– Joanna White
“Placing the epidemic within the context of….development issues and drawing upon the resources and
experiences of local initiatives might at first appear to step back from the urgency demanded by an epidemic; but
in fact, it is the only response” Collins and Rau, 2000, p.3.
Since the late 1980's, the presence of HIV/AIDS in sub-Saharan Africa (SSA) and its effects on adults in their prime years and their dependants has become more visible. In 1998 HIV/AIDS is
estimated to have accounted for more than 2 million deaths in the
region1 and this death rate is likely to increase substantially over the coming years. UNAIDS estimates that approximately
3.5 million new infections occurred in 2001, bringing the total number of people living with HIV/AIDS in the region to 28.5
The lion’s share of donor funding in response to the epidemic has traditionally been channelled
towards interventions on preventive and curative health and behaviour change. Less attention has been paid to the social and economic impacts of the epidemic. Efforts to prevent the
spread of HIV, the development of medical interventions which prolong the lives of people living with HIV/AIDS, and the research and testing of a possible cure for the virus are vital. However,
responses aimed at mitigating the social and economic impacts of the epidemic merit equal attention and resources. These impacts will persist long into the future, regardless of the
success of any HIV prevention messages, increased access to antiretroviral drugs, or even the development of an effective HIV vaccine.
HIV/AIDS can cause irreversible damage on local livelihood systems as labour is diverted to care for the sick and dependent, and assets are depleted to cope with the crisis. This increased pressure on household and community resources due to the impact of the epidemic is now part of everyday life in much of SSA. Aggregate impacts are also becoming more visible, such as chronic numbers of orphans (it is estimated that 41% of children in Uganda are living with their
grandparents3), the loss of key ‘prime age’ workers in every sector, and dramatic reductions in
life expectancy. The United Nations Food and Agricultural Organisation (FAO) now projects
that deaths caused by HIV/AIDS in the ten most affected African countries will reduce the
labour force by as much as 26% by the year 2020.4
The rural sector is especially vulnerable (in the words of one project manager, this is where "poverty is biting"). Communities in rural areas are not only responding to the needs of the sick
who are living amongst them, but in many cases relatives living in urban areas who are afflicted with the disease return to their native villages to be cared for. Families and communities are
often resilient and support the sick, the widowed and the orphaned by sharing resources, but these coping strategies take their toll and traditional safety networks are often placed under
Of additional concern is the 'bi-directional' relationship between HIV/AIDS and poverty, which means that the impact of the epidemic can impoverish or further impoverish people in a way
which increases their susceptibility to contracting the HIV virus. For example, young girls taken
out of school early, owing to their families no longer being able to afford school fees or the
need to replace lost labour at home, may seek to supplement household income through
transactional sex and find themselves at risk. Similarly, young people orphaned by AIDS who
experience ‘social exclusion’ in their home communities and are faced with limited access to
resources, may migrate from rural to urban areas to seek alternative livelihoods and find
themselves more exposed to the risk of contracting HIV.
Despite these known relationships between HIV/AIDS, poverty and vulnerability, the wider
impacts of the epidemic continue to receive relatively little international attention and
considerably fewer resources. Over recent years, however, as the effects of AIDS have
become transparent and unavoidable, there have been moves towards a response. The private
sector, in particular, has recognised the social and economic impacts of HIV and AIDS on staff
and, subsequently, business. Companies have adapted their policies and working practices
accordingly. In the world of international development, however, large-scale practical
responses have been slower to emerge. The reasons for this are unclear. There may be an
assumption amongst some policy-makers that social and economic impacts are being tackled
through ongoing development projects and programmes, which are sensitive and flexible
enough to respond to changing needs on the ground. Continued funding of generic
development work is therefore considered to be a response in itself. At the same time, some
donor and national ministry representatives (particularly in non-health sectors) have admitted
that they understand the problem, but are unclear as to what the most appropriate and useful
response should be. It appears that many are simply daunted by the enormity of the problem
and the scale of the resources which may be required to make a difference.
In contrast, AIDS-affected communities and non-governmental organisations (NGOs) have been at the forefront of responding to the impacts of the epidemic. Many innovative local
projects have emerged to tackle the devastating impact of HIV/AIDS on families and communities. Yet these have rarely been written up for public consumption, largely due to the
pressures upon development practitioners working at field level. In recognition of this fact, and in order to facilitate the exchange of information and the sharing of lessons which have been
learnt from experience to date, a project was initiated to bring together the experiences of development workers in mitigating the impacts of HIV/AIDS.
Following recommendations from specialists, including researchers, representatives of NGOs
and regional information networks, a number of interventions were selected for analysis.
Individuals who were involved in these interventions were invited to write up their experiences.
A list of questions (see Appendix 1) was circulated to those who agreed to participate to assist
them in focusing their analysis and producing a structured case study. An honorarium was
offered to each contributor. A total of nine case studies were collected from four different
countries: Uganda, Tanzania, Zimbabwe and Lesotho.
Regular communication with contributors took place to facilitate the write-up. Inevitably, the
final case studies vary in terms of detail, style and level of analysis. Most of the case studies
have been left close to their original form. This is to allow contributors to tell their own story and
retain some of the 'narrative voice' of the projects. In some cases, however, the editor adapted
the original case studies on the basis of follow-up interviews and e-mail discussions. The final
versions reproduced in this report were all approved by the original contributors.
Identifying appropriate projects to be written up was a slow process and took considerably
longer than planned. Although the specialists consulted during the early stages of this exercise
were unanimous in the belief that many successful responses to the impact of HIV/AIDS exist,
it was often difficult to locate these interventions, some of which are taking place at a very local
level. In several cases potential contributors were identified but were unable to participate due
to time and resource constraints. As a result, the final number of case studies is less than first
One of the aims of the exercise was to include examples of responses in both anglophone and
francophone countries in sub-Saharan Africa, in recognition of the lack of sharing of experience
between different regions. Unfortunately, despite numerous communications with regional
networks in francophone Africa, contributors could not be found.
A further aim of gathering these case studies was to identify possible 'best practice'
approaches in relation to responding to the impacts of HIV/AIDS. Our experience has shown
that effective assessment of 'best practice' will only be possible when more systematic
monitoring and evaluation systems are in place, enabling more rigorous analysis to be carried
out. This constraint has already been identified by other organisations which have attempted to
develop similar ' best practice' models.5
We very much hope that the work which is presented here will enhance understanding of the
responses to the impact of HIV/AIDS which are clearly necessary amongst all affected
communities and can be replicated both in SSA and beyond.
This report consists of two sections. Section 1 summarises and analyses the main findings
from the case studies, while Section 2 contains the case studies in full. The summary note for
each of the case studies was written by the editor. The views expressed in the case studies are
those of the project staff consulted.
- UNAIDS, 2000.
- UNAIDS, 2002/
- Ugandan Women Effort to Save Orphans, personal communication.
- FAO, 2000.
- See Grainger et al., 2001. “The process of identifying and sharing good practices will depend upon greater collaboration between agencies and more systematic monitoring and evaluation”. p.10