The impact of HIV/AIDS in southern Africa, which has nine of the world's most affected countries, needs to be reassessed as a "humanitarian emergency" on its own, enabling interventions to be made timeously, a leading AIDS researcher argues in a new paper.

For this to happen, Alan Whiteside, director of the Health Economics and HIV/AIDS Research Division of the University of KwaZulu-Natal, South Africa, said in the paper, co-authored by researcher Amy Whalley, the conventional understanding of a humanitarian emergency has to be rethought.

"Traditional humanitarian thinking focuses on the short term, and is often aimed at returning affected populations to 'normality'," he said in Reviewing 'Emergencies' for Swaziland: Shifting the Paradigm in a New Era.

To make the point, the authors used Swaziland, which has an HIV prevalence rate of 33.4 percent among people aged between 15 to 49 years - the world's highest, according to UNAIDS - and the world's lowest life expectancy, just 31.3 years in 2004, as noted in the UNDP's Human Development Report. The paper was commissioned by Swaziland's National Emergency Council on HIV/AIDS (NERCHA).

The region also has eight other countries with some of the world's highest prevalence rates: Botswana 24.1 percent; Lesotho 23.2 percent; Namibia 19.6 percent; South Africa 18.8 percent; Zambia 17 percent; Mozambique 16.1 percent; Zimbabwe 15.6 percent, and Malawi 14.1 percent, according to UNAIDS.

"HIV/AIDS in Swaziland has been characterised by a slow onset of impacts that have failed to command an emergency response. With insufficient resource allocation and a lack of capacity, slow onset events can become emergencies," Whiteside maintained. The situation was not very different in the region's other affected countries.

Part of the problem was that, spurred by its consistent economic growth in the 1990s, Swaziland had been classified as a "low-middle-income country" by the World Bank, and a "medium human development country" by the UN Development Programme (UNDP). This classification altered the perception of the country in donor and international eyes as a 'poor' country to that of one able to support itself, restricting potential external funding.

Whiteside has tried to establish a correlation between the ever-increasing HIV prevalence recorded by national sero-sentinel surveillance surveys - which has shot up from 3.9 percent in 1992 to 42.6 percent in 2004 and declined slightly to 39.2 percent in 2006 - and the falling social and economic indicators. "If negative trends were noticed earlier in Swaziland, some wider shocks may have been preventable".

Over the past 15 years, Swaziland has become characterised by a decline in economic growth, spreading poverty, and a rise in mortality and morbidity rates. "Current death rates now exceed the daily mortality thresholds used by agencies as an indicator of a disaster."

The number of people living below poverty line climbed from 65 percent in 1995 to 69 percent in 2001, while annual Gross Domestic Product (GDP) plunged from 6 percent in the 1990s to a current level of around 2 percent, resulting in negative per capita growth.

Whiteside said maize production had more than halved in AIDS-affected households and cited a 2004 study, A Systematic Review of the Economic Impact of HIV/AIDS on Swaziland, by F.T. Muwanga, published by the University of the Witwatersrand in Johannesburg, South Africa, showing that the average loss in GDP growth attributable to HIV/AIDS was around 1.6 percent per year.

Tardy interventions

"Had interventions happened on time, the impact of HIV/AIDS might not have been that severe," commented Derek von Wissell, director of NERCHA.

Whiteside noted that in the absence of an adequate response, Swaziland still "stands to lose the next generation of human capacity through a lack of investment in human capital, health and the continued low morale that affects workers in such contexts".

According to the paper, the UN has argued that responses require adjustment to consider a triple threat: a lethal epidemic, deepening food insecurity and a hollowing out of government capacity.

"But the point that we are trying to make," said von Wissell, "is that the response does not take into account HIV/AIDS as the root cause - and is designed as such, rather responding to the triple threat on a short-term basis - and the conditions imposed by other UN agencies such as the International Monetary Fund on funding."

Mark Stirling, the Regional Director for Eastern and Southern Africa at UNAIDS, told IRIN that in 2002 the UN system had recognised the triple threat posed by HIV/AIDS, and that this constituted an emergency. He acknowledged that the "low-middle-income" classification had prevented the country from accessing much-needed funds, saying, "There is a need to change the rules."

It was the "job of every government to protect and serve their people", he said, but not all of them had the funds to respond in time to implement effective strategies, such as universal access to antiretroviral therapy (ART). Despite the world's highest HIV prevalence rates, none of the southern African countries, including Swaziland, has achieved the goal of universal access to ART.

Regional impact

Fiona Napier, of the UK-based non-governmental organisation (NGO), Save the Children, in South Africa, pointed out that "The impact of HIV/AIDS in high-prevalence countries in southern Africa is profound. Many in government, donor and NGO communities know this, but we fail to approach HIV/AIDS with the same urgency as we approach other disasters, yet the impacts are widespread.

"A recent study Save the Children conducted found that 4 out of 10 children who had crossed borders in the southern Africa region said that the death of a family member was the main reason as to why they had left home and were seeking improved livelihoods elsewhere," she said.

Drawing comparisons from Malawi and Zambia, Whiteside and Whalley found that, as in Swaziland, HIV/AIDS was "altering the structure of society", and all three countries were experiencing falling population growth.

"This is projected to continue to fall over the next fifty years. Malawi and Zambia are both expected to experience gradual falls in population growth. Swaziland, meanwhile, has a sudden drop into negative figures over two years."

By 2025 "there is expected to be a thinning of both the older age groups and the very young [in Swaziland]; by 2050 an overall drop in population is anticipated. A recent vulnerability assessment found deaths are concentrated among 16-35 year olds. These accounted for around 45 percent of all deaths, a significant departure from the norm, where death rates remain low until people age".

According to Whiteside, the affected countries in the region are suffering from the impact of three different but related epidemics: an HIV epidemic, followed by an AIDS epidemic, which in turn leads to an impact epidemic. "As prevalence rates have now been at high levels for 10 years, impacts are being seen ... The fallout from this will be long-term, forever altering the future development paths of these countries."

Failure of HIV prevention strategies

Save the Children's Napier said it was time to acknowledge that "prevention strategies over the past 20 years have not proven successful enough to prevent the spread of HIV/AIDS in southern Africa".

"We all need to acknowledge this, and develop concerted, out-of-the-box thinking now, if we are to prevent thousands more children becoming orphaned, or having to cross borders, or resorting to other more desperate measures in order to keep food on the table and their siblings in school," she suggested.

"For a start, more resources at an international and national level need to be made available to heavily promote and offer PMTCT [Prevention of Mother to Child Transmission of HIV] at community level."

At UNAIDS Stirling said that despite the drop in HIV prevalence rates recorded in some countries in the region, he had to acknowledge that prevention strategies, particularly those targeting behavioural change, such as inconsistent use of condoms and having multiple concurrent partners, had failed.

The Swazi government itself had responded promptly to the crisis, declaring the disease a national disaster in 1999, he said. Aid workers pointed out that governance issues like the perception of the ruler, King Mswati III, "as a big spender", doling out millions for expensive cars every year, had made donors reluctant to part with their money for programmes in Swaziland.

"But donors must disassociate humanitarian issues from political and governance issues - you cannot just walk past millions dying because of that," said von Wissell, who has served as a health minister in the Swazi cabinet.

Out of the box

There was a renewed focus on impartiality and the allocation of resources on the basis of need, according to Whiteside. "While this is necessary to provide immediate assistance, it still fails to specify conditions where it will be given, and focuses on the crisis nature of emergencies instead of the nature of need."

The authors underlined the importance of assessing changes in socioeconomic indicators over time in response to the changing nature of emergencies. "A
framework assessing social and income indicators, and mixing the short-term needs of a stressed country with their long-run capacity needs, is essential".

"We are not offering any new policies or solutions; with this paper we are trying to make room for debate," said von Wissell, head of NERCHA.

Whiteside's paper harks back to a long-simmering debate in the humanitarian community on acknowledging the impact of HIV/AIDS on conventional humanitarian emergencies.

A few years ago, when Whiteside and Alex de Waal, a British writer and activist, outlined the concept of HIV-induced famine there were few takers. Unlike traditional drought-related famines, which kill dependents first, HIV-related famine affects the most 'productive' family members first.

In 2002, senior UN officials trying to respond to one of the biggest food shortages in Southern Africa, when 14.4 million people faced the threat of starvation, acknowledged that the impact of HIV/AIDS would exacerbate the famine.

"The connection between HIV/AIDS and food security has not always been recognised. The food crisis is the manifestation of a larger HIV/AIDS crisis," Urban Jonsson, then UN Children's Fund Regional Director for Eastern and Southern Africa, was quoted as saying by IRIN.

"But this time it is different," Whiteside told IRIN. "I am calling for the declaration of HIV/AIDS as a humanitarian emergency - not a global one, but in the most affected countries in Southern Africa."