Mbn hiv/aids evaluation final report Team of consultants

The following stages will be seen in relation to an HIV/AIDS epidemic:

Stage 1:	No people with AIDS are visible to the medical services, some people are infected with HIV.
Stage 2:	A few cases are seen by medical services, more people are infected with HIV.
Stage 3:	Medical services see many people with AIDS, there is some awareness of HIV infection and AIDS among policy makers outside medical specialisms. The incidence of reported TB cases increases.
Stage 4:	Numbers of AIDS cases may threaten to overwhelm existing health services. There is widespread awareness of AIDS and of HIV infection among the general population.
Stage 5:	Unusual levels of severe illness and death in the 15-50 age group produces coping problems, orphaning, loss of key household and community members. TB is a major killer.
Stage 6:	Loss of human resources in specialised roles in production and economic and social reproduction decreases the ability of households, communities, enterprises and even districts to govern, manage and/or provision themselves effectively. These difficulties elicit various responses, which may include creative and innovative ways of coping or failure of social and economic entities. Both types of response may be observed in the same country, region, enterprise or even household.

(Source: Guidelines for preparation and execution of studies of the social and economic impact of HIV/AIDS, Tony Barnett and Alan Whiteside)
We could argue, looking at the above definitions, that India is somewhere between stage 2 and 3, while South Africa would be in stage 4. Malawi and Zimbabwe could well find themselves in stage 5 when we take into account the high number of AIDS orphans and vulnerable households in these countries, exacerbated by food shortages. The following graph depicts how the pandemic has been moving over the years from HIV to the AIDS stage and subsequently to a stage where the number of orphans will be reaching unprecedented levels.

The fact that the countries find themselves in different stages of the HIV/AIDS pandemic will also result in notable differences in programme design and implementation, both for AIDS focussed and generalist counterparts, as well as in impact of HIV/AIDS on their organisational functioning. Counterparts in Southern Africa are seriously confronted by the external and internal impact of HIV/AIDS in terms of diminishing programme results and sickness and death of their staff. The impact of HIV/AIDS on Indian counterparts is not compatible with that of Southern-Africa but will require a level of preparedness since the pandemic in India continues to grow rapidly.

UNAIDS and WHO classify HIV epidemics into low level, concentrated and generalised³. It describes HIV epidemics by their current state and was developed for identifying needs in terms of different responses.

Low level:

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  Although HIV infection may have existed for many years, it has never spread to significant levels in any sub-population.
  
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  In low level epidemics, infections are largely confined to individuals with higher risk behaviour, such as sex workers, IDU, MSM. Networks of risk are rather diffuse (with for instance low levels of partner change or low levels of sharing drug injecting equipment) or the virus has been introduced only very recently.
  
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  In numeric terms, countries with low-level epidemics are countries where the HIV prevalence has not repeatedly exceeded 5% in any defined sub-population⁴.
  

Concentrated:

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  HIV has spread extensively in a defined sub-population, but is not well established in the general population.
  
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  This epidemic phase suggests active networks of risk within the sub-population. The future course of the epidemic is determined by the frequency and nature of links between highly infected sub-populations and the general population.
  
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  In numeric terms, countries with concentrated epidemics are countries where repeatedly a HIV prevalence of more than 5% has been recorded in at least one defined sub-population, whereas the HIV prevalence is still below 1% with pregnant women in urban areas.
  

Generalised:

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  In generalised epidemics, HIV is firmly established in the general population.
  
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  Although sub-populations at high risk may continue to contribute disproportionately to the spread of HIV, sexual networking in the general population is sufficient to sustain an epidemic, independent of sub-populations at higher risk of infection.
  
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  In numeric terms, countries with generalised epidemics are countries where a HIV prevalence exceeding 1% has repeatedly been found with pregnant women.
  

In countries with low-level epidemics or concentrated epidemics interventions targeted to those with higher risk or vulnerability (e.g. sex workers or IDU) is a cost-effective use of limited prevention resources. However as epidemics become generalised, as is the case today in most of sub-Saharan Africa, HIV/AIDS strategies need to be expanded to those populations which originally were not considered at high risk (e.g. married women, children, rural households), to reach all segments of society.

The apparently low national prevalence rate of India may be dangerously deceptive as it hides severe epidemics in different sub-populations or in different geographical areas. More than 50% of IDU in parts of India were found to be HIV positive. The states in the South of India do have a generalised epidemic. In other words within one country the epidemic is evolving from a concentrated epidemic to a generalised epidemic and creating an explosive situation.

Zimbabwe, Malawi and South Africa have generalised epidemics.

It is within this exceptional context that the CFAs are operating and find themselves confronted with the negative impact of HIV/AIDS on their strategic efforts to reduce poverty, build civil society and undertake advocacy and lobbying through partnerships. It is in this light, that the CFAs developed their respective HIV/AIDS policies stipulating how they intend to address the vulnerability of the constituencies they and their counterparts work to mitigate the impact of HIV/AIDS and in the full acknowledgement that HIV/AIDS has grave and long-lasting implications for development.