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The private sector and HIV/AIDS in Africa: taking stock of 6 years of applied research

Rosen, Sydney; Feeley, Frank; Connelly, Patrick; Simon, Jonathon

doi: 10.1097/01.aids.0000279693.61652.2d
Original articles

Background: Until recently, little was known about the costs of the HIV/AIDS epidemic to businesses in Africa or about business responses to the epidemic. This paper synthesizes the results of a set of studies conducted between 1999 and 2006.

Methods: Data for the studies included were drawn from human resource, financial, and medical records of 16 large companies and from 7 surveys of small, medium-sized, and large companies in South Africa, Uganda, Kenya, Zambia, Ethiopia, and Rwanda.

Results: Estimated workforce HIV prevalence ranged from 5 to 37%. The average cost per employee lost to AIDS varied from 0.5 to 5.6 times the average annual compensation of the employee affected. Labor cost increases were estimated at 0.6–10.8% but exceeded 3% at only two of 14 companies. Antiretroviral treatment at a cost of US$360/patient per year was found to have positive financial returns for most but not all companies. Managers of small and medium-sized enterprises (SME) reported low AIDS-related employee attrition, little concern about the impacts of AIDS, and relatively little interest in taking action. AIDS was estimated to increase the average operating costs of SME by less than 1%.

Conclusion: For most companies, AIDS is causing a moderate increase in labor costs, with costs determined mainly by HIV prevalence, employee skill level, and employment policies. Treatment of HIV-positive employees is a good investment for many large companies. Small companies have less capacity to respond to workforce illness and little concern about it. Research on the effectiveness of workplace interventions is needed.

From the Center for International Health and Development, Boston University, Boston, Massachusetts, USA.

Received 15 August, 2006

Accepted 27 January, 2007

Correspondence to Sydney Rosen, Health Economics Research Office, Helen Joseph Hospital (Themba Lethu Clinic), Perth Road, Westdene 2092, South Africa. E-mail:

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A vast literature exists on the extent of the HIV/AIDS epidemic in sub-Saharan Africa and its impact, real and predicted, on various sectors of society [1–3]. In many countries, between 5 and 20% of working-aged adults are HIV positive [3]. Concern about the potential impact of AIDS-related morbidity and mortality on private sector labor productivity, production costs, and competitiveness arose in the mid-1990s [4]. By the end of that decade, there were anecdotal reports of AIDS-induced shortages of skilled workers, rising absenteeism, and skyrocketing benefits costs [5]. Although some research was conducted [6–9], most evidence about AIDS and business was either drawn from case studies of single, high-profile, multinational firms [10,11] or was compiled from large qualitative surveys [12,13]. Little rigorous analysis had been done to support the claims of major impacts or to document the specific ways in which HIV/AIDS affects a company.

As business leaders and policy analysts began to consider the financial implications of AIDS among employees, advocacy organizations ramped up the pressure on multinational companies, in particular, to participate more actively in the global response to AIDS. Employers were exhorted, at a minimum, to provide care and treatment for their own HIV-positive workers and their families [14,15].

External and internal pressure and a recognition of the costs of not taking action have motivated some private firms in Africa to invest in comprehensive HIV/AIDS prevention and treatment programmes and pioneer innovative public–private partnerships. The vast majority of companies, however, have done little or nothing [13], and many have tried to diminish the need for action by changing their levels and conditions of employment [16]. The appropriate role of the private sector in fighting the epidemic, moreover, remains an unanswered question in most countries. Calls for businesses to invest more in HIV/AIDS programmes for employees risk the possibility that companies will respond by relocating to lower-prevalence parts of the world, casualizing previously permanent workers, or substituting capital for labor. Few if any countries have sought or found a strategy that both promotes private sector growth and encourages companies to invest in HIV/AIDS interventions.

If the private sector is to play a broader role in addressing the HIV/AIDS epidemic, African business and government leaders will need a better understanding of the costs of HIV/AIDS to private sector employers and the barriers to expanding the private sector response. In this paper, we draw together evidence from a wide range of countries and industrial sectors to propose answers to these questions. The studies we cite were conducted by the authors and our colleagues in African and other institutions between 1999 and 2006. Primary data were collected in Ethiopia, Kenya, Rwanda, South Africa, Uganda, and Zambia from small, medium-sized, and large companies and across many industrial sectors, including mining, agriculture, manufacturing, and tourism. The research is by no means exhaustive, and the results are specific to the times and places of data collection. Taken together, however, we believe that these studies offer the best information yet available on HIV/AIDS and the private sector in Africa.

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Three types of data were used for this research. First, we collected detailed human resource, financial, and medical data from more than a dozen large private and parastatal companies in South Africa, Uganda, Kenya, Zambia, and Ethiopia. These data were used to generate quantitative estimates of the costs of HIV/AIDS to these companies, based on a previously described methodology [17]. Second, we conducted surveys of small and medium-sized enterprises (SME) in various industrial sectors in South Africa, Kenya, and Zambia. The survey instrument elicited information about the current impact and costs of HIV/AIDS, managers' perceptions of that impact, and company responses [18]. Finally, we examined large companies' responses, interventions, or potential interventions, focusing largely but not exclusively on treatment, in South Africa, Uganda, Kenya, Zambia, and Rwanda. Some of these studies have been published; most others are available as project reports. The studies used in this paper are listed in Table 1. Each study in Table 1 is given a study reference that will be used to identify individual studies in the remainder of this paper.

Table 1

Table 1

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Cost of AIDS to large companies

Between 1999 and 2005, we made detailed estimates of the costs of HIV/AIDS in the workforce to the 14 large companies shown in Table 1 for which the focus of the study was the cost of AIDS. At these companies, we combined retrospective data on employee demographic characteristics, absenteeism, productivity, and medical care costs with unit cost information obtained from employment contracts, benefits policies, and financial statements and from interviews with managers. We then estimated AIDS-related mortality in the workforce and multiplied the nominal cost per death by the estimated number of deaths in the year of the study to obtain the aggregate costs of all AIDS-related losses per year. Results for some companies differ from those in previously published work because they are not discounted, are based on mortality rather than incidence, and are expressed in relation to total compensation (salary plus benefits), rather than base salary alone.

Table 2 summarizes our findings. It is organized by industrial sector, to illustrate differences and similarities across and within sectors. With the exception of companies 10 and 11, all of the cost studies were conducted before the widespread availability of antiretroviral therapy (ART).

Table 2

Table 2

With the exception of the mining company in Botswana (company 7) and the tourism company in Zambia (company 10), in no company studied did the estimated annual costs of losing employees to HIV/AIDS, taken as a percentage of annual labor costs, what we have elsewhere dubbed the ‘AIDS tax’ [17], exceed 3%. For most companies, HIV/AIDS appears to be raising the cost of labor by 1–2%. This should be regarded as a conservative estimate of the true costs of AIDS in the workforce, as it omits organizational costs that we could not measure, such as disruptions in established work teams and drains on management time. As is the case for companies 7 and 10, however, there are also firms that are facing a much larger AIDS tax. In both of these cases, estimated HIV prevalence was very high. As both Botswana and Zambia had relatively mature epidemics at the time of the studies, AIDS-related morbidity and mortality was also high. Finally, both companies provided generous employee benefits, leading to very high overall costs.

Direct costs such as benefits, recruitment, and training can be estimated relatively easily, and large companies can also usually predict the duration of vacancies and the time required for a new worker to become fully productive. Indirect costs associated with morbidity, losses of productivity as a result of absenteeism, and diminished performance when at work (so-called ‘impaired presenteeism’) are much harder to quantify, largely because productivity cannot usually be observed directly. Whenever possible, we used routinely collected payroll data to compare the productivity and absenteeism of workers who died of AIDS-related causes with those of workers still present in the workforce. In the non-agriculture companies in South Africa, Uganda, and Zambia, we found that in their last 2 years of service, employees who ultimately died of AIDS or suspected AIDS were on leave or absent from work between 18 and 50 days more than other employees, the equivalent of approximately 1–3 months of lost working time over the 24 months of observation.

Perhaps the best data on productivity loss associated with AIDS come from two commercial agriculture firms in Kenya, companies 12 and 13 in Table 1. Both are tea growers and processors whose workforces consist largely of tea pluckers. Because tea pluckers are paid on the basis of the quantity of tea plucked per day, these companies keep daily records of individual productivity. As the companies also maintain their own on-site medical services, we were able to observe directly both health status and productivity for more than 20 000 tea pluckers over a multiyear period. The results are shown in Table 3.

Table 3

Table 3

The findings in Table 3 suggest that manual workers, such as tea pluckers, with HIV/AIDS are approximately 25–30% less productive over their last 2 years of service than they otherwise would be.

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Impact of HIV/AIDS on small and medium-sized companies

The vast majority of private, for-profit enterprises in sub-Saharan Africa are small or medium-sized, not large. Small and SME, defined here as having between 10 and 200 employees, account for a large share of formal sector employment in most countries and are often regarded as the best hope for sustainable job creation [29–31]. (Note that we are not addressing micro-enterprises, those with fewer than 10 employees and often informally organized and reliant on family labor.)

To understand the impact of HIV/AIDS on SME and investigate the potential for SME to play a role in fighting the epidemic, we conducted five surveys of representative samples of SME in various industrial sectors in South Africa, Zambia, and Kenya, as listed in Table 1. Small and medium sized companies are less likely than large companies to have detailed cost data, accurate records of absenteeism, and other information needed to make quantitative estimates, making it harder to evaluate the impact of AIDS on these companies. The findings of the surveys, both quantitative and qualitative, about the epidemic's impact are summarized in Table 4.

Table 4

Table 4

We used the cost information from survey 5 to make a rough estimate of the cost to small tourism companies in Zambia of losing an employee to AIDS. In Livingstone District, Zambia, where survey 5 was conducted, skilled workers accounted for the majority of people employed in the tourism sector and suffered most of the deaths experienced in 2004. We estimated that losing a skilled worker to AIDS cost the surveyed companies an average of at least US$1430, equal to just over one year's annual compensation for a worker at that level. The largest components of this cost were training of a replacement worker (28% of the total), funeral and death benefits (23%), and paid sick leave (17%) [20]. The surveyed companies, however, lost an average of 0.6 employees/company to any health-related cause in the 12 months preceding the survey. If all of these losses had been caused by AIDS and were among skilled workers, the average annual cost per company would have been approximately US$858 per company per year. For the median company, this amount represented approximately a 2.4% increase in labor costs. Across the full sample, labor accounted for an average of 27% of operating expenses. AIDS-related losses were thus estimated to increase the average company's operating costs by just 0.6%. Tourism companies such as those in survey 5 have relatively skilled workforces and invest a significant amount in training; agriculture companies such as those in surveys 6 and 7 probably face even smaller cost increases.

The surveys thus produced a fairly consistent picture of small and medium-sized companies that have been only mildly affected by the AIDS epidemic so far and, as might therefore be expected, are not terribly concerned about it and have taken little action to address it. In the next section we review evidence on company responses.

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Company responses to AIDS

The studies described above also looked, to varying degrees, at the responses of large, medium-sized, and small companies to HIV/AIDS among employees. Our research on company responses can be divided into three categories: provision of services; uptake of services; and potential returns on investments in HIV/AIDS interventions.

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Provision of HIV/AIDS services

Information on the current provision of HIV/AIDS services by companies in Africa was collected in all seven of the surveys listed in Table 1. Results from most of these surveys are shown in Table 5.

Table 5

Table 5

Approximately half of the companies represented in Table 5 had provided information or education about HIV/AIDS to employees at the time of each survey. Somewhat fewer had undertaken activities that usually require more time or effort on the part of the employer, such as facilitating access to voluntary counselling and testing. No more than a quarter of the companies, and none of those sampled in South Africa or Kenya, were explicitly providing or paying for ART at the time of the surveys. It is likely that this proportion has increased slightly since the surveys were conducted, particularly in South Africa. The advent of treatment in the public sector in all study countries beginning in 2004, however, has also clearly deterred some companies from spending their own funds on the provision of treatment. By the end of 2005, employees of most of the companies surveyed in all four countries had some access to ART from public healthcare facilities.

Large companies are much more likely than small or medium-sized companies to make ART for AIDS available to their employees, either by providing it directly, contracting with an independent disease management programme, or including it in the benefits provided by the company's medical aid (health insurance) scheme. Survey 3 elicited information from 52 of South Africa's 64 private and parastatal companies with more than 6000 permanent employees. As of late 2004, approximately half of the companies surveyed made ART available to all permanent employees, covering 63% of the combined workforces of all 52 companies. Access varied widely by industry, however, all financial services companies and three-quarters of mining companies made ART available to all employees, but only 21% of retail firms and none of the construction or community, social, and personal services companies did so.

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Uptake of HIV/AIDS services

Provision of workplace-based services is an effective way to respond to AIDS only if employees agree to utilize those services. We looked at the uptake of services in two of our studies: survey 3 and company 14.

As described above, survey 3 investigated the provision and uptake of AIDS treatment services among South Africa's largest private sector employers. Although access to ART was widespread, with 63% of the nearly one million workers employed by the surveyed companies having access, uptake was low. Across the combined workforce, for which average HIV prevalence was estimated at 15%, approximately one-quarter of suspected HIV-positive employees were enrolled in care and treatment programmes, and only 4% were receiving ART, or less than 1% of the entire combined workforce. Access and uptake thus diverged in survey 3; access to services was relatively high, but uptake was quite low.

A different type of experience was documented in the study of company 14. Over the 4-year period from 2001 to 2005, 73% of company 14's workforce volunteered for an HIV test, and the testing campaign identified fully 87% of those employees believed to be HIV positive, based on a 2003 anonymous seroprevalence survey. By early 2005, 85% of employees who were medically eligible for ART had initiated treatment. Although the findings from survey 3 and company 14 are not strictly comparable, as they were conducted in different countries using very different methodologies, they do illustrate the range of testing and treatment uptake outcomes that prevail among large employers.

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Returns to investments in treatment interventions

The benefits of workplace interventions to employers are largely unquantified. The effectiveness of HIV prevention efforts is notoriously difficult to measure, and to our knowledge no quantitative, outcomes-based evaluations of workplace prevention programmes have ever been published. From an employer's perspective, the net benefits of preventing an HIV infection are of course the ‘avoided costs’ of that infection, minus the cost of the prevention programme itself. As basic prevention interventions tend to be relatively inexpensive, the average cost of an AIDS-related termination shown in Table 2 can be taken as a rough estimate of the savings to a company for each incident infection prevented. These savings will only accrue, however, 8–9 years after the infection is prevented, the average latency period for HIV, and should thus be discounted accordingly. They will also only accrue if the employee in question is still in the workforce when HIV-related illness develops. The long time lag between prevention costs, which are incurred now, and prevention benefits, which accrue years later, makes it difficult for private sector employers to capture the financial benefits of investments in prevention.

The benefits of treatment are easier to estimate, both empirically and through modelling. Many of the companies listed in Table 1 now make HIV/AIDS care and treatment, including ART, available to employees. We modelled the ‘returns to investment’ in AIDS treatment for the companies using the cost results shown in Table 2 and a hypothetical treatment programme in which treatment begins 2 years before an HIV-positive employee would otherwise have been expected to die of AIDS-related causes. Under our programme, employees who start treatment today will be able to remain in the workforce for an average of 5 years longer than would otherwise be expected, thus requiring a total of 7 years of treatment per eligible employee. After 7 years, treatment is assumed to fail, leading to a period of illness and then death similar to that experienced in the absence of treatment. Once treatment fails, employees can be retired for medical reasons immediately, curtailing the rest of the high absenteeism, low productivity, and expensive death and funeral benefits that characterize AIDS-related deaths now. Direct costs of recruitment and training a replacement worker remain the same, but all other costs are assumed to equal 25% of those associated with untreated HIV/AIDS. Our hypothetical programme costs US$360/patient per year (US$30/month). Results of the modelling for selected companies are shown in Table 6.

Table 6

Table 6

Table 6 suggests that for many businesses, such as companies 6 and 10, providing ART under the admittedly strict conditions of our hypothetical programme would result in net financial savings. For these companies, ensuring that employees have access to and utilize treatment services is beneficial to everyone involved. Company 12 represents a different outcome: treating managers is highly profitable, because they are both expensive to lose and difficult to replace, but treating unskilled and even skilled workers will not produce an immediate financial gain. Many labor-intensive, relatively low-technology industries such as textiles, agribusiness, construction, and contract services such as security and cleaning will face this situation. This is likely to be particularly true of those that are locally owned and lack both resources and pressure from an international head office. These companies often make treatment available to managers and selected skilled employees on an ad hoc basis, but rely on the public sector to care for the majority of HIV-positive workers. Seroprevalence surveys of workforces across many industries in Zambia, Botswana, and South Africa have consistently found that HIV prevalence is highest amongst unskilled and semi-skilled workers (M. Colvin, C. Connolly, L. Madurai, unpublished observations, 2006) [32], meaning that the public sector will bear most of the burden of HIV/AIDS-related illness and treatment for these labor-intensive companies.

Company 10, a large tourism company in Zambia, presented an interesting development in the business response to AIDS. As Table 2 indicates, modelling from population data suggests that HIV prevalence in company 10's workforce was extremely high, more than one out of three employees, and that the resulting increase in labor costs should have approached 11%, by far the largest ‘AIDS tax’ that we have seen. Observed AIDS-related mortality, however, was only approximately 25% of predicted mortality, and the company's actual AIDS tax was thus only 2–3%, in line with that of most other companies in Table 2. One explanation for the lower-than-expected mortality was the youthfulness of the workforce; the average age of company 10's employees was just 32 years, and most of those with HIV were probably not yet symptomatic. A second explanation was that many employees were already on ART, provided by either the public programme at the district hospital or a private doctor in the nearby town. The patient numbers reported by these two providers were sufficient to explain virtually all of the discrepancy between expected and observed mortality. Our study concluded that company 10 may represent a new trend in African workforces: high HIV prevalence but low AIDS mortality, as a result of access to ART.

There are several uncertainties that will influence the effect of ART on worker survival and productivity, and thus on the net benefits of a treatment intervention from a company's perspective. First, employees have to agree to be tested and, if positive, enroll in the treatment programme. Experience with uptake varies widely; company 14 has enrolled nearly 90% of estimated HIV-positive employees in its care and treatment programme, but in South Africa, survey 3 found uptake of treatment to be very low at most very large companies. Second, high levels of antiretroviral adherence will have to be sustained over the long term. In principal, individuals whose survival depends on remaining healthy enough to perform their jobs should be highly motivated to adhere, but there is bound to be some falling off of adherence over time. A treated but non-adherent workforce population is unlikely to be highly productive. Finally, some loss of productivity may result from treatment itself, as a result of both toxicities from the antiretroviral agents and queuing time required to obtain services in the public sector. Queues at public clinics can last for many hours, and current ART guidelines typically require many clinic visits, especially in the first year.

In conclusion, although the companies included in our studies do not approach a representative sample of all formal sector employers in Africa, clear patterns have emerged that we believe to be generalizable to many countries and industries. On the basis of the data reported above and our broader experience in conducting this research and reviewing the literature, we draw the following 10 conclusions about HIV/AIDS and the private sector in Africa.

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The impact of HIV/AIDS on firms' labor costs has so far been real but moderate

In most, although not all, of the studies we have conducted, HIV/AIDS has been found to increase labor costs by less than 3%. Companies that employ large numbers of unskilled or semi-skilled workers are likely to have a high prevalence of HIV infection in the workforce, but each employee who acquires HIV/AIDS costs the employer relatively little. Companies that rely primarily on skilled staff will face larger costs per HIV-positive employee, but the number of employees with HIV/AIDS is likely to be small, and the share of labor costs in overall operating expenses may also be relatively low. There are exceptions to this rule, however, as demonstrated by the mining company in Botswana and the tourism company in Zambia, to which untreated AIDS is estimated to have increased labor costs by 6 and 11%, respectively. Most of the large companies we studied, moreover, were multinationals or exporters. Uncritical generalizations may therefore be risky. The magnitude and nature of the impact of AIDS on business is also liable to change over time, as local epidemics mature, access to treatment expands, and companies adapt in other ways.

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A few variables explain most of the differences in costs among firms

There is variation in costs across and within countries and sectors, but there is also some consistency in the drivers of costs. First, as one would expect, costs to employers vary with HIV prevalence in the workforce population. Estimated prevalence in the companies shown in Table 2 ranged from under 6% to more than 35%. Second, the job level of affected employees is important, as morbidity and mortality among more skilled and higher paid employees impose higher costs on employers than they do among less skilled employees. Third, the structure of employment also plays a role: contract and casual workers typically receive few or no employee benefits and can easily be dismissed and replaced when they fall ill. Fourth, multinational companies, parastatals, and companies with a history of foreign or colonial ownership tend to provide more extensive employee benefits and invest more in training, and they thus face higher costs when employees become ill or die. Finally, costs vary to some extent by industrial sector; on average, mining and manufacturing firms face higher costs than service and agricultural firms, probably as a result of differences in capital intensity, labor productivity, and workforce demographics. Differences within sectors may equal or exceed differences between sectors, however.

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Responses to AIDS are also associated with consistent company characteristics

Just as there are common determinants of the cost of AIDS to employers, several factors are consistently associated with a more active management response to the epidemic. Small companies that lack dedicated human resources staff and that tend to interact with individual employees on the basis of personal relationships, rather than company policies, are unlikely to have formal HIV/AIDS programmes. Large firms with professional human resources departments, occupational health departments, and on-site medical expertise are more likely to establish a workplace AIDS policy, secure access to medical care, including ART, for HIV-positive employees, and provide other HIV-related services and benefits. Multinational companies often follow the lead of their head offices, which sometimes provide expertise and assistance to local operations, as well as setting company policy. Finally, as with many collective actions, the personal experience and initiative of individual managers, union representatives, human resources officers, and others may be as important as institutional factors in determining a company's response to AIDS.

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Treatment is a good investment for many employers

Chronic illness in the workforce is expensive for most employers, particularly when it ends with the payment of large death benefits and replacement costs. The estimated net financial benefits to employers of making ART available to employees are positive for many companies. Even for those for which there is a net cost, rather than a net saving, the cost of treatment is partly offset by the benefits. There are also many other unmeasured or non-financial benefits of providing treatment to employees, including reducing the time managers must spend coping with employee deaths and turnover, mitigating the impact of AIDS on workforce morale, motivation, and discipline, stemming the loss of skill and experience from the workforce, and allowing a company to respond compassionately to the crisis facing its employees.

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Employer provision of treatment can make sense even when public sector treatment is available

A development that is related to, but separate from, the ‘burden shift’ described below is that of large companies choosing to rely on the public sector or on individual employees to pay for treatment. Both companies we studied in Ethiopia (companies 15 and 16), for example, originally paid for ART for employees but shifted them to public clinics once treatment fees were eliminated in the public sector. If a company does not pay for treatment, an employee with AIDS can either pay for private care himself or, when available, access a public sector treatment programme. In these cases, the direct cost of treatment is transferred to the household or government, but the employer realizes the savings from the worker's continued productivity. Serious drawbacks to this strategy remain, however. First, in many places, each visit to a public sector treatment clinic requires a full day of queuing, such that treatment itself increases work absenteeism. Second, without a structured programme, a company has no way to encourage or evaluate the uptake of treatment or adherence to ART. Treatment of employees with AIDS is thus hit or miss, and the company will continue to incur the costs of AIDS-related morbidity and mortality. As a result, many large companies in South Africa and elsewhere have concluded that continuing to pay for private disease management services or health insurance is a worthwhile investment, despite rapidly expanding public sector programmes [27].

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Businesses have other ways to respond to the cost of HIV/AIDS

Most research and advocacy about the business response to AIDS have focused on HIV-specific programmes and policies. Companies have other ways of averting the costs of AIDS, however [16]. The private sector has greater scope than other employers to shift the economic burden of AIDS onto government, non-governmental organizations, households, and individuals. The phrase ‘shifting the burden’ has been used to refer to business practices that reduce a company's exposure to AIDS-related costs by transferring those costs to other sectors of society, such as households [16]. Common burden-shifting practices include pre-employment screening, reduced employee benefits, restructured employment contracts, outsourcing of less skilled jobs, casualization of previously permanent jobs, selective retrenchments, and changes in production technologies. These changes appear to be underway, to varying degrees, throughout the countries we have studied. Many of these changes are primarily responses to globalization and would have occurred in the absence of AIDS. The opportunity to minimize the costs of AIDS-related illness and death, however, may hasten or intensify these trends.

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For most small and medium-sized companies, HIV/AIDS is not a pressing issue

The surveys of SME in South Africa, Zambia, Kenya, and Uganda consistently found that HIV/AIDS ranked well below several other business issues as a concern for senior managers. Few managers report ever having discussed AIDS as a business issue, and fewer still believe that AIDS is having a serious impact on their companies. Most perceive little pressure to act from employees, shareholders, or other constituencies. While some managers may simply be misinformed, it seems unlikely that business leaders are systematically failing to notice sustained, major effects of the epidemic. A more likely explanation is that companies in Africa, and particular small and medium-sized companies, face myriad challenges to staying in business, ranging from power failures to high and unpredictable taxes to political instability. In such an environment, AIDS ranks low on the management agenda.

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Small and medium-sized companies do not have the resources to develop HIV/AIDS programmes

Most companies that have implemented an active HIV/AIDS programme have relied on dedicated human resources staff to lead the effort. Small and medium-sized companies typically do not have human resources staff, and other managers do not see enough impact to justify the investment of their own time to understand the epidemic, research the response options, and put them in place. Other deterrents to investing in HIV/AIDS programmes include relatively high employee turnover, lack of redundancy in the workforce that would allow individual workers to take time out to participate in HIV-related activities, individual rather than policy-driven relationships with employees, high discount rates, and a dearth of available cash. Smaller companies, moreover, cannot benefit from the economies of scale available to large companies. In a survey of HIV/AIDS service providers conducted in South Africa in 2004, we found that private service providers charged smaller companies, those with fewer than 250 employees, two to three times more per employee than they charged larger companies [33]. Expectations that large numbers of SME can be persuaded to establish HIV/AIDS programmes, without support from business associations or external funders, may therefore be unrealistic. Greater societal benefits may be obtained, moreover, by encouraging SME to focus on job creation, and relying on governments and non-governmental organizations to provide healthcare.

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Almost nothing is known about the effectiveness of workplace HIV prevention interventions

Many companies in sub-Saharan Africa have taken the advice of public health professionals over the past 15 years and implemented active HIV prevention programmes, including education and awareness campaigns, training of peer educators, distribution of condoms, treatment and prevention of other sexually transmitted infections, and the promotion of HIV testing. It is notoriously difficult to measure HIV prevention outcomes outside of clinical trials, and workplace settings are especially problematical, as a result of workforce turnover, changes in management policies and approaches over time, and inability to control for the effects of secular changes. Despite more than a decade of experience, we are aware of only one published attempt to measure whether these interventions have reduced HIV transmission substantially, marginally, or not at all. Disappointingly, workplace voluntary counseling and testing had no effect on HIV incidence among a large sample of employees of 22 companies in Harare, Zimbabwe [34].

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Little is known about the effect of antiretroviral therapy on worker productivity or labor costs

Highly active ART has been shown to extend survival and reduce HIV/AIDS-related morbidity in the vast majority of patients [35,36]. Although most research comes from United States and European populations, there is a growing body of evidence from Africa to suggest that treatment with antiretroviral agents is also effective in suppressing viral replication and restoring immune functions in African populations [37–39]. What is less clear is the extent to which ART will restore the productivity of workers and diminish the costs of untreated AIDS. The modelling in Table 6 assumed, arbitrarily, that treated workers would be nearly as productive as HIV-negative workers, but there is so far no evidence to support this assumption. Preliminary findings by other researchers are promising: absenteeism among Anglo American mineworkers, for example, returned to pre-AIDS levels approximately 6 months after initiating ART [40]. We and others are currently engaged in research to evaluate the effectiveness of ART in reducing the impact of AIDS on labor productivity and costs; the results are likely to be available within the year.

This paper has summarized 6 years of research on AIDS and the private sector in Africa. It has not been intended as a comprehensive literature review, but rather as a synthesis of a set of related studies. These studies have documented costs and impacts that are less damaging than many of us originally believed. On the other hand, the work has also strongly suggested that well-designed interventions can achieve the double benefit of reducing costs to employers while saving the lives and improving the welfare of individual employees. Rigorous evaluation of the outcomes and sustainability of interventions, including HIV prevention and care, as well as ART, is now the highest priority on the AIDS and business research agenda.

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Within the funding agencies, special thanks go to Neal Cohen of USAID/South Africa and Nana Poku of CHGA, who sponsored much of the research presented here. The authors also thank the many colleagues who participated in or contributed to the work cited here or commented on this manuscript, including Mary Bachman DeSilva, Margaret Bii, Yosef Burka, Paul Bukuluki, Alizanne Collier, Mark Colvin, Jill Costello, Matthew Fox, Eleanor Gouws, Petan Hamazakaza, Bruce Larson, Lawrence Long, William MacLeod, Kelly McCoy, Sarah Richards, Tobias Rinke de Wit, Ian Sanne, Donald Thea, Jeffrey R. Vincent, Alan Whiteside, and Brian Williams. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the participating companies or of the funding agencies and colleagues mentioned above.

Sponsorship: The research presented in this paper was supported by several funding agencies, including the US Agency for International Development (USAID), the US National Institutes of Health, the United Nations Commission for HIV/AIDS and Governance in Africa (CHGA), the AIDS Fond of the Netherlands, Right to Care, and PSP Ethiopia.

Conflicts of interest: None.

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