency Plan for AIDS Relief does little to help populations in desperate need of this kind of prevention. PEPFAR does discuss condom distribution among “high risk” groups, but uses the term prostitution only briefly, and only in terms of its eradication. In many of the poor countries hardest hit by AIDS, prostitution is one of few options for women, and its eradication is not easily achieved. Also, the Bush administration has been criticized for its support of pharmaceutical companies reluctant to give up patents to drug manufacturers able to make cheaper generic ARVs. According to a news briefing released by Doctors Without Borders, “the U.S. Global AIDS Coordinator and former CEO of Eli Lilly & Co., Randall Tobias, has made several public remarks which question the quality of generic ARVs, undermine international quality standards set by the WHO, and accuse providers of ARV treatment in developing countries who use generics of endangering the lives of patients”(6). And the U.S. government, from President Reagan to the current administration, has received consistent criticism for its lack of support of needle exchange programs, despite the fact that 25% of all new cases in the U.S. and Canada are due to needle use (12). By adhering to strictly conservative mores in policy making decisions concerning the global AIDS crisis, the U.S. government has evidenced the ways in which politics can interfere with the potential for real and potent action in providing effective funding, and helping people living with HIV/AIDS.
The politics surrounding HIV/AIDS are complicated and are threatened by action or inaction dictated by what is politically popular and profitable rather than what is most effective. Because the epidemic is most rampant in poor areas of the world, globally funded programs bolstered by wealthier nations are key to the fight against HIV/AIDS. Given the long-term requirements of treating AIDS patients worldwide as well as maintaining prevention and awareness programs, the likelihood of changing political climates is strong. The future of the AIDS crisis is uncertain, but will certainly rely on continuous political and governmental support.
Social and cultural challenges
The reactions of U.S. administrations and their reluctance to discuss key issues related to HIV/AIDS such as homosexuality, needle use and prostitution exemplify a larger problem in confronting the epidemic. The intimate nature of the way infection is spread is not only a challenge to leadership, but surrounds the epidemic with stigma and discrimination towards those infected, and can lead to reluctance on the part of those infected to seek out testing, counseling and treatment. Furthermore, additional social conditions such as the status and treatment of women also complicate the face of the crisis and the ways in which it must be confronted.
For those living with HIV/AIDS, stigma and discrimination can make access to services and treatment more difficult. Many fear even being tested because of the risk of others finding out about their HIV status. For example, in India, Indonesia and Thailand, surveys have shown that 29-40% of those who sought testing had their test results shared with other people without their consent. And some people living with HIV/AIDS have reported having problems when seeking treatment, as, in the Philippines, 50% of those surveyed reported experiencing discrimination from health-care workers (14).
While negatively affecting the quality of life for those seeking testing and treatment, this kind of discrimination also furthers the spread of the epidemic. Because of the stigma surrounding HIV/AIDS, people become unwilling to request testing or admit to sexual partners that they are infected. It also creates a false classification of HIV/AIDS as an illness that effects only those on the fringes of society, making precautions and testing seem unnecessary for some. And for those who do participate in high-risk activities, the idea of having to admit to homosexual contact, needle use, sex work, infidelity or promiscuity can sometimes be too shaming to seek testing, prevention and treatment. All of this only serves as fuel to the spread of HIV/AIDS.
The status of women, particularly in SSA, also affects the epidemic’s nature and the way it is spread. In some countries women are not allowed the freedom to choose their sexual partners and often fall victim to sexual assault and rape. During conflict in Bosnia, an estimated 30,000-40,000 women were raped. It became a common practice there for enemy soldiers to rape women, using unwanted pregnancy as an act of war (11). And in South Africa, for instance, one of the highest rates of rape in the world is found alongside extremely high infection rates. Additionally, women receive less education and have higher illiteracy rates, making information about AIDS prevention and treatment less available, and because of their lack of education, women who have to find work are more likely to turn to high-risk activities such as prostitution.
Women are often unable or unwilling to ask their husband or partner to wear a condom, and it has become common for women to be infected by their husbands. And within the household, women disproportionately care for children and those that are ill. With women 1.2 more likely to become infected with HIV (14), social standards that leave women particularly vulnerable to HIV could have devastating effects for families as more and more mothers and care-givers become ill and succumb to AIDS related deaths. The number of pregnant women infected with HIV has also increased dramatically, with many SSA countries reporting over 10% seroprevalance among women in antenatal clinics (14), and prevention of mother-to-child transmission is drastically under-funded, and is simply unavailable in many areas (14). Thus, while women remain an important sector of society and their health is vital to the maintenance of families and communities, especially in the face of a growing HIV/AIDS crisis, their risk of infection is much higher than that of men, and firmly embedded sociocultural customs threaten to keep women vulnerable.
While stigma, discrimination and social attitudes towards women are incredibly important factors in the global HIV/AIDS pandemic, they are also some of the more complicated challenges that the fight against the epidemic must face. Changing behaviors and attitudes that have been socially and culturally ingrained for hundreds of years is not an easy task, yet these factors must be addressed. With the implementation of awareness programs in schools, medical facilities and communities, HIV/AIDS patients may hope to find less discrimination from those they seek health care from and from the population at large. And with a greater effort to protect the rights of daughters, wives, mothers and sex workers alike, women can become empowered to protect themselves from HIV infection.
What is being done about HIV/AIDS?
Perhaps the most effective tool in the fight against HIV/AIDS is widespread access to ARV drugs. As infection begins to be perceived as a situation with some hope among those infected and those living in areas with high infection rates, there may be more willingness to participate in testing and treatment. Also, with the prospect of life ahead for those infected or at the risk of infection, more people will seek out education, will save money, start families and keep jobs. Access to ARVs not only increases quality of life, but also can help mitigate some of the negative impacts HIV/AIDS has upon families, economies and communities.
UNAIDS and the World Health Organization (WHO), two major forces in the growing, united, global effort to fight HIV/AIDS, have committed to the 3 by 5 Initiative. The initiative is an ambitious campaign aiming to treat 3 million people with ARV drugs by the year 2005. Already, by 2002, access to ARV drugs had increased 50% worldwide (17), and the 3 by 5 Initiative has the potential to save millions more. Yet treating 3 million appears less significant when reminded of the 40 million worldwide that are infected. And a recent “Progress Report” issued by WHO has indicated that funding for the initiative has been slow to materialize and the program has not made the strides it had hoped to by the end of 2003 (17). The slow start of the initiative is disconcerting as infection rates are only expected to climb and those living with ARVs tend to require more expensive medicines the longer they receive treatment.
Other programs have seen greater success, such as the previously mentioned ABC program in Uganda and also the “100% Condom Use” program in Thailand, a country that has managed to keep seroprevalence rates low among sex workers and the population at large. Worldwide, the condom use program has prevented an estimated 6 million new infections (18), and successful prevention programs inspire additional hope as they help stop the spread of HIV/AIDS and are almost always cheaper than treatment. However, the supply of condoms to those who need them is limited, with 6-9 billion distributed per year, falling short of the estimated 24 billion that are necessary. And efforts are still required to help people understand the importance of using condoms and how to use them. China, in 2002, saw less than 20% of its sex workers using condoms regularly (18).
The vast majority of the countries hardest-hit by HIV/AIDS have not seen any kind of decline in the epidemic. A 2003 UNAIDS update of the epidemic paints a disturbing picture of the insubstantial efforts made in SSA nations: Over 70% of countries reporting from Africa on efforts to reduce HIV transmission to infants and young children have virtually no programmes to administer prophylactic antiretroviral therapy to women during childbirth and to newborns. Almost half the countries reporting have not adopted legislation to prevent discrimination against people living with HIV/AIDS, and only one in four countries report that at least 50% of patients with other sexually transmitted infections (co-factors for HIV infection) are being diagnosed, counseled, and treated (14).
The growing threat of HIV/AIDS, not only its rising death toll but also its potential devastation to key economic and social structures, has been well researched and documented. A united, worldwide effort to combat the spread of the epidemic and its costly ramifications has been assembled. Success stories, such as that of Uganda, have emerged and have offered hope and guidance to those attempting to turn the tide of the AIDS crisis. However, seeing this kind of a result on a global scale is more complicated and more challenging. As the chilling statistics regarding the current situation and what lies ahead reveal, there is much work yet to be done.
1. Center for Disease Control The Global HIV and AIDS Epidemic, 2001 MMWR Weekly, June 2001, 50(21); 434-439
2. Commission on HIV/AIDS and Governance in Africa The Impacts of HIV on Families and Communities in Africa (Economic Commission for Africa, Addis Ababa, Ethiopia)
3. Commission of HIV/AIDS and Governance in Africa Africa: The Socio-Economic Impact of HIV/AIDS (Economic Commission for Africa, Addis Ababa, Ethiopia)
4. Commission of HIV/AIDS and Governance in Africa Globalized Inequalities and HIV/AIDS (Economic Commission for Africa, Addis Ababa, Ethiopia)
5. de Waal, Alex (2001) AIDS-Related National Crises: An Agenda for Governance, Early Warning and Development Partnership Justice Africa: AIDS and Governance Issue Paper no. 1
6. Doctors Without Borders (2004) Doctors Without Borders and the President’s Emergency Plan for AIDS Relief (PEPFAR)
7. Human Rights Campaign HIV/AIDS & HRC: Two Decades of Fighting for Life (HRC, Washington D.C.)
8. International Crisis Group (2004) HIV/AIDS as a Security Issue in Africa: Lessons From Uganda (ICG, Kampala/Brussels) ICG Issues Report no. 3
9. Office of the U.S. Global AIDS Coordinator (2004) The President’s Emergency Plan for AIDS Relief: A Five-Year Global HIV/AIDS Strategy (U.S. Department of State, Washington D.C.)
10. Piot, P., Seck, A.M.C. International Response to the HIV/AIDS Epidemic: Planning for Success Bulletin of the World Health Organization, 2001, 79; 1106-111
11. UK Consortium on AIDS & International Development (2002) The Silent Emergency: HIV/AIDS in Conflict and Disasters (UK Consortium on AIDS & International Development) Report of the Seminar
12. UNAIDS/World Health Organization (2004) Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections: United States of America (UNAIDS, Geneva)
13. UNAIDS Report on the Global HIV/AIDS Epidemic: Waking Up to Devastation
14. UNAIDS/World Health Organization (2003) AIDS Epidemic Update (UNIADS, Geneva)
15. U.S. Agency for International Development (2002) What Happened in Uganda? Declining HIV Prevalence, Behavior Change, and the National Response (U.S. Agency for International Development, Washington D.C.) Project Lessons Learned Case Study
16. U.S. Census Bureau (2004) The AIDS Pandemic in the 21st Century (U.S. Government Printing Office, Washington D.C.) International Population Reports WP/02-2
17. World Health Organization (2004) 3 By 5 Progress Report: December 2003 Through June 2004 (WHO, Geneva)
18. World Health Organization Western Pacific Region (2003) Asia Needs Billions of Condoms to Curb AIDS Threat (WHO, Manila) Press Release