AIDS and Development David Everatt has prepared the following research paper for the National Department of Public Works to present at the International AIDS Conference.
Introduction and overview
The National Department of Public Works (NDPW) has commissioned a series of Community Profile surveys. The surveys, conducted by Strategy & Tactics, are based on random samples drawn within a 10km radius of projects that have been implemented on behalf of the NDPW. These are predominantly rural areas, with some peri-urban centres included as well.
The surveys cover a wide range of issues. The surveys have been conducted on a bi-monthly basis over the last six months, with surveys completed in KwaZulu-Natal, the Eastern Cape and Northern Province. This paper is drawn from the survey results from these three provinces - which are also the three poorest provinces in South Africa.
Is HIV/AIDS an issue for people?
Respondents in all the provinces were given the same list of possible social issues and asked to tell us if these were problems in their community. The table overleaf highlights two key issues: firstly, HIV/AIDS is not regarded as a critical problem in any community (although the prominent position of health may include some AIDS-related concerns). Secondly, people in different parts of South Africa - while sharing the attributes of being rural and living in deep poverty - have different perceptions of the state of the HIV/AIDS epidemic.
Just over a third (36%) of respondents in KwaZulu-Natal regard HIV/AIDS as a problem in their community, dropping to one in ten in the Eastern cape (10%) and one in thirty three (3%) in the Northern Province. This may reflect two factors:
w the high level of HIV/AIDS work that has taken place (and continues) in KwaZulu-Natal, compared with other provinces; and
w the differential state of the epidemic with its epicentre in KwaZulu-Natal, and Northern Province still on the increase in terms of full-blown AIDS and AIDS deaths.
AIDS sufferers and AIDS deaths
We asked two specific questions regarding HIV/AIDS, and both gave rise to shocking responses. Firstly, we asked whether respondents had heard of anyone suffering from AIDS in their community. Then we asked whether respondents knew of anyone who had died of AIDS in their community.
Responses are dramatically different across the three provinces. This provides different windows of opportunity. In KwaZulu-Natal, the focus should be on helping those - mainly older women - who will be largely responsible for the home-based care that is the main response to the epidemic at the stage of full-blown AIDS. Preparations must also begin now for a sudden increase in AIDS orphans (some of whom will be HIV+) in the province. Who will bring them up? Who will pay for food, clothes, schooling and so on? Will any form of assistance (financial, psychological, emotional, and so on) be available for those having to care for the children?
In the Eastern Cape, the epidemic is slowly spreading, and education and awareness raising is still important. In the Northern Province, interventions may still be able to slow the epidemic before it reaches saturation point, which appears to be the situation in KwaZulu-Natal.
In every case, the results carry a clear warning for government: what is the meaning of sustainability in the context of HIV/AIDS? Programmes such as the Community Based Public Works Programme, provide communities with clusters of assets which in turn are meant to provide socially and economically sustainable inputs to impoverished communities. But with AIDS deaths increasingly accounting for working age people, who receive most of the training needed for operation and maintenance; and with the concomitant decline in economic activity, what is the future for these community assets - and the communities themselves?
Forty-eight percent of respondents in KwaZulu-Natal said they had heard of someone with AIDS (we specified AIDS, rather than being HIV+) while 45% had not (the remainder were unsure).
In all, 49% of female respondents and 46% of male said they had heard of AIDS sufferers in their community. Younger respondents were less likely to have heard of AIDS sufferers: 42% of those aged 18 to 25 had done so, compared with 50% of those aged 56 and above.
The epidemic seems to have taken root in rural areas - 50% of rural respondents had heard of AIDS sufferers in their community, compared with 31% of urban respondents - although people with full-blown AIDS may be sent to older relatives in rural areas to take care of them. This latter point needs further investigation: if true, it will place greater stress on the already stretched rural infrastructure and household resources and thus greater stress on assets provided by government via programmes such as the CBPWP. Respondents who had heard of AIDS sufferers were unevenly spread across the three District Councils, as reflected in table two.
Respondents from Uthungulu seem to have been more exposed to AIDS sufferers than those from other District Councils. Whether this derives from exposure, knowledge or the courage to face the issue cannot be gauged from the survey data.
The second HIV/AIDS question asked whether respondents had heard of anyone who had died of AIDS in their community. Many people try to hide the HIV+ status of those infected with the virus. In addition, deaths are often attributed to the presenting disease such as TB or pneumonia. In other words, there is considerable scope for denial about HIV/AIDS. In this context it is notable that one in every two respondents (51%) told us they knew of someone who had died of AIDS in their community.
Men and women were equally likely to know of AIDS deaths in their community, but as we saw earlier, older respondents were more likely than their younger counterparts to know of AIDS deaths. Rural respondents (52%) were again more likely than their urban counterparts to know of AIDS deaths (38%). Responses also differed by District Council, following the same pattern as we saw earlier: 63% of Uthungulu respondents knew of AIDS deaths, true of 48% of Ilembe respondents and dropping to 31% of those from Ugu.
Some respondents complained about the lack of information about HIV/AIDS when discussing the main problems facing their community. There should be space for the CBPWP (and other government interventions) to include an HIV/AIDS communication component in all its phases of implementation, as well as educational work among the local people employed to work on the project.
A quarter (26%) of respondents said they had heard of AIDS sufferers in their community, and the same number (27%) said they knew of people who had died of AIDS in their community. This differed across the province.
Urban respondents (42%) were far more likely than their rural counterparts (24%) to tell us they had heard of AIDS sufferers in their communities, although few other demographic differences emerged. The same was true when respondents were asked if they knew of anyone who had died of AIDS in their community.
There is an axiom among some AIDS researchers, that denial of AIDS remains steady until AIDS deaths are so widespread that denial is itself denied by reality. This may be what is happening when we compare KwaZulu-Natal - where half of respondents knew someone who had died of HIV/AIDS - with the Eastern Cape. Has the massive focus on HIV/AIDS in KwaZulu-Natal raised awareness and consciousness, and left people unafraid of acknowledging AIDS? Has the disease has a distinct geographic profile that leaves the rural hinterlands of KwaZulu-Natal and the Eastern Cape very different (and presumably linked to transport routes, the migrant labour system and so on)? Answers to these questions must be determined, and government programmes should be re-designed accordingly.
One in ten (9%) Northern Province respondents told us they had heard of AIDS sufferers in their community, and 8% said they knew of people who had died of AIDS in their community.
Northern Province is larger, less densely populated, and with fewer truck routes (and without harbours) than either the Eastern Cape or KwaZulu-Natal, which may have impacted on the development of the epidemic. The finding signals the massive amount of work that must be done to raise the risk-assessment of AIDS among ordinary citizens in the Northern Province. It also suggests that appropriate interventions should be undertaken while the epidemic is still taking hold of the province - and before AIDS becomes as inescapably part of the social landscape as it is in KwaZulu-Natal.
Attacking and defeating poverty is a cornerstone of government policy. Rural areas comprise a key target for such programmes. However, results from these three Community Profile surveys commissioned by the Department of Public Works suggests that rural areas are already witnessing high levels of AIDS-related deaths.
However, infection rates seem uneven and the epidemic is at different stages in the rural areas of different provinces. This in turn suggests that different types of intervention are required in different provinces.
What is clear is that the rural development strategy will face its greatest challenge in incorporating HIV/AIDS into every aspect - from planning to implementation to operation and maintenance - in the HIV/AIDS epidemic.