by Dr. Rene Loewenson, Director, Training and Research Support Centre, Zimbabwe and Professor Alan Whiteside Director, Health Economics and HIV/AIDS Research Division, University of Natal, South Africa.
Introduction
HIV/AIDS is having a disastrous impact on the social and economic development of countries most affected by the epidemic. In much of Africa and other affected regions, this epidemic will prove to be the biggest single obstacle to reaching national poverty reduction targets and the development goals agreed on at the United Nations
Millennium Summit. The challenge is immense: How do countries reduce the proportion of people living in poverty when up to a quarter of households are decimated by AIDS? How do countries
deliver on policies aimed at equity in access to economic opportunities and social services when AIDS widens economic differentials and undermines service delivery? How do countries deliver on promises to improve quality of life for coming generations when 40 million children will grow up orphaned by AIDS? How does a country like South Africa deliver on its goal of being a regional engine of growth with over 4 million HIV-positive people and the fastest growing infection rate in the world? The devastation caused by HIV/AIDS is unique because it is depriving families, communities and entire nations of their young and most productive people. The epidemic is deepening poverty, reversing human development achievements, worsening gender inequalities, eroding the ability of governments to maintain essential services, reducing labour productivity and supply, and putting a brake on economic growth. These worsening conditions in turn make people and households even more at risk of, or vulnerable to, the epidemic, and sabotages global and national efforts to improve access to treatment and care. This cycle must be broken to ensure a sustainable solution to the HIV/AIDS crisis. The response to HIV/AIDS so far has focused, rightly so, on the challenge of containing the epidemic and preventing new infections through advocacy, information and education campaigns, behaviour change communication, condom distribution, programmes targeting groups that are particularly vulnerable to infection, and other key interventions. The other part of the response is focusing on treatment and care for people living with HIV and AIDS — efforts that are expected to intensify as new treatments become more accessible and affordable. Both prevention and treatment are top priorities in not only saving lives and reducing human suffering, but also in limiting the future impact on human development and poverty reduction efforts.

However, despite intensifying efforts focused on
prevention and care, the epidemic continues to spread unabatedly, and as people infected by HIV become ill and die, its devastating impact is now being felt in the worst affected countries. Assuming that life-prolonging treatment will not be universally available in poor countries ‘overnight’, death rates from AIDS will continue to soar before leveling off. Recent estimates from the UN Population Division show that the population of the 45 most affected countries will be 97 million smaller in 2015 than it would have been in the absence of HIV/AIDS. Most of this loss is due to sharp increases in mortality among young adults. In the absence of national and global action to mitigate the developmental impact of HIV/AIDS, households, communities and civil society organizations will continue to bear the brunt of this tragic disaster. They are at the front lines of coping with the impact of HIV/AIDS, responding directly to the needs of people and often working with little government support. Communities are mobilizing themselves, showing great resilience and solidarity, despite their vulnerability to external shocks such as premature death of their most productive members. The response to HIV/AIDS has tended to ignore the bigger picture of the implications for development and poverty reduction. Research has been undertaken to study the impact of the epidemic, but very little has been done about it. Discussions on the implications of HIV/AIDS among development experts and policy makers has been extremely limited, and both national and global development targets and goals have been formulated without taking into account the added challenges resulting from sharp increases in AIDS-related adult mortality rates. With the same inevitability as the cyclonic and heavy rains which caused catastrophic floods in Mozambique twice in the last 18 months, with widespread devastation and loss of life, the current HIV prevalence forewarns an AIDS epidemic that is only beginning in many countries. The scale and scope of this epidemic over the next decade can be broadly predicted, planned for and mitigated. However, like people living on the riverbanks, we seem unable or unwilling to take action on the flood until we are knee-deep in water. This is not helped by the denial and the chronic, slow-moving and dispersed nature of both the epidemic and its impacts. It takes significant leadership to plan ahead, sometimes ahead of public perceptions, to deal with AIDS, and in so doing to divert resources from other more apparent problems. Yet taking meaningful steps towards mitigation demands visionary leadership armed with information on the scope and nature of the epidemic, its impacts and on options for responding. Creative, albeit scattered, individual, community and national efforts provide examples of good practice. The time is overdue to apply these more widely in those areas where we must make a difference, put in place plans to achieve this, and back them with resources.

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