For a quarter of a century, an array of agents from within the public sector, scientific community, and non-profit organizations have labored individually and in concert to respond to the challenges of the HIV/AIDS epidemic. Unfortunately, reliance on these agents alone for education, prevention, and treatment intervention has not proved sufficient to stem the tide of the epidemic . As a result, increasing attention has been directed to the potential ways in which business may become involved. The Global Business Coalition on HIV/AIDS encourages companies to develop programmes to respond to HIV/AIDS. In May 2006, the Global Business Coalition on HIV/AIDS documented the programmatic activity of 75 ‘best practice’ members, and reported that large African companies and multinationals operating in Africa are leading the way in implementing workplace programmes . This is not surprising because Africa is the hardest hit region in the world, and the epidemic has potentially catastrophic implications for society and the economy. Potential drivers of business response in southern Africa include limiting the HIV burden among workforces, controlling the costs of AIDS to employers [3,4], meeting legislative requirements, and fulfilling principles of corporate social responsibility .
As the response of the private sector in southern Africa evolves, research is progressing across a number of fronts. Available data from voluntary HIV testing in the workplace among southern African firms indicate a prevalence in the range of 12–24% [6–8]. Perhaps the most extensive study of the private sector and AIDS has focused on elucidating the cost of the epidemic to employers. Through quantitative studies estimating cost in 14 large southern African companies, Rosen and colleagues [9,10] found that HIV/AIDS on average increased labor costs annually by less than 3%.
Even as companies are informed by a growing body of literature on workplace prevalence and the estimation of costs, they do not benefit from a similar body of literature for understanding the various dimensions and impact of employer-sponsored ‘HIV/AIDS workplace programmes’. Such programmes refer to a range of interventions, including the institution of a company HIV/AIDS policy, peer education, voluntary counselling and testing (VCT), and antiretroviral therapy (ART) provision. Little is known about the prevalence and operational challenges of workplace programmes. Even less is known about how best to monitor and evaluate the efficacy of such programmes in complicated environments such as the workplace or employer-sponsored offsite programmes . The existing literature consists mostly of survey studies of company executives, case studies, and qualitative research methodologies in the workplace. A few quantitative studies of ART programmes within mining firms are available. The outcomes of such studies have, however, generally been clinical and unable to illuminate the effects of ART on employee productivity and labor costs . Evidence regarding prevention programmes in the workplace is particularly limited and what is available has not been systematically examined. This paper will review and synthesize the existing information on workplace policies and programmes in southern Africa, and ascertain the common accomplishments and challenges to implementation and efficacy.
Given the paucity of peer-reviewed academic publications, information for this review was drawn from a spectrum of sources: from scientific literature to individual key informants. A review of the scientific literature was initiated with searches within PubMed, Social Sciences Citations Index, Sociologic Abstracts, and EconLit. Key word entries included ‘private sector’, ‘business’, ‘Africa’, and ‘workplace’. Reference lists of articles identified were mined for additional sources of evidence. The most recent articles available by databases were April 2006. The next level of evidence was working papers and reports of international and national organizations as well as academic institutions. Conferences and symposia with a specific focus on HIV/AIDS and the workplace were identified, and evidence from these meetings was incorporated. Numerous business case studies were also collated, and served to inform the review and analysis. Finally, a convenience sample of 17 key informants was identified, and individual interviews were conducted. A semi-structured interview technique was employed. Key informants were based in South Africa. Although key informants were non-randomly selected, a diversity of agents related to HIV/AIDS in the workplace was represented. Informants included physicians, public health scientists, trade unionists, a medical aid (health insurance) executive, parastatal executives, a lawyer, a for-profit disease management programme (DMP) consultant and academics with backgrounds in economics and industrial and labor relations.
Data that emerged from the literature and key informants were analysed to ascertain common accomplishments in and challenges to the implementation and efficacy of workplace policies and programmes. The gathering and assessment of the evidence was an iterative process, enabling the identification of potentially common challenges and returning to existing case studies and key informants for corroboration and consensus building regarding the specificity and generalizeability of each challenge.
Although not always a linear process, the evolution of existing workplace programmes in southern Africa can often be traced from the establishment of firm-level HIV/AIDS policies that guide the design and implementation of prevention and treatment programmes. National legislation and labor policies have often informed the development of firm-level HIV/AIDS policies (Fig. 1). Although evidence from most of the southern African countries is represented, the majority of available literature and data elicited from key informants relates to South Africa.
National legislation and labor policies
In South Africa, national legislation related to labor and health establish safeguards against discrimination in the workplace and institute health-related rights [12,13]. This legal apparatus applies to HIV/AIDS in the workplace, and is expected to inform firm-level HIV/AIDS workplace policies (Table 1). In most circles, this apparatus is regarded as sufficiently protective of employees . The challenges in this arena lay in adequate monitoring and enforcement of these laws, employee access to legal services as grievances arise, and the rising trend of labor ‘casualization’. Obstacles to accessing legal recourse include lack of appropriate guidance for the aggrieved worker by the company and union, stigma and threat to confidentiality in making a complaint, and an oversubscribed court system. With the passage of the Prescribed Minimum Benefit Amendment in 2005, all medical aid schemes are required to provide ART to their members. Even as the Prescribed Minimum Benefit Amendment represents a great advance for medical aid coverage, medical aid schemes often require members to register for separate ‘HIV/AIDS programmes’. This requirement limits the number of members accessing HIV/AIDS benefits because members are reluctant to disclose their status, particularly for medical schemes that are ‘in-house’, in which employers may have access to medical records .
Although the legal apparatus establishes a groundwork for companies to develop HIV/AIDS workplace policies, further guidance on operationalizing the legal provisions and developing comprehensive programmes is offered by the South African Code of Good Practice on HIV/AIDS and Key Aspects of Employment 2000  and the HIV/AIDS Technical Assistance Guidelines . The South African Department of Labour developed the code in consultation with national trade unions. The code and Technical Assistance Guidelines offer detailed ‘step-by-step’ tools for managers and unions to develop cooperatively and locally an HIV/AIDS workplace policy and prevention programmes. Unlike the aforementioned legal provisions, the code and Technical Assistance Guidelines are voluntary frameworks for action. Available analyses of the utility of the code for HIV/AIDS management service providers and company managers demonstrate uneven awareness and low levels of adoption of its provisions for the development of programmes [18,19]. The reasons for the low utilization of these tools are not known. Another instrument intended to guide the development of programmes is the Global Reporting Initiative guidelines for reporting on HIV/AIDS . These guidelines assist companies to report their HIV/AIDS policies and programmes publicly and follow their progress based on performance indicators that draw on individual firm-level quantitative and qualitative data. An analysis of company executive perceptions of the Global Reporting Initiative guidelines revealed that competition between companies may spur their participation, but the possibility of negative press, disclosure of sensitive information, and the resources required to maintain quantitative monitoring schemes may limit participation .
The common accomplishments and challenges related to legislation and labor policy are listed in Table 2.
Workplace HIV/AIDS policies
Qualitative surveys of company executives offer some indication of the prevalence of company-level HIV/AIDS policies (Table 3). The World Economic Forum sponsors an annual worldwide survey of executives relating to the business response to HIV/AIDS . In addition to guiding the development of prevention and treatment programmes, a workplace HIV/AIDS policy may also establish the norms and standards with which a company approaches employees with HIV/AIDS. Among 187 southern African firms who have a policy, 48% affirmed that their policy addresses the issue of discrimination in promotion, pay, and benefits based on HIV status. There has been a dramatic increase in policies among the southern African firm respondents over the past 3 years, from 27% in 2003 to 58% in 2005. The South African Business Coalition on HIV/AIDS (SABCOHA) sponsors another annual survey of company executives . This survey stratifies the response of firms in South Africa by the size of firm and sector of industry. In 2005, 1032 firms responded to the questionnaire, representing an overall response rate of 22%. Large firms, defined as greater than 500 employees, as well as firms from the financial services, mining, and transport sectors lead the way in implementing workplace HIV/AIDS policies . Whereas the World Economic Forum and SABCOHA surveys offer important insights, the results of those studies should be interpreted with the limitations of their design in mind. As qualitative surveys of company executives, responses are based on the perceptions of management rather than quantitative company data [22,23]. Low response rates to the survey may also indicate selection bias and an overall lack of generalizeability of the findings. Even with these limitations, such annual surveys illuminate noteworthy trends regarding policies and programmes in the workplace.
Qualitative analyses of stakeholders other than company management offer an important insight into the development and quality of policies. Semistructured interviews of HIV/AIDS service providers and union coordinators revealed that many policies were not context specific and did not necessarily reflect a given company's characteristics, resources, and capabilities . In many instances, companies did not have the human resources to develop policies independently, particularly among smaller companies. Respondents described a superficial ‘copy and paste’ approach in which companies adopted the policies of other companies indiscriminately. Negotiating benefits for HIV-positive employees, protecting HIV-positive workers from unfair discrimination, and participating in the development of policies are some of the HIV/AIDS-related roles for shop stewards set by the Congress of South African Trade Unions guidelines . In a study of 302 union shop stewards from firms representing 10 different sectors, 15% reported that their union discussed HIV/AIDS issues with the employer, 52% reported an existing HIV/AIDS workplace policy, and only 15% reported that they had received a copy of the policy .
Even as increasing numbers of companies are reporting the implementation of HIV/AIDS policies, a growing trend of diverting the company costs of AIDS to the public sector has also been recognized . This trend, known as the ‘burden shift’, refers to companies transferring the economic burden of their employees with HIV/AIDS to households and the government by conducting pre-employment screening of HIV, reducing employee benefits such as death and disability payouts, performing selective retrenchments, and outsourcing low-skilled jobs . Firms that are shifting the burden are forgoing other strategies that could potentially manage costs such as investments in workplace HIV prevention and treatment programmes. This underscores the need for workplace prevention and treatment programmes that are proved to achieve outcomes of interest to employers at reasonable costs. These outcomes include reducing the incidence of HIV infection, avoiding morbidity, and adding additional years productive working life among their employee workforce .
The common accomplishments and challenges related to HIV/AIDS workplace policy are listed in Table 2.
Workplace HIV prevention programmes
Workplace HIV prevention programmes generally refer to the following interventions singularly or in combination: HIV awareness and education activities; condom promotion; and VCT. The percentages of surveyed firms reporting such programmes are listed in Table 3. Large firms and firms from the financial and mining sectors lead the way in instituting prevention programmes [22,23].
Few monitoring and evaluation (M&E) methods for workplace prevention programmes were identified. This is perhaps not surprising given the difficulty of determining the efficacy of prevention programmes in any setting . Those firms and contracted HIV service providers that aspire to perform M&E have had trouble deciding what the best outcome measures should be besides simply the uptake of HIV testing. The few M&E plans that exist rely mostly on establishing a baseline HIV prevalence rate and following the trend in annual HIV prevalence among the workforce as a measure of the efficacy of their package of education and prevention interventions. No evidence estimating cost-savings attributable to prevention programming in the workplace was discovered. If annual prevalence rates of HIV infection are to be utilized for M&E, solutions to the persistently poor uptake of HIV testing in the workplace will be needed. Potential reasons for poor uptake have been uncovered in case studies and qualitative analyses.
One among many factors limiting the success of voluntary HIV testing is distrust of an employers' motivation to conduct testing. Fear of retrenchment, discrimination, and confusion about whether prohibition of testing by national legislation extends to voluntary testing in addition to mandatory testing contribute to distrust. Case studies of successful workplace testing campaigns identify consulting with all major stakeholders including union leaders and peer educators, distributing communication packets, and conducting briefing sessions with HIV coordinators throughout each business unit as important preparatory steps [27,28]. Additional characteristics of successful HIV testing include campaigns conducted by an independent organization, participant awareness that company management would not have access to raw data and that the study would report back in a way that eliminated the possibility of disclosure based on any smaller demographic grouping variable . In one campaign, HIV testing was linked with a knowledge, attitude and practice intervention, which led to subsequently high rates of participation in VCT (82% requesting a test) .
In addition to employer distrust, an often cited barrier to the uptake of HIV prevention programmes is the perception of stigmatization by co-workers [29,30]. Countering stigma has been one of the objectives of workplace peer education programmes. Peer educators are credited with being one of the main forces behind HIV/AIDS education, awareness and behavioral training programmes in the workplace. In a comprehensive study of five large South African companies representing a combined workforce of more than 120 000 employees, Dickinson  described the specific ways in which peer educators provide education in the workplace. The potential contribution of peer education programmes to enabling improved HIV prevention in the workplace has been championed by many stakeholders, including management and national union officials. Only one analysis of the efficacy of peer education in achieving education and prevention objectives was, however, discovered in this review . HIV-related knowledge, attitude and practice among employees exposed to HIV/AIDS peer education was compared with employees at another company who were not exposed. Exposure did not have a significant impact on knowledge, attitude and practice . Factors affecting the overall quality of peer education programmes in the workplace may also determine whether this type of intervention is effective. These factors include the quality of training of peer educators, sufficient time allotment for education sessions, and adequate buy-in from local union officials and line managers . Even though a large percentage of peer educators are members of unions, peer educators report low levels of support from unions. Although extensive goals for union involvement in the workplace are set at the national level, at the shop level union officials are unwilling to respond to HIV/AIDS because of stigma and poor human resource capacities [18,25].
The provision of VCT is an integral component of a comprehensive workplace HIV/AIDS response. VCT represents the primary access for employees to HIV education and risk behavioral modification as well as to care and treatment programmes once a diagnosis is made. Poor participation rates in VCT have undermined the effectiveness of many HIV/AIDS policies in southern Africa. In addition to the distrust of employers and fear of stigma, other factors identified as barriers to uptake in the workplace relate to the poor overall quality of VCT services. Provision of counselling in English as opposed to the native language , poor counselling skills of the VCT provider, long queues, and compromised privacy of the room in which VCT was performed were associated with reduced uptake . One key informant recommended the formalization of the VCT provider industry in the form of an association of VCT vendors with an established set of standards and guidelines. This would assist companies in contracting high quality VCT services. Another interviewee emphasized ‘push’ and ‘pull’ factors for improving uptake. An example of a push factor would be requiring line managers to allot sufficient time for employees to attend educational and VCT sessions. An example of a pull factor would be offering a raffle prize for VCT participants. Other factors associated with improved uptake include personal or professional interaction with an individual living with HIV/AIDS and having the choice to undergo VCT at the workplace or an offsite location [29,30]. In a study randomly assigning small and medium-sized companies in Zimbabwe to either on-site rapid HIV testing or vouchers for off-site VCT at a chain of freestanding centers, the mean uptake of workplace VCT by site was 51.1% compared with 19.2% mean uptake of offsite VCT over 2 years .
For certain business sectors that rely on migrant labor, structural conditions at workplaces are exacerbating the spread of HIV/AIDS. Long separations from family and partners while residing in single-sex hostels, the easy availability of commercial sex workers (CSW), poor working conditions, and the unavailability of healthy recreational alternatives contribute to risky sexual behavior. This has been documented among workers of large mining corporations in South Africa. In a study of migrant men recruited at their workplaces in KwaZulu/Natal and Guateng Provinces in South Africa compared with non-migrant men from their home rural districts, the prevalence of HIV among migrants was significantly higher than among the non-migrants (25.9 versus 12.7%; P = 0.03) . In that study, migrants were more likely to have casual sex partners, and almost all of those worked in mines and were long-distance migrants living in single-sex hostels . In another study of female CSW living near to single-sex hostels of mineworkers, 68.6% of sex workers and 28.6% of mineworkers were HIV positive, and mineworkers had high rates of on-going casual partnerships without condom use as well as the consumption of alcohol . Although a few companies report initiatives to alleviate some of the structural conditions of migrancy that contribute to HIV risk, almost no objective documentation quantifying and evaluating these initiatives was found in this review. One available evaluation of a community-based HIV prevention intervention that included peer education among CSW and mineworkers as well as the syndromic management of sexually transmitted infection training revealed an increase in HIV knowledge and positive behavior change but also an increase in the prevalence of curable sexually transmitted infections over a 2-year period . In another study , a modelling analysis estimating the impact of establishing family housing in South African mining communities found a net reduction in the annual risk of HIV infection, if the proportion of HIV-negative concordant couples was greater than 22%. A further examination of company-initiated workplace and community-based interventions addressing the structural conditions of migrant work is needed.
As a result of limited financial and human resources capacities among other factors, small and medium enterprises (SME) have largely not responded to HIV/AIDS. Few SME managers expect HIV/AIDS to have a major impact on their companies, and HIV ranked ninth out of 10 major business concerns faced by SME . A major effort to increase HIV workplace interventions in SME involves large firms encouraging their smaller suppliers to act. In South Africa, large firms such as Eskom have purchased the SABCOHA-developed Workplace HIV/AIDS Toolkit  for their supply-chain firms. The Toolkit is designed as a step-by-step guide for SME to formulate and implement workplace HIV/AIDS programmes.
The common accomplishments and challenges related to workplace prevention programmes are listed in Table 2.
Workplace care and treatment programmes
This category of workplace programmes refers to the care and treatment of opportunistic infections as well as the provision of antiretroviral drugs. Workplace treatment programmes represent an alternative to the oversubscribed public sector ART rollout programme, and may enable employers to reduce their overall labor costs . Costing data is, however, difficult to estimate because workplace ART programmes have been undersubscribed, and the expected returns of investment have not yet been realized . The percentages of surveyed firms reporting ART programmes are listed in Table 3. Fifty per cent or less of all firms surveyed provide antiretroviral drugs [22,23,41].
An evaluation of workplace care and treatment programmes should be carried out through the lens of the service provider model. Analyses of large firms in South Africa have revealed three dominant models: (i) employer-provided; (ii) medical aid scheme; and (iii) independent disease management programmes [40,41]. In the employer-provided model, an employer internally finances and delivers treatment for HIV-positive employees through a ‘closed’ medical aid scheme, company clinic, or both . Given the relative ease of data collection and follow-up, the majority of available analyses are based on programmes implemented within the employer-provided model. In a medical aid scheme model, employers subsidize medical aid scheme premiums for employees who choose to make the co-payments . Membership in medical aid is optional. In South Africa, partly as a result of the high costs of medical aid premiums and co-payments, only approximately 7 million of the total 45 million individuals are members of medical aid. HIV/AIDS services such as VCT and treatment rendered by medical aid thus often capture a higher income population. In addition, it is more difficult to monitor and evaluate off-site VCT programmes. In the independent DMP model, a specialized HIV/AIDS disease management company is contracted by an employer to manage the costs and treatment of HIV-positive employees, independent of whatever medical aid scheme may be available . Although the use of independent DMP is a growing trend in South Africa, little is known about the efficacy and quality of their programmes because their data have been deliberately kept out of the public domain .
The best available data on the efficacy of ART programmes exist among treatment provided by employer-provided models. Employees on ART within this model have had comparable responses in CD4 cell counts and viral loads to public sector ART programmes. Specific operational challenges related to the workplace have, however, resulted in lower enrollment in ART programmes than the HIV prevalence levels in these workplaces would dictate [40,41]. These challenges include poor VCT uptake in the workplace, unwillingness to start ART in an employer-provided programme as a result of concerns about confidentiality, and a potentially greater propensity to missing follow-up appointments because of heightened concern about fellow workers inferring HIV status . In a survey of workers at a single mining site, only 20% of the employees on antiretroviral drugs disclosed their status to a fellow employee . Another challenge relates to transitioning workers who start ART in an occupational clinic to the public sector if they choose to discontinue working. The exclusion of employee partners from employer-provided workplace ART programmes may also contribute to the low uptake of programmes .
With the Prescribed Minimum Benefit Amendment, the medical aid scheme model of ART provision has become a significant opportunity to ramp up employer-initiated treatment on a wide scale. Although access to medical aid is limited by the high costs of co-payment premiums, large companies such as Eskom and BHP Billiton have managed to treat significant percentages of employees through medical aid . Other challenges include the linking of VCT programmes with enrollment in the medical aid-sponsored HIV/AIDS DMP or network of general practitioners, and standardizing the collection of data and provision of ART treatment within the network of general practitioner offices.
The common accomplishments and challenges related to workplace treatment programmes are listed in Table 2.
Limitations and conclusions
A significant limitation of this review is the undeveloped and nascent state of the literature on workplace programmes. There is a paucity of peer-reviewed publications, and the few academic papers available are mostly based on qualitative research methodologies. In addition, much of the formal research has focused on company responses in South Africa and among selected sectors. Along with the use of a convenience rather than random sample of key informants, the sum of the evidence included in this review and analysis may be of limited generalizeability. Even before considering generalizeability, however, the potential unreliability of the findings here should be acknowledged. As a result of the dearth of peer-reviewed publications, a large proportion of the materials reviewed for this analysis are based on company self-report. Given legislative requirements and pressure from civil society, companies may have an inherent interest in overestimating the prevalence and effectiveness of their HIV workplace programmes. Research conducted by parties external to companies, business coalitions, and DMP consultants represent the most reliable and least biased source for evaluating the private sector response to HIV/AIDS in the workplace. Unfortunately, numerous barriers to obtaining useful and unbiased data from the private sector have limited such research efforts. Because of the risk of disclosing sensitive trade information unrelated to their HIV workplace programmes, companies are often unwilling to open their operations up to third-party researchers. Companies also fear negative press in the civil society and business spheres that may result from public scrutiny of the HIV/AIDS problem in their workforce. Other barriers to conducting reliable analyses and obtaining useful data on workplace programmes include insufficient administrative and human resources infrastructure and limited financial resources dedicated to monitoring and evaluating existing programmes by companies. Even with these constraints, those independent DMP that have developed ways to monitor and evaluate workplace programmes are unwilling to share their methodologies and findings with third-party researchers because of the proprietary nature of this information as well as commitments to maintaining the confidentiality of their clients.
This review has revealed numerous challenges to implementing, investigating, and evaluating HIV workplace policies and programmes in southern Africa. The existing white and grey literature indicates a wide variation in workplace policies and programmes currently in place in southern Africa. Whereas some progress has been made at the legal and policy levels nationally, the widespread enforcement and implementation of these measures at the firm level has not occurred. Programmatic interventions at the firm level, including workplace HIV/AIDS policies, prevention, and treatment are even more difficult to assess given the current state of the literature. In addition to addressing firm-level operational challenges to implementing workplace programmes, strategies to monitor and evaluate the effectiveness of programmes that account for private sector confidentiality and proprietary concerns are urgently needed. The collaboration of a variety of stakeholders in civil society, academia, labor, and the private sector may enable the development of a useful and feasible research agenda.
The authors thank Thomas Coates, Greg Szekeres, Agnes Fiamma, and Brent Hanson for their generous facilitation of this study. A.P.M. is also grateful to Robert Bjork and the UCLA Clinical Scholars medical writing group for their assistance with revision of the manuscript.
Conflicts of interest: None.
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