Spring 2006, Volume 1
HIV/AIDS policy fails to address the reasons why sex and birth are more
risky in Africa. Malnutrition lowers immunity and increases viral load in
HIV-infected persons, making them more contagious. Malaria also increases
viral load and thus the risk of sexual and vertical HIV transmission. Schistosomiasis
increases risk of sexual transmission of HIV by lowering immune response
and by causing genital lesions and inflammation. The weaknesses
of developing economies and governance structures also interact with health
variables. Often the best investment for improving health and preventing
disease is outside the health sector. HIV prevention must go beyond last-minute
interventions, such as promoting abstinence or condom use, and address the
economic context in which risky behaviors occur.
1. Introduction
Global AIDS policy is at an impasse, and policy makers
admit privately that they have no answer to the continuing spread of HIV,
especially in Africa. For two decades, aid organizations have pursued the
same narrow policies while prevalence of HIV in the region and around the
developing world continues to climb. The sterility of global programs for
HIV prevention is exemplified by the only debate that manages to capture
media attention – whether abstinence or condoms are the solution to
this very complex biological and socio-economic problem. That debate demonstrates
what is wrong with AIDS policy – it only addresses sexual behavior.
Although sexual behavior is important, it does not explain the great variation
in HIV prevalence around the world nor is it very sensitive to policy interventions
for HIV prevention.
This work discusses why AIDS policy has failed, explains some of the fundamental,
but overlooked, causes of rapid spread of HIV/AIDS in sub-Saharan Africa,
and suggests some ways policymakers can intervene effectively to reduce
the transmission of HIV by reducing risk in the environment. Further, this
work argues that recognizing and exploiting positive externalities, or spillovers,
is necessary for achieving the Millennium Development Goals.
Section 2 describes briefly how AIDS policy was derailed by the assumption
that differences in sexual behavior adequately explain differences in prevalence
of HIV between countries. Section 3 provides some background on the biological
interactions among nutrition, tropical diseases, and HIV and suggests inexpensive
solutions that reduce the biological risk of HIV transmission during sex
and birth. Section 4 provides an example of a non-health investment that
reduces the risk of HIV spread while correcting a problem of economic development.
Section 5 concludes with an assessment of how to improve allocation of funds
for HIV prevention, emphasizing targets that are policy-sensitive1
and have positive spillovers. The article argues that achieving health goals
requires direct investment in broad health programs and complementary investment
in poverty eradication and economic development.
2. Policy Derailed
HIV-prevention policy has failed partly because it is driven by the assumption,
explicit or implicit, that differences in sexual behavior are sufficient
to explain differences in HIV prevalence between populations. Numerous social
science works and some policy documents explicitly make that case, relying
on hypothesis and anecdotal evidence to support their argument (e.g., Caldwell
et al., 1989; Ford, 1994; Rushing, 1995; UNFPA, 1999).2
Other policy documents implicitly uphold a behavioral explanation for differences
in HIV prevalence because the interventions they support for HIV prevention
are almost exclusively behavioral. The hypothesis that rates of concurrent
multi-partnered sexual activity vary widely among countries is not based
on empirical evidence and, on the contrary, is rejected by the few careful
studies of sexual behavior and HIV rates that have been conducted (Cleland
and Ferry [WHO], 1995; UNAIDS, 1999). Differences in sexual behavior cannot
explain 50-fold differences in HIV prevalence around the world. Yet global
AIDS policy relies almost entirely on behavioral interventions – abstinence
or condoms – for HIV prevention. (See Section 3 for multiple sources.)
Policymakers seem to be convinced (without evidence) that Africans are having
more sex than Americans. They do not ask why US college campuses, where
rates of chlamydia and genital herpes are as high as 30 to 40 percent (CDC,
1997, 1998; Fleming et al., 1997; Kost and Forrest, 1992; Michael et al.,
1994; Webster et al., 1993), do not also have high rates of HIV. Why did
people formulating AIDS policy forget almost everything they knew about
the requirements of disease transmission? Sex is part of it. People get
distracted by sex, and because HIV is sexually transmitted many people ignore
the fact that becoming infected with any disease, even a sexually transmitted
disease, requires the combination of pathogen, host, and environmental factors.
The distraction of sex is compounded by persistent and pervasive, although
often sub-conscious, Western notions of Africans that have had decisive
influence on the path of global AIDS policy. The behavioral paradigm depends
on an ethnographic approach that characterizes Africans as exotic, a notion
that resonates for Europeans and North Americans because of an abundant
literature of nineteenth-century racial science. European representations
of Africans as exotic specifically emphasized sexual otherness (see Dubow,
1995; Gilman, 1985, 1990, 1992; Gould, 1981; Stepan, 1982, 1990). While
legitimate scholars today reject racial science and the eugenics movement
that derived from it, the AIDS-in-Africa discourse continues to be marred
by an anthropological approach that begins from an assumption of racial
difference. That difference is found in supposed cultural origins of the
AIDS epidemic and continues to be promoted through anecdotal argument (e.g.,
Ashforth, 2002; Delius and Glaser, 2002; Forster, 2001).3
What the behavioral focus misses are the context of poverty in developing
countries and the environment of hazards that poverty creates, making sex
(and birth and medical care) more risky for poor people. The fundamental
causes of more rapid spread of HIV amidst poverty are biological and socio-economic.
Thus far, AIDS policy has relied too much on anecdotal ethnography and unproven
behavioral hypotheses and too little on biology and economics.
3. The Environment of Risk: Biological Causes and Solutions
There are biological reasons why HIV has spread more rapidly in poor populations,
especially in sub-Saharan Africa, including the effects of environmental
factors in weakening immune response. Malnutrition and parasitic illness
make people more vulnerable to any infectious disease, whether it is spread
by air, water, insects, or sex. HIV is no exception. Moreover, there are
specific mechanisms by which malnutrition and parasitic illness increase
the risk of sexual and vertical transmission of HIV. Consequently, eradicating
malnutrition and parasitic illness are central to an effective HIV-prevention
strategy, not an unrelated development goal.
Nutrition and the Immune System
Protein and energy malnutrition and deficiencies of specific micronutrients,
such as iron, zinc, and vitamins, contribute to increased susceptibility
to infectious and parasitic diseases. Moreover, infection and malnutrition
are synergistic; fever increases the demands for energy at the same time
that appetite decreases, and diarrheal diseases cause a rapid loss of nutrients
(Beisel, 1996; Scrimshaw and SanGiovanni, 1997).
Both under– and mal-nutrition weaken every component of the immune
system, and the effect of that damage is both immediate and long lasting.
Consumed proteins provide the building blocks (amino acids) for new cells
that can be used in T-cell replication/development and wound healing; vitamins
(such as B, E) have antioxidant effects that decrease the stimulus for replication
of pathogens; micronutrients (such as iron and zinc) can act as co-factors
in pathways involved in T-cell development.
Numerous studies have demonstrated the results of even moderate protein-energy
malnutrition (PEM) on the physical barriers to infection, epithelial (skin)
and mucosal protection (Woodward, 1998). The lymphatic system is also harmed,
affecting T-cell production (Beisel, 1996; Chandra, 1997). Children with
PEM, regardless of degree or type (stunting or wasting), have reduced immunity
(Chandra, 1997; Woodward, 1998). Protein consumption promotes cell replication
and so is very important in resistance to infection (Scrimshaw and SanGiovanni,
1997; Cunningham-Rundles, 1998; McMurray, 1998).
Micronutrient deficiencies also weaken various components of the immune
system, even when the deficiencies are relatively mild (Chandra, 1997).
Iron deficiency, the most widespread nutritional deficiency in the world,
is especially common in women and children and is one cause of anemia. The
World Health Organization estimates that, in sub-Saharan Africa, 41 to 60
percent of females and 28 to 60 percent of males (the range depending on
age) are anemic (Stoltzfus et al., 2004). Iron is essential in promoting
resistance to infection, through the lymphatic system, T-cell production,
and other immune-response components (Scrimshaw and SanGiovanni, 1997).
Zinc deficiency, even in mild cases, can cause a large decrease in immune
response (Beisel, 1996; Cunningham-Rundles, 1998). Zinc deficiency also
impedes wound healing, undermines skin integrity as a barrier to infection,
and weakens resistance to parasite infection, which aggravates malnutrition
(Chandra, 1997). World Health Organization estimates of the prevalence of
zinc deficiency in sub-Saharan Africa range from 37 to 62 percent, depending
on region (Caulfield and Black, 2004). That constitutes a very large population
with increased vulnerability to any infectious disease, but especially to
transmission of sexually transmitted diseases, which is aided by weakness
of the skin and mucosa.
Research over the past 30 years has confirmed the role of vitamin A as a
super-vitamin for the immune system (Semba, 1998). Vitamin-A deficiency
is very common in tropical areas because the diet of poor people often does
not include vitamin-A rich foods (Fawzi et al., 1997). Prevalence of vitamin-A
deficiency is higher in sub-Saharan Africa than in other world regions (Rice
et al., 2004). Infections increase excretion of vitamin A, producing a deadly
synergism of malnutrition, infection, and increased vitamin-A deficiency
(Stephensen et al., 1994). Even subclinical cases (that is, not apparent
upon examination and testing) of vitamin-A deficiency produce a lower immune
response and greater vulnerability to infection, particularly of the skin
and mucous membranes (Solomons, 1998). The role of vitamin A in the promotion
of physical barriers to infection (skin and mucous membranes) is especially
significant for the prevention of infection with HIV or other sexually transmitted
diseases (Semba, 1998).
Numerous studies demonstrate the role of other nutrients, including the
B vitamins, vitamin E, and selenium, in maintaining the integrity of the
immune system (Beisel, 1996; Scrimshaw and SanGiovanni, 1997; Meydani and
Beharka, 1998). Nutrients also act together to bolster the immune system.
Vitamin-A deficiency impairs iron utilization and so interacts with anemia.
Even vitamin A alone can improve iron utilization (Sommer et al., 1996).
Supplementation with vitamin A along with iron in pregnancy can virtually
eliminate anemia. Considering the low cost of supplementation with vitamin
A, its cost-effectiveness improves even more if we calculate its interaction
with iron.
Nutritional deficiencies interact with parasitic illness to make a combined
assault on immune status. Vitamin A strengthens immune response to malaria,
including its most severe form, Plasmodium falciparum, which is most widespread
in sub-Saharan Africa. Vitamin-A supplementation is an effective low-cost
strategy to reduce malarial illness in young children (Shankar et al., 1999).
Interventions that address nutritional deficiencies and parasitic infection
are important for their own sake and for HIV prevention. Malaria also causes
anemia, and the treatment of anemic children with transfusions of HIV-tainted
blood contributed to the spread of HIV in Zaire (Hedberg et al., 1993).
HIV is not a special case; it is an infectious disease that can most easily
be transmitted to a person whose immune system is weakened by malnutrition
and by the synergistic effects of other infectious and parasitic diseases.
An infected partner (or infected mother) is a necessary, but not generally
sufficient condition for sexual (or vertical) transmission of HIV to a healthy
person. Malnutrition and parasitic illness make sex and birth more risky.
In this discussion of nutrition and disease, the interactions among the
different Millennium Development Goals are clear. Goal 1, To Eradicate Extreme
Poverty and Hunger, is essential for success in pursuing Goal 4, Reducing
Child Mortality, and Goal 5, Improving Maternal Health. Improving maternal
health and reducing child mortality, of course, also contribute to the reduction
of poverty. What is also clear is that eradicating hunger and parasitic
diseases contributes significantly to reducing the spread of HIV as well.
HIV-Specific Interactions With Malnutrition and Parasitic Illness
There are also characteristics specific to HIV that make it spread more
rapidly in malnourished and parasite-burdened populations. Viral load is
the amount of virus in the blood, semen, and vaginal fluids, and it is the
best predictor of HIV transmission between HIV-infected persons and their
uninfected partners (Quinn et al., 2000). Malnutrition is associated with
higher viral load in HIV-infected persons making them more contagious as
sexual partners (Friis and Michaelsen, 1998). Anemia, the most widespread
nutritional deficiency among women in developing countries, also increases
viral shedding in the birth canal, increasing the risk of transmission from
mother to child (John et al., 1997).
Vitamin-A deficiency is also associated with higher transmission of HIV
from mother to child. In Malawi, it was observed that mothers who were severely
deficient in vitamin A had a much higher risk of transmitting HIV to their
children, perhaps due to the effect of the deficiency on the vaginal mucosa
or the integrity of the placenta (Semba et al., 1994; Nimmagadda et al.,
1998). Increased viral load in the mother and decreased maternal antibody
protection, both associated with impaired T- and B-cell production from
vitamin-A deficiency, are also probable causes of greater transmission (Landers,
1996).4
Parasites, such as malaria, schistosomes, and soil-transmitted worms, also
increase HIV viral load and the contagiousness of HIV-infected persons.
The interaction of malaria and HIV aggravates the risk environment in Africa
more than elsewhere because of the heavy burden of malaria in Africa. Over
300 million people in Africa suffer from acute malaria each year. More countries
in sub-Saharan Africa (39) than in all the rest of the world have high malaria
prevalence. Only two countries outside of sub-Saharan Africa have prevalence
exceeding 10 percent, whereas 14 African countries do. Particularly noteworthy
are Burundi (48 percent), Guinea (76 percent), Malawi (26 percent), and
Zambia (34 percent) (United Nations, Millennium Indicators Database; WHO,
http://www.afro.who.int/malaria/country-profile/index.html).
Malaria stimulates HIV replication (Xiao et al., 1998), and HIV viral loads
are significantly higher in malarial patients than in HIV-infected persons
without malaria (Whitworth et al., 2000). High viral load due to malaria
coinfection increases the risk of HIV transmission from blood exposure,
from mother to child, and through sexual contact. In Malawi, men with malaria
were found to have seven times the median viral load of HIV-infected men
without malaria (Hoffman et al., 1999). Malaria is a very serious health
problem in the developing world, especially in sub-Saharan Africa. Malaria
control is essential for reducing HIV transmission in children and adults
through its effect on viral load for HIV-infected mothers and sexual partners
(Corbett et al., 2002). Controlling malaria would also alleviate one of
the world’s most devastating health problems and help to achieve Millennium
Development Goals 4 and 5, reducing child and maternal mortality.
Schistosomiasis also plays a particularly sinister role in sub-Saharan Africa.
Schistosoma hematobium is a freshwater worm that colonizes the urinary tract.
Women washing clothes or collecting aquatic plants, fishermen, and children
and adults who bathe in streams are vulnerable. The worm migrates to the
genital tract and its eggs infect the vulva, cervix, and vagina, creating
open sores and inflammation and promoting HIV infection in the same way
that sexually transmitted diseases do (Leutscher et al., 1998; Feldmeier
er al., 2001; Mosunjac et al., 2003). At sexual maturity, the lesions become
more numerous and cluster in the cervix, which is the area most vulnerable
to HIV infection in young women (Marble and Key, 1995). The sores are an
open door for the HIV virus (Feldmeier et al., 1995). The inflammation is
the immune system’s response to the foreign bodies, the worm ova (Poggensee
et al., 2000; Mosunjac et al., 2003). That also increases risk of HIV infection
because the inflammation consists of the presence of T cells, which are
the cells through which HIV attacks. A cross-sectional study of over 500
women in Zimbabwe found that women with genital lesions due to schistosomiasis
were three times more likely to be HIV-infected than those without genital
schistosomiasis (Kjetland et al, 2006)
The prevalence of reproductive tract infections of schistosomiasis ranges
from 30 to 75 percent of women in endemic areas (Leutscher et al., 1998;
Feldmeier et al., 2001; Harms and Feldmeier, 2002; Mosunjac et al., 2003).
In Africa alone, 200 million people, men and women, are afflicted with genitourinary
schistosomiasis (Feldmeier et al., 1999), constituting a very large population
with increased susceptibility to HIV. In some regions, such as along the
shores of Lake Victoria, prevalence exceeds 40 percent of the population
(Mwanga et al., 2004).
Schistosomiasis is endemic throughout tropical Africa and parts of subtropical
Africa. In South Africa, prevalence of schistosomiasis ranges from 60 to
80 percent of schoolchildren in KwaZulu Natal. Prevalence is also high in
Mpumalanga, Gauteng, Limpopo (Northern Province), and North West Province.
KwaZulu Natal is the province with the highest estimated prevalence of HIV.
All of the other provinces with high schistosome prevalence are also the
provinces with the highest HIV, except Free State. There are certainly other
factors in some provinces, including large urban areas and mines with single-sex
barracks that influence HIV prevalence. The correlation of schistosomiasis
and HIV prevalence, while not a demonstration of causality, lends epidemiological
support to a biological mechanism by which the parasite is thought to increase
the sexual spread of HIV.
Effective, Inexpensive Solutions To Widespread Cofactors of HIV
Transmission
A malnourished, parasite-laden population gives rise to very different epidemic
dynamics from that of a healthier population, but models used by the major
AIDS organizations do not take that into consideration.5
They typically assume a one-risk-fits-all transmission probability, rather
than attempting to calculate the differential risk that applies to a population
burdened by hunger and disease. The models presume to give answers to the
questions: What are the determinants of HIV transmission and epidemic spread?
And how can we best prevent HIV transmission? But those questions cannot
be answered with models that abstract from endemic health problems. The
exclusive focus on behavioral variables leads to very narrow, stop-gap attempts
at solutions by organizations that control a large proportion of HIV program
funds. Consequently, policy prescriptions ignore that greater risk of HIV
infection per sex act or per birth that exists in much of sub-Saharan Africa
and similarly poor populations. It makes more sense, and it is easier and
cheaper, to reduce the risk of transmission during sex or birth than to
leave people malnourished and parasite-burdened and only attempt to get
them to stop having sex, protected or not.
Reducing the risk of HIV and meeting some of the Millennium Development
Goals is relatively inexpensive, especially when their interactions are
properly recognized. We already have the knowledge and the infrastructure
to alleviate many nutritional deficiencies. For most micronutrients, such
as iron and vitamin A, a year’s requirement can be delivered for the
price of one condom. Vitamin-A supplements can be provided twice yearly,
and the cost is US$0.02 per capsule (Sommer et al., 1996). Iron supplementation
costs US$0.02 per child per year if given weekly, or US$0.08, if given daily
(Stoltzfus et al., 1998).
Malaria is a difficult problem, but treatment of worms is not. Deworming
medications are safe, cheap, heat-stable, and easily administered by people
with very little training. The cost ranges from 5 to 25 US cents, depending
on the type of worm, to deliver twice-yearly treatment (Stoltzfus et al.,
1998; Montresor et al., 2001; World Bank, 2003). An important benefit of
deworming is that it has positive externalities, or spillovers. Even children
and adults who are not treated have reduced infection and better school
and work attendance because of the reduced worm concentrations in their
environment (Miguel and Kremer, 2001). Deworming has always been a good
investment. The direct role of malnutrition and parasites in aggravating
the spread of HIV highlights the necessity of reinforcing a biological and
multifaceted approach to HIV/AIDS.
HIV/AIDS is a complex epidemic, with multiple causes – biological,
social, economic, and behavioral. Malnutrition and parasitic illness do
not explain all of the variation in prevalence of HIV between populations,
but a biological understanding of HIV is an advance over the assumption
that differences in behavior adequately explain differences in rates of
HIV. What is needed is considerably more research on the interactions among
endemic conditions and considerably more spending on broad programs for
public health, clean water, adequate food and supplements, health education,
and access to health care.
This section has emphasized the need for investments in interrelated health
programs for health goals. The next section highlights the importance of
investments outside the health sector for achieving health goals. Both strategies
seek to alter the environment before risky behaviors or risky births occur.
4. The Environment of Risk: Economic Causes and Solutions
In addition to the biological cofactors that increase transmission of
HIV in sub-Saharan Africa, there are economic and social factors that directly
produce an environment of risk. When policymakers can recognize the opportunities
to intervene, there are straightforward, effective solutions to those economic
risk factors, as well. Until now, the excessive focus on sexual behavior
on the part of policy organizations has led to futile, end-game strategies
– intervening at the last possible moment with condoms or pleas for
abstinence. What are needed are policies that correct economic problems
and also reduce the risk of disease.
An economic problem of enormous importance in sub-Saharan Africa is caused
by border delays that strangle trade. Well-developed trade corridors are
essential for the flow of goods and also for the diffusion of new technology,
both of which contribute to job creation and opportunities for higher incomes
in the hinterland. Cumbersome trade regulations raise costs for trucking
companies, shippers, and consumers and discourage trade and investment.
Moving goods across borders in Southern Africa can take as long as ten days
in Zimbabwe, and up to seven days in other African countries (FHI, 2003).
In Uganda border officials do not work on Saturday or Sunday, and in some
places border posts close at four in the afternoon (Synergy Project, 2002).
Ten-day delays at a border mean: ten days of idle capital (the trucks);
ten days of wages for idle skilled and semi-skilled truckers and their assistants;
bribes to petty officials to clear paperwork; impediments to shipping perishable
goods; impediments to shipping high-value goods because of increased risk
of theft; and impediments to shipping low-value goods because of high fixed
costs of border delays.
In addition to these very considerable burdens on African economies, border
delays are mentioned repeatedly in the AIDS policy literature as contributing
to HIV transmission, particularly in sub-Saharan Africa. It is argued that
border crossings have been an important source of HIV spread along highways
because truckers find that no hotels are available or that staying with
a commercial sex worker is cheaper than staying in a hotel. The health toll
on drivers who stay with sex workers at border posts is high. Among truckers
in South Africa, 403 AIDS-related deaths for every death from other causes
were expected by 2005 (Synergy Project, 2002). A Zambian trucking company
lost 39 of its 144 drivers to AIDS in three years (Synergy Project, 2002).
To all the other costs of border delays, one must add higher health-care
costs for trucking firms for HIV-infected employees; higher training costs
to replace workers who have died from AIDS; and higher costs for the national
economies as HIV spreads along highways and into town and village populations.
An Economic Policy Solution
The diffusion of HIV/AIDS along trucking routes naturally demands
a response from AIDS-policy organizations. There is an immediate, policy-sensitive,
and obvious solution to this problem, if it is seen as an economic development
issue – eliminating intra-regional customs regulations to permit the
free flow of goods across borders. Governments in Africa that are reliant
on customs duties for revenue might be very reluctant to reduce tariffs.
If so, improving the efficiency of border crossings, without tariff reductions,
would still be a significant improvement. Both solutions would reduce costs
for shippers and trucking companies and increase trade and incentives to
local and regional production, while also eliminating a contributing cause
of the AIDS epidemic.
There are numerous historical and political obstacles to the free flow of
goods and factors of production across international borders. Although openness
is associated with growth in African countries (Sachs and Warner, 1997),
most African countries have significant trade barriers that are intended
to protect domestic industry as well as generate government revenue (Dean
et al., 1994; Sachs and Warner, 1997; Khandelwal, 2004). This is not the
place to evaluate all the arguments for and against protectionist trade
policy, however, even a limited solution, such as regional trade pacts with
a common external tariff, would probably be more beneficial than the current
arrangement. The costs of intra-regional barriers are numerous, including
the costs to the government of maintaining the system, the private costs
listed above, and the pervasive corruption and its insidious effect on good
governance, efficiency, and personal incentives. To all that we must now
add the mushrooming costs of the AIDS epidemic, which is partly fueled by
border delays.
Border regulations could be dismantled in a very short time because the
template and the technology are already available. The European Union is
an example of a region that has freed intra-regional trade from costly restrictions
but still maintains barriers to external trade. Of course, African economies
lack many of the strengths that European economies had at the time of union,
but the benefits of a common market could contribute to building stronger
economies in sub-Saharan Africa.
North America offers a model for facilitating truck transport, with computerized
systems for paperless truck logs and surveillance procedures that allow
trucks to maintain highway speeds while passing weighing stations, ports
of entry, and agricultural inspection stations (see PrePass at www.prepass.com).
The International Chamber of Commerce (ICC) also has a well developed program
for trade facilitation, including paperless customs procedures and other
border surveillance, such as agricultural and security checks (www.iccwbo.org).
There is a very valuable opportunity here for the Bill and Melinda Gates
Foundation or other funding groups to modernize trucking and trade by financing
the computerization of customs for the trade corridors in Africa, Asia,
and Latin America. Low national income is not an obstacle to trade facilitation.
India is computerizing truck checks at state borders. The intention was
probably to reduce corruption, a worthwhile goal. But the new procedures
also improve oversight and increase profits in other ways, including reduced
travel time, lowering capital and labor costs for shippers (Nachiket Doshi,
personal communication). Compared with the economic and health costs of
border delays, a $100 laptop computer and a transponder for every truck
would be a small investment.
The Myopic Behavioral Solution
This structural economic and political problem offers a disappointing example
of the failure of aid agencies to recognize policies that would reduce the
environment of risk for the spread of HIV/AIDS. USAID, the development agency
of the US government, initiated a costly program, called Corridors of Hope,
to reduce HIV transmission at border crossings. It contracted that project
to three of its private-sector partners: Family Health International (FHI),
Population Services International (PSI), and The Futures Group International
(TFGI). The primary activity of each of those organizations is behavior-change
communication and condom distribution (see institutional websites: www.fhi.org;
www.psi.org; www.tfgi.org). Their solution was, not surprisingly, behavior-change
communication and condom distribution at the borders, rather than eliminating
costly delays and the need for their services.
USAID trapped itself in a market-failure problem, a case of supplier-induced
demand, outsourcing the solution for border delays (transport logistics
and customs procedures) to organizations experienced primarily in behavior-change
communication. It did not enlist the help of the World Bank, the International
Chamber of Commerce, or the European Union, all of which have expertise
in trucking and customs facilitation, to solve an economic problem with
serious public health effects. The primary cause of the border delays is
a problem of economic development – costly trade regulation and corruption
– that falls outside the expertise of those organizations USAID contracted
and consequently is not addressed in Corridors of Hope. Behavior-change
communication is part of the answer, but it does not attack the problem
in a sustained way geared for maximum impact.
USAID chose partners with the wrong incentive structure for solving the
border problem. A ten-day delay at the border means ten days’ supply
of condoms that PSI needs to provide. The longer the wait, the more it seems
an emergency with no room for more complex ideas like structural change
in the economic, social, or bureaucratic setting. If USAID had sought the
advice of different organizations, the problem could have been addressed
to correct economic problems while preventing the spread of HIV. And the
solutions would provide incentives for the business community to cooperate
because of reduced costs.
Programs such as reforming border procedures are within the direct control
of policy makers because they only require enforcement of administrative
changes within the government. Behavior change, in contrast, is not subject
to the direct control of governments. Governments can educate and exhort,
but they cannot enforce behavior change or even find out if they have successfully
changed anyone’s behavior. The priority in strategies should always
be those over which the agency can reasonably expect to exert control and
those that have the broadest, most sustainable impact because they get to
the fundamental cause.
USAID is not alone in its reliance on the wrong organizations and the wrong
measures. All of the major organizations involved in HIV prevention –
UNAIDS, UNFPA, WHO, the World Bank, the Global Fund, the European development
aid agencies, as well as USAID and its private-sector partners – fund
almost exclusively behavior-change communication and condom distribution
(see HIV at a Glance, http://www.worldbank.org; Schwartländer et al,
2001; USAID, 2001, 2003; Global Fund Disbursements, http://www.theglobalfund.org).
Very little HIV/AIDS funding has yet gone to the development of clinics
and human capital for health promotion, although there is increasing recognition
of the necessity to develop African health sectors to combat AIDS.
Exploiting Externalities in Multi-sectoral Programs
Sometimes the best investment to solve a health problem will be outside
the health sector. There are countless ways to promote development and reduce
the risk of HIV transmission. In every sector—agriculture, industry,
commerce, government, education, and others—there are opportunities
to curtail the health crisis in Africa and other developing regions. The
modernization of trucking and trade is just one example of obvious ways
to help prevent HIV transmission while achieving other worthwhile goals.
Too often, a multi-sectoral approach to HIV prevention, or “mainstreaming,”
as it has been called, has meant taking a bite out of every ministerial
budget in order to fund HIV-prevention activities. Painting AIDS messages
on trucks and rail cars does not use the transport budget with maximum effectiveness
if trucks still sit for days at the border. Sending agricultural extension
agents to training programs to become sex counselors diminishes their impact,
unless they can also help farmers increase production and sale of their
crops to reduce malnutrition and rural poverty.
5. Conclusion
There are plenty of ways to help prevent HIV by changing the biological
and economic context in which the epidemic is spreading. They are often
inexpensive and can generate a high rate of return. Behavioral interventions
are necessary, but their effectiveness is often a matter of faith more than
documented results. So far, neither preaching abstinence nor handing out
condoms has had an appreciable impact on the epidemic because sexual behavior
is not the most important difference between high-prevalence and low-prevalence
populations.
It is not a coincidence that the countries with the highest rates of HIV
have serious environmental, economic, and bureaucratic problems. Pragmatic
solutions to those problems – from reducing border delays to parasite
control – reduce the environment of risk for HIV and are policy-sensitive.
Governments can change customs regulations or deliver safe water supplies
and multivitamins more easily than they can chase down every person having
unprotected sex. Some of the money for HIV prevention should be spent where
it has positive spillovers for productivity and development and can directly
prevent new cases of HIV.
There is also good news. The methods of eliminating parasitic illness are
already known, and the organizations already exist that are equipped to
manage eradication campaigns. Strategies for improving the efficiency of
economies and governments are already known. The template exists, and the
technical assistance could be readily available. The best news is that,
because of externalities, or positive spillovers, the whole package of investments
in good health and economic development will actually cost less than current
projections (e.g. CMH, 2001). Development and health goals are not contradictory.
On the contrary, they can only be achieved together and by recognizing and
exploiting the benefits that accrue from one to the other.
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