Introduction/background: (approximately 400 words) 434

Speaking last December, President Jacob Zuma of South Africa compared the struggle against HIV
with the struggle against apartheid.

“At another moment in our history, in another context, the liberation movement observed
that the time comes in the life of any nation when there remain only two choices: submit
or fight,” he said. “That time has now come in our struggle to overcome AIDS.”

The challenges posed by HIV/AIDS in the modern world is a complex one which highlights
many key global health issues which both the developed world and third world countries have yet to
come to grips with. It's devastating effect can be seen with a recent warning from the World Bank
to South Africa that AIDS could cause complete economic collapse within 3 generations if the
epidemic is not controlled. At present we are losing the war against infectious disease and with
HIV infection in particular which is becoming increasingly a condition of the poor, under-educated
and under-served members of our society.

HIV is like the most invasive of all weeds, suffocating all in its path, since the conditions for its
growth and spread are so deeply rooted in the injustices facing those who are poorest, most
marginalised, and most voiceless in all our societies. These conditions and taboos are social,
economic, and political in nature, affecting the development of all of us, wherever we live. They
reach to the core of all our belief systems. If we wish to curb the spread of HIV effectively and in a
sustainable way, it follows that it is these conditions, the root causes of HIV, which need to be
challenged and changed. Without addressing the global causes, we will not only be unable to
mitigate the global effects of HIV and AIDS, we will also be unable to achieve the Millennium
Development Goals by the beginning of the 22nd century, let alone by 2015 (Hecht et al. 2006).

Clearly the benefits of globalisation are enormous, yet some of its sequelae have served to
increase not only global welfare inequalities but also serve to increase the spread of the aids
pandemic through first, the universalization of cultural practices and the compression of both time
and space leading to increased spread of the disease.

Across the world, the dominant drivers of globalisation (multinational corporations, the
multilateral institutions of global economic governance and the G8 group of powerful states)
structure not only the contours of the pandemic in terms of transmission and new infections, but
also the outcomes once an individual is sick with complications of HIV infection (Berwick et al.,
2002, Cheru, 2000, Poku, 2002a).

Background: (approximately 500 words)

•description of the breadth of the problems including a short literature review

I would struggle to purvey the breath of the problem through statistics and figures so I put forward
a piece I read by a lady called Sisonke Msimang (who is Programme Director of the Open Society
Initiative for Southern Africa (OSISA), where she also serves as the Manager of the HIV and AIDS
Programme) with a wonderful description of how the last century of globalisation has provided a
solid platform for the current AIDS crisis:
If there was a recipe for creating an AIDS epidemic in Southern Africa, it would read as follows:
‘Steal some land and subjugate its people. Take some men from rural areas and put them in hostels
far away from home, in different countries if need be. Build excellent roads. Ensure that the
communities surrounding the men are impoverished so that a ring of sex workers develops around
each mining town. Add HIV. Now take some miners and send them home for holidays to their rural,
uninfected wives. Add a few girlfriends in communities along the road home. Add liberal amounts
of patriarchy, both home-grown and of the colonial variety. Ensure that women have no right to
determine the conditions under which sex will take place. Make sure that they have no access to
credit, education, or any of the measures that would give them options to leave unhappy unions, or
dream of lives in which men are not the centre of their activities. Shake well and watch an epidemic
explode.’ There’s an optional part of the recipe, which adds an extra spice to the pot: African
countries on average spend four times more on debt servicing than they do on health. Throw in a bit
of World Bank propaganda, some loans from the IMF, and beat well. Voilà. We have icing on the
cake.
It appears from the latest UNAIDS report that the aids epidemic seems to have slowed with
a gradual decline in new HIV infections since the late 1990s, coinciding with fewer Aids related
deaths and an associated scaling up of anti-retroviral treatment in certain areas. However that I'm
afraid is where the good news ends as overall levels of infections are staggering with the disease
crippling those stricken by poverty in large areas of the continent of Africa. According to estimates
by WHO and UNAIDS, 33.4 million people were living with HIV at the end of 2008. That same
year, some 2.7 million people became newly infected, and 2.0 million died of AIDS, including 280
000 children. Two thirds of HIV infections are in sub-Saharan Africa.

About 40% of all adult women with HIV live in southern Africa. The biggest epidemics in
sub-Saharan Africa, Ethiopia, Nigeria, South Africa, Zambia and Zimbabwe, have either stabilized
or are showing signs of decline. But those epidemics had grown so large that they continue to
impose crippling burdens, especially on countries in southern and East Africa.. We can see classic
examples of gender inequity, inequity in health and the education system, discrimination against
marginalized people, and unequal resource pathways throughout the story of AIDS in Africa
These statistics from the latest UNAIDS reports highlight the health inequalities present and show
how Sub-Saharan Africa still bears an inordinate share of the Global HIV burden.

Public Health Relevance and Importance of the issue(s): (approximately 1000 words)

•Discuss why the issue, or issues, raised are of global health importance
•This section should include referenced evidence or statistics from wider reading/research around
the subject to substantiate your arguments
•Include any evidence that might question the validity of your arguments
•Provide examples of initiatives to address some of the issues highlighted

HIV and AIDS are having a major negative impact on many facets of African society. Households,
healthcare, education, productivity and economic growth and development are all caught in this
destructive cycle and will only begin to improve once Africa’s ability to cope with the epidemic
improves. The AIDS epidemic is devastating communities and years of development progress is
being lost due to the weight and pressure that the disease is putting on health systems and resources.
Future generations are being disempowered in their fight to handle the challenges life will throw at
them as their parents are dying before they have the opportunity to pass on essential life skills and
advice, further entrenching these families and communities in a mire of social and health
inequalities.

This will only be alleviated by a sustained international development effort and a

meaningful participation by all stakeholders in the global health community. The commitment and
desire to take on this battle has in a sense has already been made through the Millenium
Development Goals, and the reason why it is of global health importance to my mind is not just due
to the threat it causes to mankind due to the scale of the epidemic and our struggle to cure or contain
it, but also from a social justice perspective in that the well should take care of the sick, the rich
should take care of the poor and this is why the world must commit more strongly to this problem
crippling countries in Africa and elsewhere.

For me, an area of moral clarity is: you`re in front of someone who`s suffering and you have the
tools at your disposal to alleviate that suffering or even eradicate it, and you act.
Paul Farmer

Gender inequalities and HIV

The gendered dimension of deprivation noted earlier becomes particular significant in considering
women’s vulnerability to HIV/AIDS. Today, more women than men are dying of HIV/AIDS and
the age patterns of infection are significantly different for the two sexes (Gupta, 2000).
According to the latest (2008) WHO and UNAIDS global estimates, women comprise 50% of
people living with HIV. In sub-Saharan Africa, women constitute 60% of people living with HIV.
HIV/AIDS can signifi cantly increase maternal mortality ratios. Evidence suggests that suppressed
immunity causes higher risks of prenatal and childbirth complications including miscarriage,
anemia, postpartum hemorrhage, and puerperal sepsis, in addition to increasing the chances of
dying from indirect causes during and after pregnancy, such as malaria or pneumoniai
Gender norms can lead to men engaging in more and riskier sexual practice with multiple
partners, in addition norms related to femininity disempower women from seeking the information
or treatment they need to help or educate them, this contributes to higher infection rates among
young women. Only 38% of young women have accurate, comprehensive knowledge of
HIV/AIDS according to the 2008 UNAIDS global figures.
In addition women who are subjected to violence domestically are not only more likely to contract
HIV due to rape and unprotected sex that can be associated with violent relationships but also may
be too scared of the repercussions of checking, admitting or dealing with their HIV status
These gender related barriers, social taboos and age old traditions are massive stumbling blocks in
the treatment and prevention of HIV and AIDs in Africa. Women in these societies become
subjugated and marginalized when their contribution and equally importantly their health is needed
most

Health, Development and financing of health systems

Finding the necessary funds to address the HIV epidemic is one of the big challenges in
health and development today. This is primarily done through donations from governments
in the form of bilateral aid and contributions to the Global Fund to Fight AIDS, Tuberculosis
and Malaria (the Global Fund) and other financing channels such as UNITAID (the
international drug purchase facility). Other channels include multilateral institutions, the
private sector, and domestic spending by many affected-country governments and the
households and individuals within them.

The status quo right now is that the UN, individual donor countries and organisations have
to go through national governments in their efforts to administer aid, implement health reform and
stem the increase in the spread of HIV/AIDS. Therefore, measures to prevent HIV transmission and
to care for the infected and affected are not implemented, even if resources are put at disposal. In
addition lack of political will and of infrastructure is causing an implementation crisis.

Even in certain cases, the activities of major institutions are worsening the effects of the pandemic.
The US government’s ‘President’s Emergency Programme for AIDS Response’ (PEPFAR) is the
world’s largest single donor to HIV and AIDS programmes but only focuses on a limited number of
key priority countries, and is currently constrained by a conservative approach to HIV prevention.
This approach, based on right-wing fundamentalist Christian values, and not on a clear and widely
documented scientific evidence-base (especially in relation to prevention messages, harm reduction,
and access to condoms) has caused the disruption and collapse of many sound programmes in
PEPFAR-funded countries.

Elizabeth Pisani an epidemiologist best known for her work on HIV/AIDS, in particular for her
controversial book The Wisdom of Whores: Bureaucrats, Brothels and the Business of
AIDS[1]argues that a substantial portion of the funding devoted to HIV/AIDS is wasted on
ineffective programming, the result of science and good public health policy being trumped by
politics, ideology, and "morality." She says “ there are only two issues, really: ‘sex and Aids’ and
‘drugs and Aids’. If you don’t want to deal with those things (‘Not in my institutional mandate,
guv’) then you’d better butt out of HIV prevention” Of course, that is not what’s happening
This sums up “one of the great difficulties of public health prevention: helping unseen masses stay
disease-free is less tangible than giving medicine to people who are already suffering. Prevention
doesn’t deliver the same feel-good sense of compassion. And it provides fewer photo-opsii

Recommendations: (approximately 400 words)

•Include any recommendations you would make to address the public health issue(s)
To quote poster and UNAIDS Goodwill Ambassador Ms Annie Lennox: “HIV is a complex
issue, with many different facets that need to be addressed. Until thereis a
vaccine or a cure, the solutions are not straightforward”

Countries need to work towards eradicating the social stigma of HIV by embarking on large
scale HIV testing campaigns and making it the norm to be aware of one’s HIV status. Combined
with measures to influence decision-making through HIV prevention campaigns communicated
through the various media including social networking sites which make staying HIV-negative
easier through reinforcing HIV prevention norms (delay of sexual debut, Preventing mother-to child
transmission during delivery and breastfeeding, male circumcision, reduction in the number of
sexual partners) and ensuring the practice of safe sex through widespread availability of
contraception including empowering women to make choices for themselves through the
advocation and distribution of female condoms.
Another avenue that would certainly improve the prevention effort would be an innovative,
simplified antiretroviral program that helps HIV prevention as well as reducing the effect of the
virus on the immune system, studies have shown that people on antiretroviral therapy are less likely
to infect others when their viral load is low so treatment as a prevention straegy needs to be an
important element of any strategy . This could be achieved by making available to those that need
it and can’t afford it an easy to use pill with minimal side effects that doesn’t lead to drug resistance
whose efficacy can be easily monitored in the home making maintenance less cumbersome.
Furthermore an increased effort on the logistics and supply side would hopefully increase access
and availability of the treatment. Microbicides are another aspect of the treatment that can
potentially help in the future of prevention, particularly microbicidal contraceptives which protect
against unwanted pregnancies and HIV thus killing two birds with the one stone.
HIV prevention investments must be evidence based, cost-effective and reach those most at
risk so that all resources are utilised to their greatest effect with all efforts purely focused on
preventing, treating and educating those most likely to perpetuate the spread of this deadly virus.
If each country could analyse how it’s own HIV situation has developed through a ‘modes of
transmission’ analysis by looking at how the last 10000 infections occurred this would help prevent
unnecessary spending on programmes that might not be suitable or effective and thereby producing
a more tailored and suitable programme of HIV prevention worldwide.

The key to the use of both national and international HIV prevention funds must be long-term
sustainability . In an ideal world health sector reform should come to a tipping point at which the
local government begins to assume substantial responsibility for managing the health sector and
outcomes continues to improve. This helps ensure that health conditions will continue to improve
once external actors departiii. Training indigenous personnel is a critical aspect of sustainability.
Otherwise as Robert Wilensky argues “the programs neither reflect favourably on the host
government nor will they remain effective after withdrawal of outside forcesiv

Conclusion: (approximately 200 words)

•Summarize main points made

At the end of the day, countries being crippled by the burden that AIDS is placing on them need to
sit back and be honest and frank about what has brought about their particular situation. The
international community need to dig deep and give as much help as is humanly possible to help
these countries, however there is no doubt this help would exponentially increase if the leaders of
countries particularly in Africa were less blind to the problems and to the solutions and more honest
and transparent in their actions. Be it the sex trade, social traditions or social stigmas driving
unhealthy sexual practices, injecting drug users or the international trafficking of girls and women,
whatever is driving the spread of HIV and AIDS needs to be identified clearly and then treated and
prevented in a non –discriminatory fashion. When this occurs the opportunity for true social and
health reform will be there.

Last Submission Time & Date: 1200 hours on Friday 10th December 2010: This date has now
been changed to Friday 28th January, 2011

Ensure that when submitting, you have signed the submission record with the secretary.

N.B.: Penalties (for late submission of Course/Project Work etc.): Where work is submitted up
to and including 7 days late, 10% of the total marks available shall be deducted from the mark
achieved. Where work is submitted up to and including 14 days late, 20% of the total marks
available shall be deducted from the mark achieved. Work submitted 15 days late or more shall be
assigned a mark of zero. (Book of Modules, UCC)

If you require an extension resulting from unanticipated or extenuating circumstances, you must
discuss this with the Lecturer, Colette Cunningham, prior to the due date. Alternatives will then be
discussed. To arrange an appointment, please send an email to c.cunningham@ucc.ie

http://www.uneca.org/CHGA/doc/globilized.pdf
CHGA
Economic Commission for Africa
CHG Commission on HIV/AIDS and Governance in Africa
Globalised Inequalities and HIV/AIDS

UNICEF (2005) ‘HIV/AIDS: Adeadly crisis each day in Zimbabwe’, New

York: UNICEF, available at: www.unicef.org/aids/zimbabwe_25834.html
(last accessed September 2007).

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Caraël M, Holmes KK. Dynamics of HIV epidemics in sub-Saharan Africa: introduction. AIDS
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Ferry B, Caraël M, Buvé A et al. Study Group on Heterogeneity of HIV Epidemics in African Cities.
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In: MMorris, ed Network Epidemiology. Oxford: Oxford University Press, 2004; 58–84.
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HIV and AIDS

Edited by Alice Welbourn with Joanna Hoare
W O R K I N G I N Gender & Development
This edition © Oxfam GB 2008

ISBN 978-0-85598-603-2
i Graham W, Hussein J (2003) Measuring and estimating maternal mortality in the era of HIV/AIDS. New York: United Nations Population
Division, Department of Economic and Social Affairs. Available: http:⁄⁄www.un.org/esa/population/publications/adultmort/GRAHAM_Paper8.pdf.
ii
iii Jones et al., Securing Health Lessons from Nation Building Missions, p. 290.
iv Wilensky, Military Medicine to win Hearts and Minds, p. 132.