Each day more than 10,000 people in Sub-Saharan Africa are handed what is almost surely a death sentence, and all of them will likely be dead by 2010. These people are infected with HIV/ AIDS. It is now clear that the deaths of so many adults in their most productive years will have a devastating impact not only on individual families, but also on communities and entire countries.

"The realization that we need to focus on AIDS as a development rather than just a health problem has only really come in the last year or two," says Stuart Gillespie, a research fellow at IFPRI. Although health-oriented strategies to combat HIV/AIDS have been under way since the 1980s, attempts to address the socioeconomic repercussions of illness and death on such a massive scale have only just begun.

And the repercussions are enormous. In countries with the highest rates of infection, gains in economic growth, life expectancy, and educational attainment are all being reversed. The sheer number of deaths in Africa is already causing problems for efficiency of businesses and government services. Environmental problems caused by inability to combat agricultural pests and to maintain irrigation systems could occur. The disease is contributing to rapid changes in cultural values, and those changes may alter social bonds. "The epidemic will change these societies, there's no doubt about that," says Tony Barnett, professor of development studies at the University of East Anglia, in the United Kingdom. "But those changes are unpredictable."

Indeed, researchers are still learning what the full range of effects may be. "The research is fragmentary so far," admits Hans Binswanger, the World Bank's sector director for rural development in Africa, "but the signs of what is to come are obvious."

The Scope of the Epidemic

Of the 36 million people worldwide currently infected with HIV/AIDS, 95 percent live in the developing world and 70 percent live in Sub-Saharan Africa, where infection rates in some countries are as high as 35 percent. Sub-Saharan Africa has already lost nearly 14 million to AIDS, and another 23 million will die there by 2020. According to the Worldwatch Institute, life expectancy in Botswana is expected to fall from 66 years to 33 years by 2010.

Infection rates in Asia and Latin America are currently much lower than those in Africa, but many countries there are expected to face rising infection rates and millions of AIDS deaths during the first two decades of the 21st century. It is estimated that India has the highest absolute number of infected citizens. "Even though India is 'only' at a 1 percent infection rate, things can move very fast from there. I believe India, China, and the Philippines, in particular, are at a huge risk," says Binswanger.

Greatest Risk for the Poor

HIV/AIDS takes an especially heavy toll on the poor in the developing world. Poverty and HIV/AIDS can create a vicious circle: conditions imposed by poverty increase the risk of infection, and the effects of the disease in turn exacerbate poverty. The intensification of poverty caused by the disease is not limited to the person dying of AIDS, because survivors are left to live on diminished assets and income.

Poverty increases the risk of infection in a number of ways. The poor in many countries are likely to be uneducated and illiterate, which can make it difficult to reach them with information about preventing infection. People living in poverty sometimes leave their villages to find work in cities. Separated from their spouses and unsupervised by local norms, they may engage in risky sexual behavior. Untreated sexually transmitted diseases are a recognized factor in the transmission of HIV, increasing the risk of HIV infection for women by 300 to 400 percent.

Finally, poverty can make it difficult for people to concern themselves with long-term risks. Gabriel Rugalema, a research fellow in the Group on Technology and Agrarian Development at Wageningen Agricultural University in the Netherlands, says, "Sex workers I've spoken to in Dar es Salaam, for instance, say they have to focus on feeding and educating their children in the here and now."

Cultural stigmas and lack of access to medical care combine to keep most people from being tested. Once they are infected, the disease spreads as people infect their spouses through sexual intercourse and mothers infect their children at birth or through breastfeeding. Because they do not know they are infected, individuals do not prepare themselves and their families for the financial and emotional impact of their impending illness and death.

Even when the poor know they are infected, their time is relatively limited because of the prohibitive cost of life-prolonging drugs. According to nutritionist Vivica Kraak, who led a team of Cornell University researchers in East Africa, "Malnourished people are likely to see a faster progression from HIV infection to full-blown AIDS and to die sooner of AIDS-related complications, especially when they don't have access to prophylactic and antiretroviral drugs."

AIDS Leads to Hunger

Households caring for an AIDS patient turn to a number of different coping strategies, most of which lead to less income and less food security. AIDS decreases income and agricultural production by removing from the labor force not only the sick person, but also other members of the household who must care for the patient. According to a 1999 report from the Joint United Nations Programme on HIV/AIDS (UNAIDS), families in Côte d'Ivoire, Tanzania, and Thailand who were coping with HIV/AIDS experienced a fall in income of 40 to 60 percent. Loss of income and agricultural labor in turn cause a decrease in the household's access to nutritious food. Rural families will often plant root crops because they require less labor, but such crops also offer a lower nutritional value. To raise cash to pay for health care or food, families sell food-producing assets, such as chickens or goats. When cash is lacking, households simply eat less.

The death of a major adult member does not mark the end of a family's food security problems. "In my experience in Cambodia," says Margrethe Juncker, a physician and volunteer with the Catholic organization Maryknoll, "the husband got sick first and the wife had to spend all their money to care for him. Then he dies, the mother is now also infected and has no source of income, and the kids have had to be taken out of school. It's a downward spiral." The survivors may not have the ability or energy to farm the land they retain and may not have the income to hire help, or they may lose land completely because of land tenure practices.

Says Alan Whiteside, director of the Health Economics and HIV/AIDS Research Division at the University of Natal, South Africa, "We need to look at ways to safeguard household assets, both the physical assets like the plow and the cattle, but also the human re-sources, the knowledge represented by adults. For example, Dad may know not to plant cassava in a particular corner of the field because it always floods there, but his children might not. When Dad is gone, so is that knowledge."

Food insecurity caused by AIDS can extend beyond individual households. When a large enough number of people are ill or dead because of AIDS, food production for an entire region or nation could be compromised. Vivica Kraak found evidence of this during research in East Africa in 1999. "In Uganda farmers in the region around Kampala have traditionally grown matooke [green banana] and supplied it to other regions of the country. Because of the loss of labor caused by AIDS-related illnesses and deaths, the production of matooke has fallen, and this decrease in production has affected not only people growing matooke for their own uses, but also the availability of the crop for people in other parts of the country."

Loss of labor and income can also cause survivors to abandon agricultural practices that raise yields and protect soil fertility, like fallowing and use of fertilizers.

Children Are Hardest Hit

Almost everyone agrees that the gravest long-term impact of the HIV/AIDS crisis is that on children. Even before they face the emotional loss of parents, children may have suffered from the choices their parents have had to make in response to HIV/AIDS. These choices can cause children to suffer from lack of food and parental attention, to be withdrawn from school because fees could not be paid or because their labor was needed, or to be sent away from home to live with relatives.

"The most obvious way children are affected is through orphaning," says Whiteside. "But they're really orphaned before the death of their parents. Orphaning is a series of events, with the death of the parent the culminating one. We are ending up with millions of children who are unloved, unsocialized, and uneducated."

UNAIDS estimates that by 2010 there could be as many as 42 million orphans in Sub-Saharan Africa. "Young children and adolescents are losing more than their parents," says Anita Alban, senior economist in the Policy, Strategy, and Research Department of UNAIDS. "They are losing basic life skills such as caring for one another. The norms of such children might change not only their future but the community they will have to adapt to." Because they are, by definition, years away from adulthood, caring for these children will require the commitment of long-term resources.

Mitigation Efforts Are Changing

Since HIV/AIDS was viewed exclusively as a health issue until recently, most support efforts have focused on providing medical care to the sick and dying. Now attention is being turned to aiding those left behind when AIDS victims die. In general, such mitigation efforts have been carried out by the affected communities themselves. For example, a World Bank study in Tanzania found that 90 percent of assistance to families that had lost a major adult member came from families or communities. These kinds of support strategies include community-based child care; volunteer labor to assist in increasing agricultural output and caring for HIV/ AIDS patients; and apprenticeship and training for orphaned adolescents.

Nongovernmental organizations often team with local communities to offer mitigation assistance. Small programs, like the one run by Maryknoll in Cambodia, often start with basic care of AIDS patients and move on to more extensive mitigation efforts. Juncker, for example, started an income-generating activity with patients she cared for in Maryknoll's Seedlings of Hope clinic. Income generated by making patchwork quilts earns people in the program $62 a month. "After six months, I now have 11 people sewing the quilts and more families working at home to cut donated fabric for the sewers," she says. Juncker hopes to expand the program by opening a creche so that widows with young children will have somewhere to leave their children while sewing. Similar programs throughout the developing world provide opportunities for HIV/AIDS-affected people and families to protect themselves from the worst of the poverty-exacerbating impacts of the disease.

Yet, while these programs are important, they do not reach enough of those who need help. Binswanger of the World Bank refers to them as "tiny boutiques, which do good work but only reach 1 to 2 percent of the population."

Development agencies are more likely to have the financial and organizational capital to reach more of those in need. For instance, the World Bank trains agricultural extension workers to offer advice on what crops to grow when there are fewer adults available to farm the land. The United Nations Children's Fund (UNICEF) works to improve orphan registration efforts and to promote the right of HIV/AIDS children to stay in school. However, according to Daphne Topouzis, a consultant specializing in HIV and agriculture and rural development, international agencies have focused their efforts on research. "It's very hard to generalize," she says, "but it is certain that they have done more on the research side than on practical mitigation efforts."

There are signs that this focus may be changing, among them the fact that in September 2000 the World Bank approved a multicountry HIV/AIDS program for Africa. Funds will go to projects developed by individual countries. According to the World Bank, the program "will support efforts to scale up national prevention, care, support, and treatment programs, and to prepare countries to cope with the unprecedented burdens they will face as the millions living with HIV today develop AIDS over the next decade."

Prevention Is the Ultimate Solution

No matter how widespread mitigation efforts are, the devastating impact of HIV/AIDS will continue unabated until its incidence can be drastically reduced. Since development of a vaccine appears to be at least a decade off, other methods must be found to stem the tide of infection. Some argue that aggressive education campaigns targeting those most at risk can accomplish this goal. That strategy has had significant success in Thailand. In 1990 both Thailand and South Africa had adult infection rates of less than 1 percent. In 1999 South Africa's infection rate was 20 percent; Thailand's was 2 percent.

Despite the case of Thailand, many researchers now argue that prevention strategies will have to aim at the underlying issue of poverty to be truly successful. Rugalema says, "Prevent-ing AIDS through information and messages doesn't really make sense to me. People can't eat information. Where the economy is very weak, sending information is not going to solve the problem. You have to start with rehabilitating the economy so people will have some hope for the future." Gillespie adds, "There has been too much on awareness raising and too little on the specific conditions that have to change before behavior can change."

In a way, then, successful mitigation strategies can themselves be prevention techniques because of the two-way relationship between HIV/AIDS and poverty. Desmond Cohen, former director of the HIV and Development Programme of the United Nations Development Programme, points out, for example, that children who are malnourished, lack education, and have missed out on normal processes of socialization because of the impact of HIV/AIDS on their families and societies are more likely, because of these very conditions, to become "the next cohort of the HIV infected." Improving the conditions under which these children live could prevent them from becoming infected and, ultimately, end the epidemic.

Still, even if no new infections were to occur beginning tomorrow, Africa and some areas in Asia and Latin America will be facing severe socio-economic repercussions for decades to come. Vigorous efforts are already under way by donor agencies, NGOs, and communities themselves to understand and act on the ramifications of HIV/AIDS. There are some hopeful signs that national governments and the international community are beginning to understand that increased political will and financial resources must be directed toward this epidemic. Only when that commitment is made will communities, governments, and their partners in the developing world be able to make a real impact on the disaster of HIV/AIDS.

Reported by Sara E. Wilson

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