The impact of HIV & AIDS in Africa

Two-thirds of all people infected with HIV live in sub-Saharan Africa, although this region contains little more than 10% of the world’s population.¹ AIDS has caused immense human suffering in the continent. The most obvious effect of this crisis has been illness and death, but the impact of the epidemic has certainly not been confined to the health sector; households, schools, workplaces and economies have also been badly affected.
During 2008 alone, an estimated 1.4 million adults and children died as a result of AIDS in sub-Saharan Africa.² Since the beginning of the epidemic more than 15 million Africans have died from AIDS.³
Although access to antiretroviral treatment is starting to lessen the toll of AIDS, fewer than half of Africans who need treatment are receiving it.⁴ The impact of AIDS will remain severe for many years to come.

The impact on the health sector

In all heavily affected countries the AIDS epidemic is adding additional pressure on the health sector. As the epidemic matures, the demand for care for those living with HIV rises, as does the toll of AIDS on health workers. In sub-Saharan Africa, the direct medical costs of AIDS (excluding antiretroviral therapy) have been estimated at about US$30 per year for every person infected, at a time when overall public health spending is less than US$10 per year for most African countries.⁵

The effect on hospitals

Nurses working on the HIV ward at Kisiizi Hospital in Uganda

As the HIV prevalence of a country rises, the strain placed on its hospitals is likely to increase. In sub-Saharan Africa, people with HIV-related diseases occupy more than half of all hospital beds.⁶ Government-funded research in South Africa has suggested that, on average, HIV-positive patients stay in hospital four times longer than other patients.⁷
Hospitals are struggling to cope, especially in poorer African countries where there are often too few beds available. This shortage results in people being admitted only in the later stages of illness, reducing their chances of recovery.

Health care workers

While AIDS is causing an increased demand for health services, large numbers of healthcare professionals are being directly affected by the epidemic. Botswana, for example, lost 17% of its healthcare workforce due to AIDS between 1999 and 2005. A study in one region of Zambia found that 40% of midwives were HIV-positive.⁸ Healthcare workers are already scarce in most African countries. Excessive workloads, poor pay and migration to richer countries are among the factors contributing to this shortage.
Although the recent increase in the provision of antiretroviral drugs (which significantly delay the progression from HIV to AIDS) has brought hope to many in Africa, it has also put increased strain on healthcare workers. Providing antiretroviral treatment to everyone who needs it requires more time and training than is currently available in most countries.

The impact on households

The toll of HIV and AIDS on households can be very severe. Although no part of the population is unaffected by HIV, it is often the poorest sectors of society that are most vulnerable to the epidemic and for whom the consequences are most severe. In many cases, the presence of AIDS causes the household to dissolve, as parents die and children are sent to relatives for care and upbringing. A study in rural South Africa suggested that households in which an adult had died from AIDS were four times more likely to dissolve than those in which no deaths had occurred.⁹ Much happens before this dissolution takes place: AIDS strips families of their assets and income earners, further impoverishing the poor.

Household income

In Botswana it is estimated that, on average, every income earner is likely to acquire one additional dependent over the next ten years due to the AIDS epidemic. A dramatic increase in destitute households – those with no income earners – is also expected.¹⁰
Other countries in the region are experiencing the same problem, as individuals who would otherwise provide a household with income are prevented from working – either because they are ill with AIDS themselves or because they are caring for another sick family member.
Such a situation is likely to have repercussions for every member of the family. Children may be forced to abandon their education and in some cases women may be forced to turn to sex work ('prostitution'). This can lead to a higher risk of HIV transmission, which further exacerbates the situation.

Basic necessities

A study in South Africa found that poor households coping with members who are sick from HIV or AIDS were reducing spending on necessities even further. The most likely expenses to be cut were clothing (21%), electricity (16%) and other services (9%). Falling incomes forced about 6% of households to reduce the amount they spent on food and almost half of households reported having insufficient food at times.¹¹

"She then led me to the kitchen and showed me empty buckets of food and said they had nothing to eat that day just like other days."¹²

Food production

The AIDS epidemic adds to food insecurity in many areas, as agricultural work is neglected or abandoned due to household illness. In Malawi, where food shortages have had a devastating effect, it has been recognised that HIV and AIDS are diminishing the country’s agricultural output.¹³ It is thought that by 2020, Malawi’s agricultural workforce will be 14% smaller than it would have been without HIV and AIDS. In other countries, such as Mozambique, Botswana, Namibia and Zimbabwe, the reduction is likely to be over 20%.¹⁴
A study in Kenya demonstrated that food production in households in which the head of the family died of AIDS were affected in different ways depending on the sex of the deceased. As in other sub-Saharan African countries, it was generally found that the death of a male reduced the production of ‘cash crops’ (such as coffee, tea and sugar), while the death of a female reduced the production of grain and other crops necessary for household survival.¹⁵

Healthcare expenses and funeral costs

Taking care of a person sick with AIDS is not only an emotional strain for household members, but also a major strain on household resources. Loss of income, additional care-related expenses, the reduced ability of caregivers to work, and mounting medical fees push affected households deeper into poverty. It is estimated that, on average, HIV-related care can absorb one-third of a household’s monthly income.¹⁶
The financial burden of death can also be considerable, with some families in South Africa easily spending seven times their total household monthly income on a funeral. Furthermore, although many South Africans contribute to some sort of funeral insurance plan, many of these are inadequately funded, and it is arguable that such financial arrangements detract from other savings plans or health insurance.¹⁷
Aside from the financial burden, providing home based care can impose demands on the physical, mental and general health of carers – usually family and friends of the sick person. Such risks are amplified if carers are untrained or unsupported by a home-based care organisation.

How do HIV/AIDS-affected households cope in Africa?

Three main coping strategies appear to be adopted among affected households. Savings are used up or assets sold; assistance is received from other households; and the composition of households tends to change, with fewer adults of prime working age in the households.
Almost invariably, the burden of coping rests with women. Upon a family member becoming ill, the role of women as carers, income-earners and housekeepers is stepped up. They are often forced to step into roles outside their homes as well. In parts of Zimbabwe, for example, women are moving into the traditionally male-dominated carpentry industry. This often results in women having less time to prepare food and for other tasks at home.

"I used to stay with the children, but now it is a problem. I have to work in the fields. Last year I had more money to hire labour so the crops got weeded more often. This year I had to do it myself.” Angelina, Zimbabwe¹⁸

Older people are also heavily affected by the epidemic; many have to care for their sick children and are often left to look after orphaned grandchildren. Older people left caring for the sick face the burden of providing financial, emotional and psychological support at a time when they would usually be expecting to receive more support as their energy levels drop with older age. Due to the amount of time spent caring for dependents, older people may become isolated from their peers as they no longer have the time to dedicate to their social networks that need to be fostered to prevent isolation and loneliness.
Tapping into savings if available and taking on more debt are usually the first options chosen by households struggling to pay for medical treatment or funerals. Then as debts mount, precious assets such as bicycles, livestock and even land are sold. Once households are stripped of their productive assets, the chances of them recovering and rebuilding their livelihoods become even slimmer.
The number of working adults in a family will often decrease.

“Our fields are idle because there is nobody to work them. We don't have machinery for farming, we only have manpower - if we are sick, or spend our time looking after family members who are sick, we have no time to spend working in the fields." Toby Solomon, commissioner for the Nsanje district, Malawi¹⁹

One of the more unfortunate responses to a death in poorer households is removing the children (especially girls) from school. Often the school uniforms and fees become unaffordable for the families and the child's labour and income-generating potential are required in the household.

“Because I’m a poor African woman, I can’t raise enough money for three orphans. The one in secondary school, sometimes she misses first term because I’m looking for tuition. The others miss schools for two or three days at a time. I had a cow I used to milk, but as time went on the cow died, so I can’t find any other income…” Barbara, Uganda ²⁰

The impact on children

It is hard to overemphasise the trauma and hardship that children affected by HIV and AIDS are forced to bear. The epidemic not only causes children to lose their parents or guardians, but sometimes their childhood as well.
As parents and family members become ill, children take on more responsibility to earn an income, produce food, and care for family members. It is harder for these children to access adequate nutrition, basic health care, housing and clothing. Fewer families have the money to send their children to school.
Often both of the parents are HIV positive in Africa. Consequently, more children have been orphaned by AIDS in Africa than anywhere else. Many children are now raised by their grandparents or left on their own in child-headed households.
As projections of the number of AIDS orphans rise, some have called for an increase in institutional care for children. However this solution is not only expensive but also detrimental to the children. Institutionalisation stores up problems for society, which is ill equipped to cope with an influx of young adults who have not been socialised in the community in which they have to live. There are other alternatives available. One example is the approach developed by church groups in Zimbabwe, in which community members are recruited to visit orphans in their homes, where they live either with foster parents, grandparents or other relatives, or in child-headed households.
The way forward is prevention. Firstly, it is crucial to prevent children from becoming infected with HIV at birth as well as later in life. Secondly, if efforts are made to prevent adults becoming infected with HIV, and to care for those already infected, then fewer children will be orphaned by AIDS in the future.
To learn more, see our children HIV & AIDS page.

The impact on the education sector

The relationship between AIDS and the education sector is circular – as the epidemic worsens, the education sector is damaged, which in turn is likely to increase the incidence of HIV transmission. There are numerous ways in which AIDS can affect education, but equally there are many ways in which education can help the fight against AIDS. The extent to which schools and other education institutions are able to continue functioning will influence how well societies eventually recover from the epidemic.

"Without education, AIDS will continue its rampant spread. With AIDS out of control, education will be out of reach." Peter Piot, Director of UNAIDS²¹

Fewer children receiving a basic education

Children at a school in Illinge, South Africa. Many are affected by HIV and AIDS.

A decline in school enrolment is one of the most visible effects of the epidemic. This in itself will have an effect on HIV prevention, as a good, basic education ranks among the most effective and cost-effective means of preventing HIV.²²
There are numerous barriers to school attendance in Africa. Children may be removed from school to care for parents or family members, or they may themselves be living with HIV. Many are unable to afford school fees and other such expenses – this is particularly a problem among children who have lost their parents to AIDS, who often struggle to generate income.
Studies have suggested that young people with little or no education may be around twice as likely to contract HIV as those who have completed primary education.²³ In this context, the devastating effect that AIDS is having on school enrolment is a big concern. In Swaziland and the Central African Republic, it has been reported that school enrolment has fallen by 25-30% due to AIDS.²⁴

The impact on teachers

HIV and AIDS are having a devastating affect on the already inadequate supply of teachers in African countries; for example, a study in South Africa found that 21% of teachers aged 25-34 are living with HIV.²⁵
Teachers who are affected by HIV and AIDS are likely to take periods of time off work. Those with sick families may also take time off to attend funerals or to care for sick or dying relatives, and further absenteeism may result from the psychological effects of the epidemic.²⁶
When a teacher falls ill, the class may be taken on by another teacher, may be combined with another class, or may be left untaught. Even when there is a sufficient supply of teachers to replace losses, there can be a significant impact on the students. This is particularly concerning given the important role that teachers can play in the fight against AIDS.
The illness or death of teachers is especially devastating in rural areas where schools depend heavily on one or two teachers. Moreover, skilled teachers are not easily replaced. Tanzania has estimated that it needs around 45,000 additional teachers to make up for those who have died or left work because of HIV and AIDS. The greatest proportion of staff that have been lost, according to the Tanzania Teacher’s Union, were experienced staff between the ages of 41 and 50.²⁷

The impact on enterprises and workplaces

HIV and AIDS dramatically affect labour, setting back economic and social progress. The vast majority of people living with HIV in Africa are between the ages of 15 and 49 - in the prime of their working lives.
AIDS damages businesses by squeezing productivity, adding costs, diverting productive resources, and depleting skills. Company costs for health-care, funeral benefits and pension fund commitments are likely to rise as the number of people taking early retirement or dying increases. Also, as the impact of the epidemic on households grows more severe, market demand for products and services can fall. The epidemic hits productivity through increased absenteeism. Comparative studies of East African businesses have shown that absenteeism can account for as much as 25-54% of company costs.²⁸
A study in several Southern African countries has estimated that the combined impact of AIDS-related absenteeism, productivity declines, health-care expenditures, and recruitment and training expenses could cut profits by at least 6-8%.²⁹ Another study of a thousand companies in Southern Africa found that 9% had suffered a significant negative impact due to AIDS. In areas that have been hit hardest by the epidemic, it found that up to 40% of companies reported that HIV and AIDS were having a negative effect on profits.
Some companies, though, have implemented successful programmes to deal with the epidemic. An example is the gold-mining industry in South Africa. The gold mines attract thousands of workers, often from poor and remote regions. Most live in hostels, separated from their families. As a result a thriving sex industry operates around many mines and HIV is common. In recent years, mining companies have been working with a number of organisations to implement prevention programmes for the miners. These have included mass distribution of condoms, medical care and treatment for sexually transmitted diseases, and awareness campaigns. Some mining companies have started to replace all-male hostels with accommodation for families, in order to reduce the transmission of HIV and other sexually transmitted diseases.³⁰
In Swaziland, an employers' anti-AIDS coalition has been set up to promote voluntary counselling and testing. The coalition not only includes larger companies but also small and medium sized enterprises.³¹ In Botswana, the Debswana diamond company offers all employees HIV testing, and provides antiretroviral drugs to HIV positive workers and their spouses.³² This policy was introduced in 1999 when the company found that many of their workforce were HIV positive. With a skilled workforce, it is financially worth their while to protect the health and therefore the productivity of their workers. Nevertheless, workplace programmes for HIV treatment and prevention remain scarce in Africa.³³

The impact on life expectancy

A coffin maker and his workshop in Nkhata Bay, Malawi

In many countries of sub-Saharan Africa, AIDS is erasing decades of progress in extending life expectancy. In the worst affected countries, average life expectancy has fallen by twenty years because of the epidemic.³⁴ Life expectancy at birth in Swaziland is just 31 years - less than half of what it would be without AIDS.³⁵
The impact that AIDS has had on average life expectancy is partly attributed to child mortality, as increasing numbers of babies are born with HIV infections acquired from their mothers. The biggest increase in deaths, however, has been among adults aged between 20 and 49 years. This group now accounts for 60% of all deaths in sub-Saharan Africa, compared to 20% between 1985 and 1990, when the epidemic was in its early stages.³⁶ By affecting this age group so heavily, AIDS is hitting adults in their most economically productive years and removing the very people who could be responding to the crisis.

The economic impact

Through its impacts on the labour force, households and enterprises, AIDS has played a more significant role in the reversal of human development than any other single factor.³⁷ One aspect of this development reversal has been the damage that the epidemic has done to the economy, which, in turn, has made it more difficult for countries to respond to the crisis.
One way in which AIDS affects the economy is by reducing the labour supply through increased mortality and illness. Amongst those who are able to work, productivity is likely to decline as a result of HIV-related illness. Government income also declines, as tax revenues fall and governments are pressured to increase their spending to deal with the expanding HIV epidemic.
The abilities of African countries to diversify their industrial base, expand exports and attract foreign investment are integral to economic progress in the region. By making labour more expensive and reducing profits, AIDS limits the ability of African countries to attract industries that depend on low-cost labour and makes investments in African businesses less desirable. HIV and AIDS therefore threaten the foundations of economic development in Africa.³⁸
The impact that AIDS has had on the economies of African countries is difficult to measure. The economies of the worst affected countries were already struggling with development challenges, debt and declining trade before the epidemic started to affect the continent. AIDS has combined with these factors to further aggravate the situation. It is thought that the impact of AIDS on the gross domestic product (GDP) of the worst affected countries is a loss of around 1.5% per year; this means that after 25 years the economy would be 31% smaller than it would otherwise have been.³⁹

The future impact of HIV/AIDS

This page has outlined just some of the ways in which the AIDS epidemic has had a significant impact on countries in sub-Saharan Africa. Although both international and domestic efforts to overcome the crisis have been strengthened in recent years, there is little sign of the epidemic diminishing. The people of sub-Saharan Africa will continue to feel the effects of HIV and AIDS for many years to come. It is clear that as much as possible needs to be done to minimise this impact.
As access to treatment is slowly expanded throughout the continent, millions of lives are being extended and hope is being given to people who previously had none. Unfortunately though, the majority of people in need of treatment are still not receiving it, and campaigns to prevent new infections (which must remain the central focus of the fight against AIDS) are lacking in many areas.
AIDS in Africa is linked to many other problems, such as poverty and poor public infrastructures. Efforts to fight the epidemic must take these realities into account, and look at ways in which the general development of Africa can progress. As the evidence discussed in this page makes clear, however, AIDS is acting as the single greatest barrier to Africa’s development. Much wider access to HIV prevention, treatment and care services is urgently needed.

References

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34. UNAIDS (2008) 'Report on the global AIDS epidemic', Chapter 1
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