Alan Whiteside

New variant famine: AIDS and food crisis in Southern Africa.

Southern Africa is undergoing a food crisis of surprising scale and novelty. The familiar culprits of drought and mismanagement of national strategies are implicated. However, this crisis is distinct from conventional drought-induced food shortages with respect to those vulnerable to starvation, and the course of impoverishment and recovery. We propose that these new aspects to the food crisis can be attributed largely to the HIV/AIDS epidemic in the region. We present evidence that we are facing a new variant famine. We have used frameworks drawn from famine theory to examine the implications. HIV/AIDS has created a new category of highly vulnerable households--namely, those with ill adults or those whose adults have died. The general burden of care in both AIDS-affected and non-AIDS-affected households has reduced the viability of farming livelihoods. The sensitivity of rural communities to external shocks such as drought has increased, and their resilience has declined. The prospects for a sharp decline into severe famine are increased, and possibilities for recovery reduced.

Poverty and HIV/AIDS in Africa

HIV/AIDS is the major threat to development, economic growth and poverty alleviation in much of Africa. And yet the full extent of the catastrophe facing the continent is only just being recognised, and still not by all. The international development targets set by the great and the good of the global community--or at least by those members of the community who attend the international summits that set these goals--do not consider what HIV/AIDS means and are unachievable. This paper begins by setting the scene, describing the epidemic, explaining why it is so important and what makes HIV/AIDS different. It then explores how the poverty/epidemic cycle works, whereby poverty increases the spread of HIV and AIDS increases poverty. It suggests we need to look beyond monetary poverty to understand these relationships. Finally the paper assesses what can and should be done to break the HIV/AIDS poverty cycle.

The social and economic impact of HIV/AIDS in poor countries: a review of studies and lessons

This review accompanies the Guidelines for Preparation and Execution of Studies of the Social and Economic Impact of HIV/AIDS. Its purpose is to supplement and complement those practical guidelines by presenting some of the literature which informed their development. The first section of the review provides some background to the epidemic and an indication of where on the World Wide Web up to date information may be found. This complements the broader range of sources of data which is presented in the Guidelines. The idea of impact is defined making clear that the impact of an epidemic cannot be thought of only as a shock but must also be understood as a series of slow cumulative events over a long time period. The Guidelines make very clear that data are vital for effective impact studies. To underline this point the first section of the Review: Data and Methods for studying Impact provides an account of the different theoretical approaches to studying impact not from a disciplinary perspective - the Review argues that most impact studies have been done by economists and demographers - but rather from a consideration of the quality and type of data used. It recognises that diverse types of data will be used in impact studies and those undertaking such studies must be aware of the uses and limitations of such material and furthermore or the ways that data are related to the theories and methods which informed their collection. (excerpt)

HIV/AIDS and development: Case studies and a conceptual framework

This article presents outline accounts of some social and economic features of the HIV/AIDS epidemics in five countries: the United Kingdom, Botswana, Uganda, India and Ukraine. It suggests that: (a) certain key features of society and economy are major determinants of the degree to which epidemics become generalised to whole populations; (b) these features can be conceptualised in ways that will assist in more effective targeting of preventive interventions and measures to confront the medium- and long-term impacts of raised morbidity and mortality associated with the occurrence of generalised HIV/AIDS epidemics.

Scale-up of HIV Treatment Through PEPFAR: A Historic Public Health Achievement

Abstract: Since its inception in 2003, the US Presidents Emergency Plan for AIDS Relief (PEPFAR) has been an important driving force behind the global scale-up of HIV care and treatment services, particularly in expansion of access to antiretroviral therapy. Despite initial concerns about cost and feasibility, PEPFAR overcame challenges by leveraging and coordinating with other funders, by working in partnership with the most affected countries, by supporting local ownership, by using a public health approach, by supporting task-shifting strategies, and by paying attention to health systems strengthening. As of September 2011, PEPFAR directly supported initiation of antiretroviral therapy for 3.9 million people and provided care and support for nearly 13 million people. Benefits in terms of prevention of morbidity and mortality have been reaped by those receiving the services, with evidence of societal benefits beyond the anticipated clinical benefits. However, much remains to be accomplished to achieve universal access, to enhance the quality of programs, to ensure retention of patients in care, and to continue to strengthen health systems.

Addressing the structural drivers of HIV:a luxury or necessity for programmes?

The social, economic, political and environmental structural factors that increase susceptibility to HIV infection and undermine prevention and treatment efforts continue to pose a challenge. The papers in this series highlight the importance of sustaining those efforts to address the structural drivers of the HIV epidemic, and that initiatives to achieve HIV elimination will only come about through a comprehensive HIV response, that includes meaningful responses to the social, political, economic and environmental factors that affect HIV risk and vulnerability. In the context of declining resources for HIV/AIDS, the papers speak to the need to integrate responses to the structural drivers of HIV/AIDS into future HIV investments, with both initiatives to integrate HIV into broader gender and development initiatives, as well as adaptations of current service models, to ensure that they are sensitive to and able to respond to the broader economic and social responsibilities that their clients face.

A cut above the rest: traditional male circumcision and HIV risk among Xhosa men in Cape Town South Africa.

BackgroundRandomized clinical trials have shown that medical male circumcision substantially reduces the risk of contracting HIV. However, relatively little is known about the relationship between traditional male circumcision and HIV risk. This article examines variations in traditional circumcision practices and their relationship to HIV status. MethodsWe used data from the fifth wave of the Cape Area Panel Study (n = 473) of young adults in Cape Town, South Africa, to determine attitudes towards circumcision, whether men were circumcised, at what age, and whether their foreskin had been fully or partially removed. Probit models were estimated to determine the association between extent and age of circumcision and HIV status. ResultsThere was strong support for traditional male circumcision. 92.5% of the men reported being circumcised, with 10.5% partially circumcised. Partially circumcised men had a 7% point greater risk of being HIV positive than fully circumcised men (P < 0.05) and equal risk compared with uncircumcised men. Most (91%) men were circumcised between the ages of 17 and 22 years (mean 19.2 years), and HIV risk increased with age of circumcision (P < 0.10). ConclusionsEfforts should be made to encourage earlier circumcisions and to work with traditional surgeons to reduce the number of partial circumcisions. Data on the extent and age of circumcision are necessary for meaningful conclusions to be drawn from survey data about the relationship between circumcision and HIV status.

The economic impact of AIDS in Africa

The experience of acquired immune deficiency syndrome (AIDS) in Africa is very different from that in the developed world. In the West, AIDS affects few people, and for those who are infected, it is an increasingly manageable illness. In Africa, huge numbers of people are being infected - mainly young adults through sexual intercourse. This is having a dramatic effect on key demographic indicators. Child mortality in some countries has doubled, while up to 25 years of life expectancy have been lost. The economic impact of AIDS is difficult to establish, but it is certainly leading to increased poverty in African families and communities. Development advances are being reversed, but the impact is incremental rather than catastrophic.

The end of AIDS: Possibility or pipe dream? A tale of transitions

Globally, in the last 20 years health has improved. In this generally optimistic setting HIV and AIDS accounts for the fastest growing burden of disease. The data show the bulk of this is experienced in Southern Africa. In this region, HIV and AIDS (and tuberculosis [TB]) peaks among young adults. Women carry the greater proportion of infections and provided most of the care. South Africa has the dubious distinction of having the largest number of people living with HIV in the world, 6.4 million. HIV began spreading from about 1990 and today the prevalence among antenatal clinic attendees is 29.5%. A similar situation exists in other nations of the region. It is an expensive disease, requiring more resources than are available, and it is slipping off the global agenda, both in terms of attention and international funding. Those halcyon days of the decade from 2000 to 2010 are over. This paper explores the concept of three transition points: economic, epidemiological and programmatic. The first two have been developed and written about by others. We add a third transition point, namely programmatic, argue this is an important concept, and show how it can become a powerful tool in the response to the epidemic. The economic transition point assesses HIV incidence and mortality of people infected with HIV. Until the number of newly infected people falls below the number of deaths of people living with HIV, the demand for treatment and costs will increase. This is a concern for the health sector, finance ministry and all working in the field of HIV. Once an economic transition occurs the treatment future is predictable and the number of people living with HIV and AIDS decreases. This paper plots two more lines. These are the number of new people from the HIV infected pool initiated on treatment and the number of people from the HIV infected pool requiring treatment. This introduces new transition points on the graph. The first when the number of people initiated on treatment exceeds the number of people needing treatment. The second when the number initiated on treatment exceeds the new infections. That is the theory. When we applied South African data from the ASSA2008 model, we were able to plot transition points marking progress in the national response. We argue these concepts can and should be applied to any country or HIV epidemic.

Revisiting new variant famine: the case of Swaziland

The ‘new variant famine’ hypothesis posits links between HIV/AIDS and new patterns of impoverishment, food insecurity and hunger, in southern and eastern Africa. This paper explores the relevance of the NVF hypothesis to understanding Swaziland’s recurrent food crises and high HIV prevalence. Evidence exists that all four markers of NVF are present in Swaziland. The national government and the international community will have to contend with this phenomenon in future planning for the wellbeing of Swazi citizens.