Introduction
The World Economic Forum [1], the Global Business Coalition on HIV/AIDS [2], and the South African Business Coalition on HIV and AIDS have placed the role of business in HIV/AIDS prevention and care high on their agendas. These groups have secured endorsement from leading companies for specific policies related to HIV/AIDS in the workplace.
Business involvement in HIV/AIDS activities can occur at several levels. Industries and businesses can adopt policies and recommendations regarding HIV/AIDS in the workplace. They can spearhead treatment initiatives and routinely offer prevention and diagnostic services, such as voluntary counselling and testing, in the workplace and in communities. They can examine policy, economic, and structural barriers and facilitators to prevention and care, and engage in structural changes to produce better health outcomes. They can engage as leaders in advocating for similar businesses or their suppliers to adopt workplace policies and programmes. They can also engage in philanthropy that might stimulate and support government programmes, provide pilot grants to initiate programmes and research, build facilities and structures, or promote programmes that governments or other funders might avoid.
In an effort to advance the discussion and implementation of business action on HIV/AIDS, the UCLA Program in Global Health at the David Geffen School of Medicine at the University of California, Los Angeles, USA, hosted a think tank in Durban, South Africa, from 21 to 23 June 2006. The meeting brought together businesses, civil society organizations and academic researchers from southern Africa, the United States, and Europe. Its goals were: To review and consider available evidence on the epidemiology and impact of HIV/AIDS in the workplace; To establish how businesses have responded to the HIV/AIDS epidemic, and document what is known about the efficacy of workplace prevention and care programmes; To assess the wider role of the private sector in advancing the key goals of accountability, equity and leadership in the fight against the virus; To determine future research needs and how those needs can be met; To make evidence-based programmatic and policy recommendations to maximize the contributions that the business sector can make towards HIV/AIDS prevention and care in South Africa.
The rationale for business action
There are three main motivating factors behind private sector involvement in HIV/AIDS: To limit the potential negative macroeconomic impact of HIV/AIDS in the country or region in which the business is located; To reduce the direct costs to firms by decreasing the number of sick and deceased staff and the negative impacts on productivity, enhancing worker retention, and maintaining quality of services and products; To fulfill business's responsibility under the framework of good corporate citizenship, the ‘triple bottom line’ that asks companies to consider their financial, social and environmental performance.
An interesting irony regarding business and HIV/AIDS has been the lack of negative macroeconomic impact. In previous years, predictions of the collapse of economies such as South Africa's were commonplace. In fact, the opposite has happened. Not only has the economy of South Africa not collapsed, it is thriving. Nonetheless, within this context, unemployment remains at 50% in some segments of the population, and is higher than 60% among young African men. This has led some to hypothesize that HIV/AIDS is disproportionately affecting those at lower income levels, and that the growing divide between rich and poor also includes a disease divide (see article by Marais, in this issue).
Participants at the think tank therefore examined in depth business' motivations for action, looking at economic and other driving forces (see article by Matthews and two articles by Rosen et al. in this issue). We examined how AIDS might impact in different ways large multinationals, small, medium and micro enterprises, the public sector, and parastatal organizations (see articles by Rosen et al. and Weston et al., in this issue). Finally, we looked at the moral case for business involvement (see articles by Oppenheimer and Brink and Pienaar, in this issue).
Leadership, equity, accountability, and partnerships
The Ford Foundation launched its Global HIV/AIDS Initiative under the leadership of Deputy Vice President Dr Jacob Gayle to advance and raise the profile of HIV/AIDS work. The Foundation's four priorities for HIV/AIDS are Leadership, Equity, Accountability, and Partnership. These four priorities guided the discussions at the think tank.
Leadership
Leadership involves creating deeper talent pools of professional and community leaders who are knowledgeable about best practices for preventing and treating HIV/AIDS. There is no greater need in the AIDS epidemic, domestically and globally, than leadership development. Leadership needs to be replenished in all sectors: science, programme management, community organizing, and policy and advocacy. In the developing world, in many cases, the first generation of leaders will need to be cultivated, supported, and mentored. A second kind of leadership transfer must occur, namely the transfer of leadership in the fight against HIV to the communities and countries hardest hit by the epidemic. This will require some individuals, institutions, and countries to step back from the limelight in order to allow those hardest hit by the epidemic to take charge of the response, defining both the nature and form of the response and leading others in that effort.
Equality
Equality means that all individuals will have access within their own countries to HIV-related services and evidence-based approaches most appropriate for their circumstances, unaffected by their sex, social or economic status. It means that individuals will be able to gain access to HIV-related services they need without having to jeopardize their human rights. This means encouraging equal access to prevention and treatment across all axes of social inequality, including sex, age, socioeconomic status, religion, race, ethnicity and sexual orientation.
Accountability
Accountability means pressing developed and developing country governments, civil society (including business) and global agencies working on HIV/AIDS to make their programmes more accountable to the public. Gregg Gonsalves' talk at the International AIDS Society meetings in Toronto in 2005, in the special session entitled ‘25 Years of AIDS – Reflecting Back and Looking Forward’, highlighted three important points. First, he stated that ‘…the largely unaccountable, self-justifying infrastructure (which has come about in response to AIDS) privileging the policy preoccupations of the major industrialized countries, privileging generalized, international responsibility instead of specific local political accountability, privileging technical skill and experience over local knowledge; promoting “development” or assistance instead of social change.’
Second, he stated ‘…facing the structural and environmental factors that are the fuel for this great fire of an epidemic and watch the flames grow higher because to act on these issues moves beyond charity and far too close for comfort to them to politics.’ Third, he stated clearly that ‘AIDS is essentially a crisis of governance, of what governments do and do not do to and for their people. We have the drugs to treat HIV infection, we have the tools to confront the risks that drive HIV transmission and prevent infection itself. What we don't have is national political will necessary to scale up our response. We have demanded too little from our leaders, excused far too much.’
Partnerships
Partnerships means conducting all work in partnership with countries and organizations most affected by the HIV/AIDS epidemic in such a way that the partnership is equal or, even better, puts the developing country into a leadership position. Dr Lawrence Altman, reporting on the Toronto AIDS Conference in The New York Times commented that the principal talks at the conference were given by individuals in the developed world, who were speaking, albeit eloquently and passionately, for the individuals in the developing world. Unfortunately, the President of Liberia cancelled because of the failure of the Prime Minister of Canada to appear at the conference. She would have been the only major African leader to speak at the conference. Partnerships means that those who are directly affected by the epidemic will be fully equipped for and actively engaged in the development, implementation, and management of the HIV programmes and policies within their countries and regions.
The meeting opened with a keynote speech by Jonathan Oppenheimer of De Beers (see Commentary, in this issue). The first day was devoted to presentations on the epidemiology of HIV/AIDS in the workplace (Colvin et al. and Marais et al., in this issue), evaluations of its impact on business (Rosen et al., in this issue), and evaluations of policy, prevention, and care programmes (Mahajan et al. and Charalambous et al., in this issue). Breakout groups then answered questions about programmatic, policy, and research priorities (see Weston et al., in this issue).
We present here our major overarching policy and programmatic recommendations. Some might argue that these recommendations are not different from the needs of society in general. We believe that these recommendations, emanating from this meeting, are important to highlight, especially from the perspective of the role that business can plan in advancing the fight against HIV/AIDS not only within its workforce but also in the larger community. It should be noted that these recommendations represent the thinking of the authors of this paper, that no attempt was made to reach consensus regarding these recommendations, and that these ideas should not be construed as the opinion of anyone attending the meeting or the policy or opinion of any of the think tank sponsors.
Overall recommendations
Leadership
Business leadership is essential in fighting the HIV/AIDS epidemic in South Africa and in sub-Saharan Africa. Various programmes to develop leadership within business, but also within universities and especially business schools in Africa should be undertaken. Business should be encouraged to: Take leadership and join with advocacy groups in moving government towards effective testing, prevention, and care services; Develop, export, and sell products, skills and services that will provide more efficient testing, prevention, and treatment; Lead the way in teaching public sector workplaces how to devise, implement, and evaluate testing, prevention, and treatment programmes; Implement supply chain strategies to encourage HIV/AIDS programmes among suppliers; Examine its own business practices and determine if those practices provide social, economic or contextual factors that fuel the spread of HIV or fail to deter its progression. Examples that need to be addressed include the role of alcohol in the spread of HIV, migration and the status of migrant workers, commercial sex work, disparities in pay because of sex or other factors.
Encourage HIV testing
We recommend bringing together a broad group of organizations and individuals from various sectors in southern Africa to debate strategies for encouraging HIV testing, including routine, opt-out, mandatory, incentivized and community-based testing. From this should come agreement about a series of experiments to determine whether or not fears and concerns associated with various strategies are borne out.
The uptake of HIV testing remains low, even with the availability of antiretroviral treatment. This is partly a result of the heavy stigma associated with HIV/AIDS, but also the enormity of the meaning of an HIV diagnosis. It is possible that much more could be done to encourage, incentivize or mandate testing, and thereby ‘normalize’ testing and reduce stigma. Increased testing and a greater number of individuals knowing their HIV status will contribute to reduced transmission and increased treatment uptake.
Technological research to increase clinical efficiency
Work is needed to encourage technological research to increase the efficiency of testing, prevention and treatment services without sacrificing quality. Each step of this process implies financial, human and opportunity costs. For example, Oppenheimer (this issue) observes that CD4 cell testing not only requires financial resources for the assay itself, but also that individuals take time away from work for the blood draw as well as to secure the results and determine the next steps. It might be possible to develop technologies that enable individuals to test for HIV at home, determine if CD4 cell counts or viral loads are above or below some cutoff for treatment consideration, and access helplines and other strategies so that they do not lose time at work. Just as an engineering process needs to be scrutinized to make it maximally efficient, the process of delivering testing, prevention, and treatment needs to be analysed to determine how financial, human, and other efficiencies can be attained.
Male circumcision and new prevention strategies
Business should plan now for incorporating new testing, prevention and treatment technologies. The evidence from studies in South Africa that male circumcision reduces HIV transmission is encouraging, and has been replicated by studies in Kenya and Uganda.
Other studies are underway examining the efficacy of pre-exposure prophylaxis, acyclovir for the suppression of herpes simplex virus 2, other barrier methods such as the diaphragm, and microbicides. Many businesses still do not provide female condoms, and acceptance studies of female-controlled methods need to be bolstered. Business should be ahead of the curve in its preparations for the outcomes of these trials and the incorporation of these methods into an overall workplace strategy.
Business influencing communities
Business should lead the way in developing and evaluating new methods for delivering testing, prevention and treatment services. Brink and Pienaar in this issue describe a programme undertaken by Anglo American to develop prevention and care strategies for entire communities affected or influenced by a given industry. The Global Business Coalition on AIDS has developed and is evaluating strategies whereby small, medium and micro enterprises can group together, much as in a group insurance scheme, to provide prevention and treatment services that are affordable and well adapted to that kind of workplace. The World Economic Forum has developed policies and strategies for supply-chain management of HIV/AIDS. Additional novel strategies might include the use of traditional healers to deliver HIV voluntary counselling and testing services, directly observe antiretroviral or prophylactic therapy in patients, or provide other prevention services.
Philanthropy
Business should consider ways in which it can use its philanthropic funds and expertise to make specific inroads against HIV/AIDS. Examples might include the expansion of educational opportunity as a way to fight HIV/AIDS, the stimulation of micro enterprises, or the use of economic and incentive models to encourage education or the avoidance of risk taking. Business can also use its philanthropic funds to build structures within society to sustain the fight against HIV and the social forces that propel it. This includes stabilizing educational institutions, medical research institutions and facilities, as well as civil society structures needed to counter HIV.
Public relations and advertising
Business should use its messaging, public relations, and advertising expertise to send out a new message both to its workforce and to the population, namely that one should avoid HIV, but one can live productively with HIV.
Equity and partnerships: for black Africans, for women, and for youth
A think tank should be assembled to discuss the reasons for and ways to relieve the heavier burden of HIV infection among black Africans and women. Focus should be placed on important contextual factors such as income, migration, alcohol use, and other such factors, especially those under the control of business. Rates of HIV infection among black Africans are two to three times higher than those of white or coloured South Africans, or those of Asian descent. Understanding the reasons behind this is key to addressing the problem.
Equity for those not in the formal workforce
There is a need to understand differences in HIV prevalence between those in the workplace and those not in the workplace to determine where prevention and care resources might need to be focused. Data comparing workplace epidemiological investigations and those from national surveys show a lower workplace prevalence of HIV. Microenterprise is in very large demand in the informal work sector and is already geared towards poor women in the most economically disenfranchised communities. The microenterprise sector will therefore need to be examined for the extent to which it is feasible to build HIV/AIDS prevention and treatment into its operations and to evaluate existing programmes. This is particularly important given the degree to which poverty and sexual inequality intersect to shape the dynamics of the epidemic in South Africa.
Equity for contract and casual labour
There is a need to develop legal and policy remedies for individuals employed under contract or casual labour so that they can benefit from testing, treatment, and prevention programmes.
African youth
There is nothing more urgent than the HIV epidemic among African youth. An emergency appeal to step up prevention efforts must be made. New understandings of the high prevalence and incidence of HIV in South Africa specifically, and in southern Africa generally, are needed. In addition to sexual behavior, focus should be placed on other risk factors such as other endemic infections, alcohol use, and genetic risk factors. Understanding the mechanisms by which historical forces and poverty contribute to high prevalence and incidence is also needed. We recommend convening a think tank to review the known data on sexuality, risk behaviors and risk factors of various southern African communities. The implications of these data for prevention policies should be discussed, articulated and advanced.
Accountability: evaluate workplace programmes
We recommend that more concerted research be conducted to assess the impact of workplace testing, prevention and treatment programmes. Such efforts should also focus on determinants of differences in programme outcomes with a view to establishing the most effective and cost-efficient workplace strategies.
More information is needed about the outcomes of testing, prevention and treatment elements of workplace programmes, and about the barriers to uptake of different programme elements. When programmes are determined not to be cost-effective for individual businesses, documentation of successful collaborations across sectors should be disseminated among firms.
Business should be held accountable to civil society under the triple bottom line framework of good corporate citizenship, which asks companies to consider their performance against financial, social and environmental targets. Business should also be encouraged to use its data capture and feedback mechanisms to make prevention and care services more efficient. Business might also be incentivized to engage in philanthropy to build and support societal structures needed to fight HIV/AIDS and other diseases. Finally, business should be encouraged to lead the effort to ensure that testing, prevention, and treatment services are evidence based, and that public monies are used wisely and well and in accordance with the best possible science.
A final note: action orientation
If HIV could be crushed by paper, it would have been obliterated long ago. Our goal is not to create more paper, discussions, or studies for their own sake. Rather, we take a deliberate stance that all research should be action oriented. Results of epidemiological studies can be used to advocate for better programmes (such as the case of South African educators) or to focus resources where they are needed the most. Evaluations of prevention and treatment programmes should be used immediately for quality improvement. Studies of novel concepts (such as the case of Anglo American, see Brink and Pienaar, in this issue) can document what is possible with the right resources, and be used to advocate for more resources.
One thing is clear, HIV is not going away any time soon. We will all be living with it, and it will kill many, for generations to come. The first 25 years are just the beginning, and we need to continue to do all that we can to prevent it from being transmitted, to treat it in those infected, and to address the societal conditions that make both of those objectives difficult to reach. We hope that this meeting and series of recommendations make some advances in that direction.
Acknowledgements
The authors would like to thank Mr and Mrs Michael Steinberg for inspiring this meeting, and also providing partial support for it. They also thank the other sponsors, in particular: the John M. Lloyd Foundation; the Diana, Princess of Wales Memorial Fund; the Franklin Mint Foundation; the Ford Foundation; the UCLA AIDS Institute and the UCLA Center for AIDS Research; the UCLA Center for HIV Identification, Treatment, and Prevention Services (CHIPTS; Mary Jane Rotheram-Borus PhD, Director, funded by the National Institute of Mental Health grant no. 2P30MH058107) and the Columbia Center for HIV Clinical and Behavioral Studies (Anke Ehrhrardt PhD, Director, funded by the National Institute of Mental Health grant no. P30MH43520). None of the views expressed herein necessarily represent those of the conference attendees or their organizations or employers, or of the sponsors or any employees of the sponsors.
Participants
Jonathan Berger, AIDS Law Project, University of the Witwatersrand
Scott Billy, Society for Family Health (SFH)
Cal Bruns, Mat©hbox
Alice Brown, JD, Ford Foundation, South Africa; Council on Foreign Relations
Stuart Burden, Director, Community Affairs, Levi Strauss and Co. and the Levi Strauss Foundation; Funders Concerned About AIDS; Boston College Business Network on Integrating Corporate Citizenship
Gavin Churchyard, MBBCh, FCP (SA), Mmed, PhD, Director, Aurum Institute for Health Research; Department of Medicine in the Faculty of Health Sciences, University of KwaZulu-Natal; University of Cape Town; London School of Hygiene and Tropical Medicine; International Consortium to Respond Effectively to the AIDS/TB Epidemic (CREATE); Centre for the AIDS Program of Research in South Africa (CAPRISA); South African Tuberculosis Trials Consortium and South African AIDS Vaccine Initiative (SAAVI)
Thomas J. Coates, PhD, Michael and Sue Steinberg Endowed Professor of Global AIDS Research, Division of Infectious Diseases, Department of Medicine, UCLA David Geffen School of Medicine; Director, UCLA Program in Global Health; Associate Director, UCLA AIDS Institute
Mark Colvin, BSc, MBChB, DOH, MS, Centre for AIDS Development, Research and Education (CADRE)
Catherine A. Connolly, MPH, Medical Research Council (MRC)
Russell L. Deweese, Consultant
David Dickinson, PhD, Associate Professor, Wits Business School, University of the Witwatersrand
Robert DuWors, MPA, Deputy Director, UCLA Johnson Cancer Center
Shari L. Dworkin, PhD, MS, Assistant Professor, Behavioral Medicine, Department of Psychiatry, Columbia University; Research scientist, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University
Paul Edwards, Merryn Capital and Starcomms; Kuito Relief Fund; Igageng Community Development Trust; Joint Aid Management (JAM)
Agnès Fiamma, MIPH, Director, Africa and Asia Programs, UCLA Program in Global Health, Johannesburg office
Donna Futterman, MD, Director, Adolescent AIDS Program; Professor of Clinical Pediatrics, Albert Einstein College of Medicine, Bronx, New York
Jacob A. Gayle, PhD, Deputy Vice President, Ford Foundation Special Global HIV/AIDS Initiative
Gavin George, MCom, Health Economics and HIV/AIDS Research Division, University of KwaZulu-Natal
Errol Gottlich, MD, Discovery Health; Morningside Mediclinic
Glenda Gray, MBBCH, FCP, Director, Perinatal HIV Research Unit, University of the Witwatersrand
F. Gray Handley, MSc, Associate Director for International Research Affairs; Acting Director, Office of Global Research, National Institutes of Allergy and Infectious Diseases, National Institutes of Health
Brent W. Hanson, Research Associate, UCLA Program in Global Health
Risa Hoffman, MD, MPH, Fellow, Infectious Diseases Division, UCLA David Geffen School of Medicine
Perry A. Jansen, MD, Director, Partners in Hope, Lilongwe, Malawi
Mary Jordan, United States Agency for International Development (USAID), Pretoria
Mpho Letlape, MBA-HR, ESKOM; Institute of People Management; Enterprise Development Forum; Black Management Forum; Institute of Directors
Chris Low, CEO Standard Chartered Bank, South Africa
Tandiswa Lusu, MBCHB, Diploma HIV management (SA), Expert Treatment Programme (ETP); Direct AIDS Intervention (DAI)
Sylvester N. Madu PhD, Chair, Department of Psychology, University of Limpopo; World Council for Psychotherapy, African Chapter; UCLA/South African Trauma Research Training Program
Anish Mahajan, MD, MPH, Robert Wood Johnson Clinical Scholar, University of California, Los Angeles
David Mametja, Population Program, Atlantic Philanthropies
Hein Marais, Writer/journalist, South Africa
James McIntyre, MBChB FRCOG, Director, Perinatal HIV Research Unit, University of the Witwatersrand; Principal investigator, CIPRA-SA ‘Safeguard the Household’ Collaborative South African Research Program
Mike Minder, Principal, Samson Investment Company of Nevada; Southland National Bank; Capistrano National Bank
Skhumbuzo Ngozwana, MBChB (UCT), M MED Pharm (UP), MBA (GIBS), Lifeworks
Carol O'Brien, B. Proc (Law); MBA (Oxford-Brookes), Director, South Africa Office, Global Business Coalition (GBC)
Dean Peacock, MSW, Sonke Gender Justice Project; Men Overcoming Violence (MOVE) Youth Program
Fazel Randera, MD, National Centre for Occupational Health, South Africa; Department of Family Medicine, University of the Witwatersrand; Truth and Reconciliation Commission; Gauteng Premier's Commission of the Inquiry, Gauteng Hospitals
Robert H. Remien, PhD, Research Scientist and Director of the Community Collaboration Core HIV Center for Clinical and Behavioral Studies New York State Psychiatric Institute and Columbia University; Associate Professor of Clinical Psychology (in Psychiatry) and Clinical Supervisor in Residence Program, College of Physicians and Surgeons, Columbia University, New York, NY, USA
Linda Richter, PhD, Director, Child, Youth, Family and Social Development (CYFSD), Human Sciences Research Council of South Africa; University of KwaZulu-Natal; Department of Paediatrics and Child Health, University of the Witwatersrand; AIDS Programme of Research in South Africa (CAPRISA); Department of Psychiatry, University of Melbourne
British Robinson, MA Government, US Department of State, Office of US Global AIDS Coordinator
Sydney Rosen, MPA, Assistant Professor, Center for International Health and Development, Boston University; Director, Health Economics Research Office, Wits Health Consortium, University of Witwatersrand
Jean-Baptiste Rudatsikira, Research Associate, UCLA Program in Global Health
Helen Schneider MB ChB, Director, Centre for Health Policy, Wits School of Public Health, University of the Witwatersrand; Gauteng Department of Health
Martin F. Shapiro, MD, PhD, Chief, Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine; Morbidity Monitoring Program for HIV, CDC
Geoffrey Setswe, Dr PH, MPH, Social Aspects of HIV/AIDS and Health Research Programme (SAHA) of the Human Sciences Research Council (HSRC)
Jonathon Simon, MPH DSc, Chair, Department of International Health, Boston University School of Public Health
Michael Steinberg, Retail Consultant; former CEO, Macy's West
Greg Szekeres, Associate Director, UCLA Program in Global Health
Mark Weston, Consultant, River Path Associates
Lauren Whitebread, MA-IR, Children's Hospital Trust (Red Cross War Memorial Children's Hospital)
Alan Whiteside, D. Econ, Director, HEARD, University of KwaZulu-Natal, Governing Council of the International AIDS Society; Governing Council of Waterford Kamhlaba College; United Nations Commission on HIV/AIDS and Governance in Africa
Steven Whiting, Perinatal HIV Research Unit, University of the Witwatersrand; HIVSA
Gail Wyatt, PhD, Department of Psychiatry and Biobehavioral Sciences, UCLA; UCLA AIDS Institute
Conflicts of interest: None.
