AIDS in the Twenty-First Century
Disease and Globalization

AIDS in the Twenty-First Century

Fully Revised and Updated Edition

'...a unique and important book. It is accessible, innovative and far-sighted. This is the most important recent book to understand the longterm consequences of AIDS in Africa.' - Peter Piot, Executive Director UNAIDS

'The foundation text for postgraduate courses on AIDS and development, AIDS and politics and so on... the best reference book for those who are - or should be - grappling with the implications of AIDS in development planning, business and public affairs.' - Alex de Waal, London Review of Books

April 2006 - Paperback - £14.99 - 1403997683 Order now

First published in 2002, AIDS in the Twenty-First Century met with widespread praise from researchers and policy makers. This edition is fully revised to take account of the latest facts and developments in the field. All statistics and evidence have been updated and their meanings reconsidered. Latest developments in vaccines, anti-retroviral treatments and microbicides are discussed along with information about the President's Emergency Plan for AIDS Relief and The Global Fund to Fight AIDS, Tuberculosis and Malaria. A revised and extended bibliography is an important resource for students and researchers, and each chapter contains key readings and websites for further research and discussion. Carefully written to be accessible, this book is theoretically informed, practical and remains the leading text in its field.

TONY BARNETT is ESRC Professorial Research Fellow at the Development Studies Institute, London School of Economics, UK, and a Co-Director of the Mackinder Centre for the Study of Long Wave Events. His other publications on this subject include AIDS in Africa: Its Present and Future Impact (with Piers Blaikie, 1992), The Effect of HIV/AIDS on Farming Systems in Eastern Africa, Economics of AIDS and Access to Care in Developing Countries (edited with Jean-Paul Moatti and others) and HIV/AIDS in Eastern Europe and the Commonwealth of Independent States: Reversing the Epidemic - Facts and Policy Options (co-author). In 2003, Tony Barnett was awarded the Lucy Mair Medal by the Royal Anthropological Institute, and in 2004 was appointed to the Advisory Committee of the UK Government's Foresight Project on the Detection and Identification of Infectious Diseases. He has provided policy advice to many UN and bilateral agencies.
To view Tony Barnett's website, please click here: www.lse.ac.uk/collections/LSEAIDS/

ALAN WHITESIDE was an Overseas Development Institute Fellow from 1980 to 1983 when he joined the University of Natal (now University of KwaZulu-Natal), South Africa. He is a Professor and Director of the Health Economics and HIV/AIDS Research Division which he established in 1998. He has numerous publications including the best selling AIDS: The Challenge for South Africa (co-author with Clem Sunter, 2000). From 2003 to 2005 he was a Commissioner for the United Nations Commission on HIV/AIDS and Governance in Africa and was a Leverhulme Visiting Professor at Southampton University, UK, and a Visiting Professor at the Liverpool School of Tropical Medicine, UK. He is a member of the International AIDS Society Governing Council.
To visit Alan Whiteside's website, please click here: www.heard.org.za/

Chapter Summaries

Part 1: Introduction

Chapter 1: Disease and Denial
A review of the latest data about the HIV/AIDS epidemic, its geographical variation and social and economic effects. This chapter argues that development must now be seen in relation to four long-wave events associated with the HIV/AIDS epidemic:
1. the wave of HIV infection
2. the wave of tuberculosis (some of it multi-drug resistant) which, because it is the most common opportunistic infection, is usually the first visible wave of the epidemic
3. the wave of AIDS illness and death
4. the wave of impact – which includes household poverty, orphaning and many other effects which will be discussed in this book.
This long-wave event, the global effects of unusual levels of illness and death will profoundly affect the lives of many individuals and many societies for decades to come.

Chapter 2: The Disease and its Epidemiology
HIV/AIDS is not the first global epidemic, and it won’t be the last: it is a disease that is changing human history and shows up global inequalities. Its presence and impacts are felt most profoundly in poor countries and communities. Here we look at its origins, how it is transmitted and the particular characteristics which make consideration of its social and economic roots and impacts necessary. Because of its scale and the international and local concern it evokes, we are confronted by quantities of information that may threaten to overwhelm us. Thus, in the last part of the chapter we look at data: what we know about AIDS and HIV, and how we know it, and how those data are used to construct particular accounts of the epidemic process.

Part 2: Susceptibility

Chapter 3: Epidemic Roots
We may think of epidemics as unusual events, moments when disease organisms cross boundaries between habituated and non-habituated populations. We should rather consider an alternative view: that epidemics have their deepest foundations in ‘normal’ social and economic life. In this chapter we review the implications of thinking about the HIV/AIDS epidemic in this way.

Related Websites:
United States Census Bureau
AVERT
Centers for Disease Control and Prevention

Chapter 4: Case Studies
While the precise routes to a risk environment may differ, the outcomes are similar. There are as many national epidemics as there are countries. It is important to know why the epidemic has spread in certain ways in some countries and not in others, and to have some idea of its future trajectory. This is the advantage of the concept of susceptibility and why understanding the plausible relationship between seroprevalence, social cohesion and wealth becomes important. Here we look at a number of different epidemics. First countries which can be characterised as societies with high social cohesion and high wealth – the UK is our case study. Second are countries providing examples of high social cohesion and low wealth – those societies with strong religious cultures or good governance or integrating ideologies: we draw on data from the Philippines , India and Senegal . Third are countries with low social cohesion and low wealth – countries experiencing civil war or economic collapse, such as Uganda in the early 1980s, or possibly the current situation in Eastern Europe . Fourth are countries with low social cohesion and high wealth; South Africa and Botswana provide examples.

Related Websites:
Human Development Reports - Eastern Europe 2004
Health Protection Agency - UK
UNAIDS

Chapter 5: Is Africa Exceptional?
At the beginning of the nineteenth century, Africa’s income levels were roughly one-third of those of Europe . Since then, the continent has fallen behind the rest of the world. This chapter examines some of the reasons why the HIV/AIDS epidemic may have developed as rapidly and to such high levels in Africa as compared with other world regions with case studies from Uganda , Tanzania , Democratic Republic of Congo and South Africa. It concludes that geographic disadvantage, political disordering, relative deprivation, inequality and poverty have all played their part.

Part 3: Vulnerability and Impact

Chapter 6: Introduction to Impact
Epidemic impacts are history-changing events. They terminate some lives, incapacitate others and stunt the capabilities of those who have to divert energy and time into care. In the end, sufficient numbers of deaths and illnesses make a society take a path other than that which it would previously have followed. This is impact. In this chapter we outline concepts for understanding impact. We note that vulnerability to impact is differential; not all societies and nations will be equally affected. The most clearly discernible impact is demographic, which is dealt with here.

Related Websites:
UNAIDS country data at: http://www.unaids.org/en/geographical+area/by+country.asp
USAID and US Department of Commerce, US Census Bureau, Global Population Profile: 2002, ( Washington DC , March 2004), available at US Census Bureau

Chapter 7: Individuals, Households and Communities
Changes in mortality and life expectancy result from the many hundreds and thousands of individual deaths. The impact of individual ill health and death depends on who the individuals are, their place in society and the resources they, their households, communities and societies have available. The great challenge for those who would assist communities, households and individuals to deal with the awful consequences of the AIDS epidemic is to face realities – to develop interventions and methods of support which recognise these realities, which can be effective at the local level, and can take full account of the forces of globalisation which will otherwise only exacerbate the already established processes of poverty and exclusion.

Related Websites:
Hitting Home: How Households Cope with the Impact of the HIV/AIDS Epidemic: A Survey of Households Affected by HIV/AIDS in South Africa
The Importance Household Surveys - interview with Dr Frikkie Booysen

Chapter 8: Dependants: Orphans and the Elderly
The HIV/AIDS epidemic has altered and will progressively alter the demographic structure of many societies. In Chapter 6 we showed how it is cutting away the middle generation of society. Population pyramids are becoming indented. This chapter focuses on two of the most affected groups. The first are the orphans and other vulnerable children created by the epidemic. The second group are the elderly, is largely ignored, but bearing the burden of care.

Related Websites:
UNICEF

UNAIDS, UNICEF and USAID, Children on the Brink 2004: A Joint Report of New Orphan Estimates and a Framework for Action, ( Washington DC , July 2004)

John Williamson, Adrienne Cox, and Beverly Johnston, Conducting a Situation Analysis of Orphans & Vulnerable Children Affected by HIV/AIDS: A Framework and Resource Guide, (U.S. Agency for International Development, Bureau for Africa Office of Sustainable Development (AFR/SD), Washington DC, February 2004),55 pages

Orphans and Other Vulnerable Children Support Toolkit: Jointly established by the International HIV/AIDS Alliance and Family Health International, this website makes available many key documents relevant to children affected by HIV/AIDS

Chapter 9: Rural Livelihoods and Agriculture
Agriculture is the cornerstone of human life. Farming feeds agricultural workers, other rural dwellers and those living and working in urban areas. In 2001, agriculture accounted for only 3.81% of value added to global domestic product, in contrast to industry’s 28.29% and the 67.9% contributed by services. However these statistics do not reflect the real importance of the agricultural sector. Without this sector there would be no industry, no services and no urban areas. We all have to eat. Seed production, plant breeding, food production, processing and marketing have been interlinked worldwide activities for thousands of years. This chapter examines the effects of HIV/AIDS on rural livelihoods and asks just how much we really know about this problem?

Related Websites:
IFPRI Conference 2005

Chapter 10: Private Sector Impact
This chapter looks at how HIV/AIDS affects large organisations using examples mainly from commerce and industry. Many principles can be applied to any large organisation, from a government ministry or department through parastatals to NGOs. Organisations survive by providing services or producing other kinds of output. Business organ¬isations aim to make a profit. We look at how AIDS is affecting these organisations. The chapter includes the methodology for doing an institutional audit.

Related Websites:
Global Business Coalition on HIV/AIDS
Global Health Initiative

Chapter 11: Development and Economic Growth
AIDS certainly has an adverse macro-economic impact. The complexity and long-term interrelated nature of these impacts is beginning to be appreciated. Government and policy makers are not, and need not be, passive in the face of the epidemic. There are things they can do but they must be imaginative and act now. Policies will need to be innovative. This chapter reviews and assesses what we know about AIDS, development and economic growth.

Related Websites:
International AIDS Economics Network
The World Bank - HIV/AIDS

Chapter 12: Government, Governance and Security
Reviews of HIV prevalence show that the worst sexually transmitted epidemics are in the ‘new’ nations of Africa and the Caribbean with Papua New Guinea an outlier; in former Soviet countries and satellites, drug-driven epidemics are spiralling out of control. Those countries in Europe, Asia and Latin America with a history of nationhood have the lowest prevalence. Although in the final chapter we argue that states and governments are becoming less powerful, especially in the global context, government is the major producer, employer and provider of social and welfare services. In such societies the impact of AIDS on government will be considerable. Yet HIV/AIDS is the major challenge to government in most poor countries. In this chapter we argue that AIDS will affect government’s ability to deliver goods and services, its efficiency and, in extreme cases, its existence.

Part 4: Responding to the Epidemic

Chapter 13: Strategies, Tactics and Timing
This chapter looks at the range of responses to the HIV/AIDS epidemic, where priorities have been and where they should have been. We argue there should be a continuum of policy and practice from prevention through care and treatment to impact mitigation. Prevention, care and treatment and impact mitigation are interlinked. Prevention responses have been inadequate and generally ineffective. While some care has been provided and this remains crucial, the idea that treatment can be provided in resource poor settings has only been accepted since 2000. In the poor world the spread of HIV continues, requiring planning for impact mitigation. There are few signs that this is happening. In this chapter we explore concepts that help understand the challenges of response and then look at key responses.

Related Websites:
Rationing antiretroviral therapy for HIV/AIDS in Africa : choices and consequences. (Public Library of Science Medicine; a peer reviewed open access journal (no place of publication) September 2005) available at: http://medicine.plosjournals.org/perlserv/? request=get-document&doi=10.1371/journal.pmed.0020303
International Aids Vaccine Inititiative (IAVI)
International Partnership for Microbicides
The World Bank - HIV/AIDS

Chapter 14: Globalization and Inequality
The implication of the HIV/AIDS epidemic is that we must examine and reflect upon the ideas of ‘health’ and ‘well-being’ critically and anew. We cannot act as though we were inhabitants of a medieval city state and exclude those who are sick and/or poor. Will we build just and cohesive societies both within and beyond national borders? Or will we continue to isolate and defend ourselves in islands of prosperity. The international system has failed to engage with the impact of HIV/AIDS. The epidemic is a long-wave event and that system and its employees and political masters are all culpable. They have not taken responsibility today for dealing with problems that will affect generations to come. In this chapter we look at how and why we should respond.

Related Websites:
HEARD
LSEAIDS

For further information please contact Clare Lawson at c.lawson@palgrave.com

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AIDS in the Twenty-First Century Disease and Globalization

AIDS in the Twenty-First Century
Disease and Globalization