Describe and discuss who is impacted in by hivaids

Mortality peaks at 4. Regarding the impact on the civil service, it is important to note that for ages 20—54, a range that includes most public servants, mortality averages 2.

The data also show a strong sex bias, with women affected at an earlier age and suffering higher mortality overall. It shows that death-related attrition rates increased substantially between and , for example, from 0. This suggests that government employees cannot be replaced easily and that an increase in the attrition rate may be causing serious disruptions to the affected government units.

Increased attrition, in addition to its adverse impact on current government operations, has structural effects that accumulate over the years. Most important, the age composition will change, as fewer government employees survive until retirement or to any given age.

Table 7. Because absenteeism, unlike sick leave, is characterized by informal absences, whether for extended periods or only for several hours at a time, it is very difficult to measure. For instance, the Government of Malawi and UNDP estimate that absenteeism averages 65 days a year for employees with full-blown AIDS, and 15 days a year for those who are infected but have not yet developed the full symptoms.

This means that if 2 percent of public servants have full-blown AIDS, and another 20 percent take health-related absences of 15 days each, then absenteeism will amount to 2.

Grassly and others estimate that absenteeism amounts to an average of 1. With an overall HIV prevalence rate of 20 percent, this would mean a rise in absenteeism of 2. When public servants become too sick to work, they can usually request sick leave at full or reduced pay for a specified period.

In Zambia, for example, the Ministry of Agriculture, Food, and Forestry allows for a continuous absence of 90 days at full pay, and another 6 months at half pay. In Swaziland a public servant may take up to 6 months of sick leave at full pay, and another 6 months at half pay. Apart from morbidity-related absenteeism and sick leave, another primary cause of absenteeism is attendance at the funerals of those who have died of AIDS. However, these aggregate numbers are likely to understate the disruptions caused by funeral attendance.

As government employees die of AIDS and their colleagues attend the funeral, the work of the affected government agency can come to a standstill. At least in the case of informal absences and in light of existing budget constraints , it is likely that this would not translate into additional hiring, but instead into reduced productivity and reduced delivery of public services. Moreover, the problem of increased absenteeism will be compounded by an increase in vacancies if positions are not filled immediately.

Although these increased vacancies do not directly contribute to costs indeed, for a given number of positions, an increase in vacancies would reduce personnel costs , they are likely to exacerbate service disruptions. In countries with weak governance and nontransparent public records, the efficiency of the public service may also suffer if deceased government employees remain on the payroll, to the benefit of corrupt government officials or the surviving dependents.

Government employees generally enjoy some form of medical benefits, which can take the form of medical insurance, free and possibly privileged access to public health services, or discretionary funds for example, at the ministerial level. HIV prevention, care, and treatment are discussed in more detail below. Because public pension funds may cover the civil service only or parts of the private sector as well, this issue is treated in more detail below.

Government agencies often cover the funeral expenses of their employees, whether by formal or informal arrangement. The cost can be substantial. If the government also provides funeral grants for family members of its workers, the total could be substantially higher. One way is to multiply the estimated average cost of training per person by the number of new staff needed.

Another is to assess, using more aggregated data on the existing capacities and budgets of educational institutions, how much these institutions will have to expand.

In this case, if mortality among teachers increases by 2 percent, the additional training of teachers will cost an amount roughly equivalent to 0. However, for positions requiring several years of university education, the costs can be much higher. The primary advantage of the second approach is that it requires fewer data: in its simplest form, all one needs is data on attrition rates with and without AIDS.

This method can also be applied to identifying bottlenecks in the capacities of relevant training institutes. One very important factor in determining training costs, especially in health services, is brain drain.

Especially in low-income countries, recent graduates may leave the country to take higher-paid positions in other countries in the region or further abroad. To some extent this is presumably included in estimated rates of attrition, but such measures do not capture brain drain among new graduates.

If, for example, 20 percent of graduates immediately take jobs abroad, estimates of the required costs of training using the first method described above would need to be adjusted upward by 20 percent. The second method, which applies a multiplier to the total number of people actually trained, does account for this form of brain drain, provided that the rate of brain drain does not change in response to increased HIV prevalence.

One other consideration is often overlooked in analyses of the cost of training, namely, that at the national level the number of job candidates with suitable skills is limited. In the worst-affected countries in sub-Saharan Africa, there is considerable slack in the labor market for the lower educational categories.

For higher educational or skill categories, however, the labor market is much tighter, and hiring additional staff in these categories would crowd out hiring by other employers. Increased attrition rates and absenteeism for medical reasons or to attend funerals discussed above cause disruptions to work processes and thus affect the efficiency of public services.

Some of the efficiency losses—those related to sick leave, increased absenteeism for medical reasons, and funeral attendance—have already been discussed in the context of personnel costs. In a private sector context these losses would result in an increase in unit costs, which can be interpreted either as an increase in production costs to achieve a given output, or as a decline in the productivity of a given number of employees.

In the public sector these losses are most likely to result in a decline in the quality of services rather than additional hiring, for two reasons. First, almost all government employees are permanent employees, and the positions of those falling ill cannot be filled before they either die or retire.

Thus the responsibilities of an ill employee are typically taken on by someone else in an acting capacity who in turn usually must pass on some of his or her normal responsibilities or shared between colleagues in the same unit. Second, staff allocations are typically driven by a centralized annual budget process, and so there is little flexibility to hire additional staff to cover bottlenecks in particular units, especially on a temporary basis.

These efficiency losses are likely to go beyond those caused by increased absenteeism. Once a government employee dies or retires, the position cannot be filled instantaneously. Many government jobs, in particular senior positions, need to be advertised, the applications screened, and candidates interviewed.

The government agency then selects one or more candidates and makes offers, which may be rejected or may have to be negotiated. Once a candidate accepts an offer, the appointment needs to be confirmed. Especially for senior positions, the entire process can take several months or more to complete. Aggregate estimates of increased absenteeism do not reflect differences in the extent to which the workload of government employees can be reallocated temporarily during episodes of sickness.

The first group includes primarily senior government staff, who often have advanced degrees and many years of experience. When these public servants fall ill, the efficiency of the government units reporting to them can be undermined.

Government services in rural areas are particularly vulnerable because the units providing these services are generally smaller or more decentralized.

Examples include local schoolteachers and agricultural extension workers see Topouzis, In the smallest local government units such as a school with one or two teachers , it is simply impossible to cover for the sickness or death of a public servant by reallocating work to co-workers. Also, because of the distances involved, supervisors are likely to be less aware of an increase in health-related absenteeism.

The change in the age structure of government employees also has implications for the efficiency of public services. Again, senior government staff are typically drawn from a pool of public servants with many years, even decades, of experience. Increased mortality means that this pool is shrinking.

Assume, for example, that a minister has to be appointed, and that ordinarily there would be six candidates on the short list, all of them about 50 years of age. If the example from Table 7. By thinning out this stock of experience, increased mortality—in addition to disruptions caused by sickness and higher attrition—can have an accumulative effect.

To gain a sense of the implications of HIV for institutional memory, consider its impact on the number of government employees with a tenure of 10 years. Equivalently, institutional memory here measured by the number of employees remaining with the institution for 10 years declines by 22 percent.

An analysis of general health expenditure and human resources in some of the worst-affected countries follows, leading into the discussion on care and treatment. That discussion takes a broad perspective, including an assessment of the macroeconomic costs and benefits of antiretroviral treatment. The prioritization differs, however, from country to country. For example, countries with low HIV prevalence at present would be advised to place more emphasis on general prevention; in countries where the epidemic is concentrated in particular subgroups, targeted prevention programs would carry a larger weight.

Estimates of resource needs for treatment also reflect an assessment of how quickly access to treatment can be expanded in a given coun-try. Within the category of preventive activities, some measures aim at specific population groups, largely those at high risk of infection such as sex workers, men who have sex with men, prisoners, migrants, and truck drivers. In order to reach young people before HIV prevalence in their cohort rises, prevention strategies for this group should include education in the classroom at relatively low additional cost, since it is delivered through an existing service , and outreach programs for out-of school youth who are at greater risk of contracting the virus.

Workplace programs, at 4. These measures are complemented by interventions targeting the general population, such as mass media campaigns and voluntary counseling and testing. The latter is one of the more expensive components of the total response, accounting for 9. About one-third Within this category, antiretroviral therapy The remainder 6. Although the line items in Table 7. The mix can also vary according to the main transmission modes of the virus, which can differ between and within countries.

For example, achieving and maintaining high rates of coverage of antiretroviral treatment will often be possible only if prevention measures succeed at keeping the number of new infections low.

From a broad fiscal perspective, three points about Table 7. The epidemic has a devastating effect not only on the individuals affected, but also on their households and, in countries with high prevalence rates, on societies see Haacker, Chapter 2 of this volume. Improved access to treatment can mitigate these effects, but they can be avoided only if successful prevention measures bring down the number of infections. Nevertheless, even from this narrow perspective, some prevention measures are known to be highly cost-effective as discussed further below , and institutions such as UNAIDS emphasize the role of effective prevention programs as a prerequisite to successfully expanding access to treatment.

Against this background, the discussion here will focus on a few issues that are particularly relevant from a fiscal and general policy perspective. Moreover, in light of the limited capacities of providers of antiretroviral treatment, the only way to provide sustainable expanded access to treatment is by sharply reducing the incidence of HIV through expanded prevention programs UNAIDS, a. The link also runs in the opposite direction: improved access to treatment enhances prevention efforts, such as voluntary counseling and testing, by adding an incentive to get tested for HIV.

In the former, prevention measures are targeted at key populations at risk such as sex workers, injecting drug users, and men who have sex with men , to keep the epidemic from spreading through the general population. Programs targeting high-risk groups are also among the most efficient preventive interventions. For example, World Bank , on the basis of assessments of alternative measures in Guatemala, Honduras, and Panama, suggests that the most cost-effective measures include free condom distribution to high-risk groups; information, education, and communication targeting these groups; as well as some measures aimed at the more general population, such as social marketing of condoms and voluntary counseling and testing.

The Global HIV Prevention Group also stresses the control of sexually transmitted diseases, safe injections for drug users, and the prevention of mother-to-child transmission. The most comprehensive studies of the costs of prevention programs, as well as of the costs of care and treatment, are World Bank AIDS Campaign Team for Africa and Creese and others It also reports estimates of the underlying unit costs.

Creese and others synthesize the available cost estimates at the country level; in addition to unit costs, they provide estimated costs per HIV infection averted and per disability-adjusted life year saved Table 7.

The estimated costs of preventive measures per HIV infection prevented are lower in most cases, much lower than the costs of care and treatment which are discussed in more detail below per infection.

The unit costs reported range widely, reflecting, to some extent, the fact that several measures were subsumed under one heading. For example, in the case of condom distribution, different measures targeted people of different risk categories. However, much of the discrepancy related to cost differences across countries. Thus it is very difficult to make inferences regarding global resource needs from country-level studies or, vice versa, to draw conclusions regarding costs at a national level from global estimates.

Finally, the cost estimates in Table 7. The marginal effectiveness of spending on any specific prevention program would eventually decline, and the cost of an additional HIV infection averted would increase. Except in countries with very low HIV prevalence, the share of people at risk and thus the resource requirements for prevention is similar across countries, and so are the fiscal and human resource implications of expanded prevention measures.

As a consequence, spending on prevention does not raise the same type of fundamental issues regarding the management of public sector financial and human resources that expanded care and treatment do. In some regards, however, the situation and policy challenges regarding expanded prevention measures are similar to the obstacles to increased access to treatment. This applies, in particular, to the limited coverage rates of prevention measures.

In sub-Saharan Africa in , only 6 percent of people had access to voluntary counseling and treatment, and only 1 percent of pregnant women had access to treatment to prevent mother-to-child transmission Global HIV Prevention Group, Within countries, coverage of prevention is also correlated with social status as is access to treatment ; for example, fewer out-of-school youth have access to prevention programs than do youth attending school.

Enhanced prevention measures help to contain these costs. The United Kingdom and the United States are also included as comparators. These differences in spending on health services across countries mainly reflect differences in GDP per capita.

As a percentage of GDP, the range in health expenditure is much narrower, from 3. To put it another way, whereas absolute expenditure varies across the developing countries in the table by a factor of 75, expenditure as a share of GDP differs by a factor of only 2.

If the purchasing power of the dollar differs across countries, because prices for services and nontraded goods are lower in lower-income countries, health spending in dollar terms is a poor indicator of the quality of services.

First, older people generally account for a disproportionate share of health expenditure, and the age distribution of southern African countries is tilted toward the young.

Second, the official data are likely to exclude the informal sector including moonlighting physicians; see Over, Chapter 10 of this volume , which presumably is larger in low-income countries. Third, in the lowest-income countries, those individuals who can afford it may seek treatment abroad; national data would not capture these outlays. Another difficulty in interpreting the available national data on general access to health services is that health spending may be skewed toward spending in expensive hospital facilities, available only in few major cities and towns, rather than toward basic health services with universal coverage; the aggregate data do not show which of these is the case.

More generally, public health expenditure, in the absence of general access to private health insurance the case in many low-income countries , provides implicit insurance, and thus mitigates the economic risks associated with sickness. An alternative indicator of the quality of health services is the availability of skilled staff.

The best-trained health workers—physicians—are extremely scarce in the poorest countries in the region. Among the countries covered in Table 7. However, in the poorer countries a larger range of health services is provided by staff who are not formally qualified as physicians.

For example, the ratio of nurses to doctors ranges from 10 to 1 to 20 to 1 in southern African countries, whereas a ratio of 3 or 4 to 1 is more common in industrialized countries.

In addition to data on financial and human health resources, Table 7. The availability of hospital beds serves as a measure of the availability of health services at the high end. Although differences between countries on this measure are less pronounced, the quality of hospital beds, in terms of the available facilities and services, and in light of the data on health expenditure, is likely to differ substantially across countries. However, limited geographical coverage also translates into higher costs of accessing health care, which creates a barrier to access, especially for the poor.

Moreover, that demand is likely to increase more than proportionally with the spread of HIV, because it affects primarily individuals of working age, who account for a disproportionate share of health expenditure see Over, Chapter 10 of this volume.

Also, the treatment of AIDS and the opportunistic infections that accompany it tends to be more costly than that of many other common diseases see, for example, Hansen and others, In 5 of the 15 countries covered in Table 7. Especially in the worst-affected countries, hospital occupancy rates may understate the impact on health facilities, because hospitals may operate above capacity yet reported rates do not exceed percent, and because reported rates may mask a deterioration in the overall quality of health services, if hospitals respond to increased demand by rationing.

On the other hand, the numbers reported generally refer to clinical beds; in surgical and pediatric wards the share of HIV patients is lower. The indicative estimates of the numbers of AIDS patients per physician are based on the assumption that 10 percent of HIV-positive individuals seek the services of a trained physician. Although this figure is admittedly arbitrary, it is more meaningful than the simple ratio of the number of HIV-positive individuals to physicians, because many infected persons are asymptomatic and do not know they are infected.

The estimates illustrate that, in order to expand health services and treatment for HIV patients, it is crucial to overcome the existing shortages in human resources. In only two of the countries with prevalence rates over 20 percent Namibia and South Africa is the ratio of HIV patients to doctors lower than to 1. At the other extreme, it exceeds to 1 for Lesotho and Malawi. Although successful prevention programs contribute to keeping down the number of people requiring treatment, ongoing efforts to substantially expand access to treatment will also, all else equal, increase the number of patients, mostly because successful antiretroviral treatment extends life expectancy.

By highlighting the existing human resource constraints, Table 7. It was shown above, in a more general public sector context, that the implications of increased mortality for the required number of newly trained staff can be substantial. The consequences of increased mortality for the functioning of the health sector are presumably even more severe than for the public service in general, because the demand for health services is increasing sharply at the same time that supply is shrinking.

Especially in countries with very low income per capita and thus low salary levels , brain drain is another source of losses of qualified personnel.

Some of these highly skilled workers may move from one to another of the countries covered in Table 7. The discussion now turns to an assessment of the financial costs of expanding treatment. Most of the earlier literature distinguished between the treatment of opportunistic infections, on the one hand, and antiretro-viral treatment, which attacks the virus causing AIDS directly, on the other.

Antiretroviral treatment was therefore not considered a viable option for public health services in many low- and middle-income countries. However, prices of antiretroviral treatment have come down markedly in recent years partly as a result of efforts to broaden access to treatment , and this approach to treatment has therefore become a central component of national and international strategies to fight the epidemic and mitigate its impact.

Many countries have started to offer antiretroviral treatment through their public health services. Access remains limited in low- and middle-income countries, however: WHO c estimates that only , people in these countries were receiving this form of treatment as of mid Opportunistic infections occur as HIV suppresses the immune system and people living with the virus become more susceptible to infections. Various studies have estimated the costs of expanding treatment for opportunistic infections on the basis of case histories of HIV-positive patients and the unit costs of different treatments.

Creese and others synthesize the studies available at the time of their writing and provide indicators of the cost-effectiveness of various forms of treatment. Hansen and others assess the costs of treatment of HIV-positive and HIV-negative patients in hospitals and find that the costs per stay were about twice as high for the former.

Although the cost per inpatient day did not differ substantially between the two groups, HIV-positive patients stayed longer in the hospital. The most common conditions presented by HIV-positive patients were tuberculosis, pneumonia, and meningitis. If a very high proportion of hospital beds are occupied by HIV patients, in the absence of a very substantial increase in the number of beds, this means that hospitals are dealing with the increased demand for their services by rationing, admitting patients only at a later stage of HIV infection than before.

Thus the quality of health services declines as existing resources are overwhelmed by increased demand. Substantial reductions in the price of antiretroviral drugs have opened the door to greatly increased access to highly active antiretroviral therapies HAARTs : for example, the 3 by 5 initiative of the World Health Organization WHO aims to provide HAARTs to 3 million patients by The fact that IDUs made up only 8 percent of new HIV infections in versus 23 percent in — demonstrates the progress made in HIV prevention and treatment within this population.

In the United States, an estimated 3. Injection drug use, HIV, and HCV create a complicated tapestry of ailments that present a variety of challenges to healthcare providers. The newer HCV medications boceprevir and telaprevir — approved by the U. The added burden of drug addiction further complicates treatment regimens. Regional variations of HIV incidence in women have changed over time. In the early years of the epidemic, incidence in women predominated in the Northeast, but infection rates and mortality have been steadily increasing in the southern United States.

A recent study conducted by the Massachusetts Department of Public Health reported 40 percent of White women contracted HIV through injection drug use. HIV surveillance data show that the rates of new HIV infection are disproportionately highest within ethnic minority populations. African- Americans account for a higher proportion of HIV infections than any other population at all stages of the disease from initial infection to death see text box. Moreover, specific minority subgroups are at particular risk.

Globally, in , 38 African countries had a mean life expectancy of 47 years, representing 5. The burden of the disease is not felt only at individual level; it affects households, communities and the whole nation hospitalisation, healthcare, orphanhood [ 12 , 15 , 17 ]. Consequently, it is affecting business, investment, industry and agricultural sustainability, and ultimately reducing families' income and economic growth. However, many tentative estimates have been made.

The loss of labour force is indisputable, though it is not directly perceived by employers because it is essentially comprised of non-qualified workers who can easily be replaced from the large reservoir of unemployed. As stressed in the MDGs, education is essential for human development and needs to be enhanced especially in low- and medium-income countries.

More generally, during the period , orphaned children represented More globally, the disease is seen to have a threefold impact on education. It affects the cognitive ability of children, the capacity of teachers and the efficiency of staff and managers.

Kenya: Number of orphans by type. The disease is impeding development by imposing a steady decline in the key indicators of human development and hence reversing the social and economic gains that African countries are striving to attain [ 11 , 16 ]. Being at the same time a cause and consequence of poverty and underdevelopment, it constitutes a challenge to human security and human development by diminishing the chances of alleviating poverty and hunger, achieving universal primary education, promoting gender equality, reducing child and maternal mortality and ensuring environmental sustainability [ 11 , 13 , 15 , 18 ].

We are aware of the importance of the topic considered in this paper and the necessity to deal with it seriously and precisely. However, our search relied only on published data by different African countries and international institutions. Consequently, we were limited to data and the numbers available and this may be frustrating not to give a complete panorama of this interesting subject.

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