Avert* discusses the impact of HIV/AIDS on the health sector and on households in Africa.
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 12% of the world’s population. HIV and 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 2010 alone, an estimated 1.2 million adults and children died as a result of AIDS-related illnesses in sub-Saharan Africa; and more than 15 million Africans have died from AIDS-related illnesses. Fewer than half of Africans who need treatment are receiving it.
The impact 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. 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. Government funded research in South Africa has suggested that, on average, HIV-positive patients stay in hospital four times longer than other patients. 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 HIV and 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. 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 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. 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.
Impact on Households
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. The presence of AIDS causes many households 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 more likely to dissolve than those in which no deaths had occurred. AIDS strips families of their assets and income earners, further impoverishing the poor.
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 is also expected. 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. Children may be forced to abandon their education and in some cases women may be forced to turn to sex work. This can lead to a higher risk of HIV transmission, which further exacerbates the situation.
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.
The HIV and 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 have diminished the country’s agricultural output. It was calculated in 2006 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. 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. 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. 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.
Through its impacts on the labour force, households and enterprises, AIDS has played a significant role in the reversal of human development in Africa. The impact of HIV and 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. HIV and AIDS is a serious barrier to Africa’s development. Much wider access to HIV prevention, treatment and care services is urgently needed.