AIDS and poverty are mutually reinforcing negative forces. An excerpt from ActionAid-Asia’s report ‘Time to Act: HIV/AIDS in Asia’.
HIV is said to know no boundaries and be blind to colour, creed, region and communities. Why then are some countries, some communities, some age-groups and some populations more affected than others? The overwhelming burden of the epidemic today is borne by developing countries, where the disease threatens to reverse some important achievements in human development. AIDS and poverty have now become mutually reinforcing negative forces. Mostly, it is the poor, dispossessed, the excluded and vulnerable groups that are most affected by HIV/AIDS. The processes of impoverishment also amplify vulnerabilities of the poor to the virus. The virus thrives under certain conditions; some host populations are more welcoming than others.
The reasons for this discrimination are complex and varied and include poverty, illiteracy, migration, trafficking, war and conflict, distress, violence against women, alcoholism, drug use and trafficking, lack of good governance, lack of political will, prostitution, low status of women and girls, powerlessness of marginalised groups, social disintegration, changing lifestyles and sexual habits. It is clear that the virus targets the poor. However, the ability to live with the infection and lead productive lives is a privilege of only the rich. The cost of HIV/AIDS drugs and care are far beyond what poor people can afford...
…In the emerging global context, the poor, dispossessed and vulnerable groups face renewed exclusion from opportunities and access to services...
….For instance, forces that dispossessed and disempowered people in Southern Africa are again at work, leaving people to be destroyed by HIV/AIDS, thereby pushing poverty and land issues to the background...
In Asia too, the war against poverty is becoming a war against poor and vulnerable groups – a process hastened by HIV/AIDS. .
Given the increased susceptibility of HIV-positive women to illnesses, their lack of access to care and support, it is not surprising to note that out of the 21.8 million people estimated to have died of AIDS by 2000, the number of women was more than that of men – 9 million women, 8.5 million men, 4.3 million children...
The fact that HIV/AIDS poses a far greater threat to women and young girls is now an undisputed fact -- in 1997, women represented 41% of the adults infected by the virus. By 2000, this figure had reached 47%. It is also clearly evident that there is a direct correlation between increase in HIV prevalence and proportion of women infected with HIV...
Whereas a lot of HIV transmissions in Asia in the 1990s occurred through commercial sex, half the new HIV infections now appear to be occurring among the wives and sexual partners of men who were infected several years ago...
It is unfortunate that HIV/AIDS affects marginalised groups, further isolating them in the process. As the most common route of transmission is sexual, social morality prevents acceptance of those infected into the mainstream...
Youth are particularly vulnerable. About 2.1 million young people, aged between 15 and 24, are living with HIV in the Asia-Pacific, as the UNAIDS Fact Sheet 2002 notes. Of the world’s 6.1 billion population in 2000, over 1 billion people, or 19.1%, belonged to the age-group 10-19. The Asian and Pacific regions comprise 717 million people in this age-group as the fact sheet notes…
…In all countries of the region, HIV among those engaged in male-to-male sex features significantly in the epidemic. Countries that measured HIV prevalence among men who have sex with men have found it to be rather high –14% in Cambodia. Male Thai sex workers also show the same infection level. Conflicts and mass movements of people in the Central Asia region and its fallouts have provided fertile grounds for the disease...
Vulnerability is further compounded by lack of access to information, education, health services and safe blood. A significant number of HIV transmissions take place through contaminated blood, a route that can be controlled to a large extent, mainly through state intervention. Still the fact that there are many blood banks in the region that are un-registered and thousands of people who still do not have access to safe blood and blood products reflects the importance given by governments to this route of transmission...
Fuzzy strategies
Ever since HIV/AIDS was first acknowledged as a problem, the strategies to address the issue have focused on it as a disease, if not the disease. Despite the growing rhetoric in recent years about HIV/AIDS being a development issue, there has been little attempt to convert this perception into meaningful strategies...
Little has been done to address the root causes of vulnerability to infection. Large amounts of resources are invested into specific ‘high priority’ health problems, divesting, in the process, resources from a comprehensive approach that is sustainable and would benefit both HIV-positive and negative people. There has however been little attempt to integrate HIV/AIDS into overall development initiatives, improve basic health services or strengthen the primary healthcare system. The focus in Asia continues to be on prevention rather than treatment...
People living with HIV/AIDS get little more than routine counseling and some treatment of opportunistic infections. Apart from concerns for the human rights of people infected with the virus, Asian countries will have to offer adequate care for over 7 million people living with the virus in the next few years. The question is whether we have the facilities and political will to support this. The few community care centres that many Asian countries have are not enough. Health budgets are totally inadequate. And primary health care centres are not equipped to treat the repeated illnesses that these people suffer from...
Governments should invest more in anti-retroviral (ARV) therapies, which will prolong people’s lives. Placing the treatment for HIV and response for AIDS in the ambit of primary health care is perhaps the right way to begin. ARV can be made affordable...
Hunger and poverty are key amplifying factors responsible for the progression and spread of the epidemic. Rather than focusing only on individuals and their ‘behaviour’, we need to change the larger social, economic and political systems that make these individuals vulnerable.
Root causes
The economic dimension of the HIV/AIDS scenario is often overlooked in discussions about its causative factors. The World Bank, one of the biggest ‘donors’ of the HIV/AIDS programmes worldwide, has also been responsible for structural adjustment programmes and a model of development based on the ‘free’ market system. These moves have only increased the gulf between the rich and the poor, inequity in health and diseases of poverty...
When addressing the AIDS pandemic, the Bank conveniently ignores these underlying causes of poor health. Public health investment in India fell from 1.3% of the gross domestic product (GDP) in 1990 to 0.9% in 1999. India’s new health policy of 2002 recommends an increase to 2.0% by 2010. However analysts in the People’s Health Movement argue that the new policy is a ‘sell-out to forces of privatisation’ and demands at least a 5.0% allocation...
Poverty is not only a cause of HIV/AIDS spread but also a consequence. Limited gains from anti-poverty initiatives are getting washed off with HIV/AIDS. The World Health Organisation (WHO) estimates that a nation can expect a decline in GDP of 1% per year when more than 20% of the adult population is infected with HIV. Studies quoted in a 2002 UNDP factsheet note that rural families in Thailand show that farm output and income fell between 52 and 67% in families affected by AIDS. With the cost of medical care shooting up and governments surrendering health care to the private sector, medical expenses have become the leading factor of rural indebtedness in many Asian countries...
Because the disease grew so fast in the early years, death rates are going up. A recent study by the World Bank notes: “AIDS destroys human capital selectively, wrecking the health of the most productive members of society.”
Money matters
In the developing world the number of people dying daily because of untreated HIV/AIDS has risen to 8,500, causing the WHO to declare the lack of access to antiretroviral (ARV) therapy a ‘Global health emergency’. Despite its emergency status, the resources generated to deal with HIV/AIDS are far from adequate. The Global Fund, the latest in a series of institutional mechanisms set up in January 2001 as a new multilateral emergency response to the growing pandemics of AIDS, TB and malaria has been facing a serious funding shortfall...
Unless the Global Fund raises additional funds from the US and other donors, its well-publicised and WHO-promoted goal to provide therapy to 3 million people by 2005 will remain a distant dream...
Only 2,40,000 people, or 8% of the total number of patients, will be on ARV treatment by 2005, according to Global Fund officials. At the same time, many countries seem to be diverting funds from their existing aid budgets to meet their global fund commitments; making the amount of ‘new’ money committed to the fund far less than it seems...
“Downsizing the scope and speed of the Global Fund makes sense if delegations want to shield themselves from criticism about their own stingy contributions,” says Asia Russell of the Global Access Project. “But if you are one of the 3.2 million people living with HIV who will die without access to treatment next year, it makes no sense.”
The Global Fund centralises the administration and takes planning and resources further away from communities. The emphasis of the Global Fund is on drugs, and it reinforces the approach of seeing HIV/AIDS as a medical matter rather than a social issue. Such approaches expose the fund to the criticism that drug companies and the World Bank have a disproportionate presence in their decision-making bodies, compared with representatives of people’s groups and governments of developing countries...
The transparency of the entire process of accessing, managing and disbursing Global Fund money leaves much to be desired. Positive people’s networks, community groups and non-government organisations (NGOs) have not been adequately involved in the country coordinating mechanisms...
It appears that substantial Global Fund resources are diverted to the functioning of country offices of the WHO. Global Fund also has to take into account the local political and legal situations when financing programmes. The fund, for instance, has granted a sum of US$1,000,000 for AIDS to an NGO of drug users in Thailand. But since February 2003, the Thai government has been engaged in a brutal crackdown against people suspected of smuggling and dealing in drugs. There has to be some way to ensure the human rights of people dependent on drugs.
Bitter pills
While it is reiterated that AIDS is not a death sentence, 7 million people in Asia will die well before their time if they are not immediately treated with life-saving drugs that are now available. We are talking about poor people who have very little access to health care, adequate nutrition, health insurance and are discriminated against in every sphere of their lives once their HIV status is known. HIV/AIDS-related drugs are now a commodity for which a bitter battle is waged between western pharmaceutical giants backed by their governments against the poor people of the world...
Stringent patent laws often take essential drugs beyond the reach of the poor. Drug prices add to the mounting cost of the HIV/AIDS epidemic and changes in worldwide trade-related laws could improve the situation. There was pressure on pharmaceutical companies and the US government to make some concessions at the fourth World Trade Organisation (WTO) ministerial conference in Doha, Qatar (November, 2001). Despite having made a promise to uphold the rights of countries to protect public health and promote access to medicines for all, the developing nations are now trying to restrict the proposals in a manner that will effectively sabotage the process...
The basic issue relates to how countries in need of affordable essential generic medicines will get access to them. The ‘compulsory licensing policy’ which upholds the right of poor countries to manufacture patented drugs without consent of the patent holder has one major flaw – WTO rules require countries to produce and consume medicines domestically...
Many countries are too small and too poor to be able to do this, and therefore need to access the drugs from somewhere else. This is the key issue that is currently the focal point of the battle over AIDS-related drugs. Pharmaceutical companies in countries like India are now able to manufacture these drugs at a fraction of the costs at which their western counterparts produce them. But trade barriers prevent these affordable drugs from reaching other countries...
Peoples and countries must retain the right to access drugs from sources most affordable. The patent for HIV/AIDS related drugs must be placed in the public domain, thereby enhancing the capability of governments to serve people in a sustainable manner...
Related to this issue is another problem -- even with the lower costs of manufacturers in the developing countries, many HIV-infected persons are still unable to afford them. It is here that governments of developing countries have an additional responsibility.
(Excerpted from ‘Time to Act: HIV/AIDS in Asia’, a report by ActionAid-Asia, November 2003, edited by Max Martin, Shoba Ramachandran, Mariette Correa, Unnikrishnan P V)
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