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A Continuing Global Epidemic

Geographic Trends
It is now quarter of a century since the first cases of AIDS were The AIDS epidemic is continuing to grow and there is evidence detected. In the intervening period, AIDS has killed more than 25 that some countries are seeing a resurgence in new HIV infection million people, orphaned millions of children and slowed economic rates which were previously stable or declining. In 2006, around 40 development, even reversing it in some cases. Around 40 million million people globally were estimated to be HIV positive and 2.9 people now live with HIV. The epidemic is growing in many parts of million died of AIDS (2.8 million died in 2005). : the world, but is worst in sub-Saharan Africa. Our study has looked atthe extent of the problem, its relevance to business and the various • Sub-Saharan Africa remains the worst affected region with South responses to it. It culminates in the examples of three major UK Africa’s epidemic showing no evidence of a decline. In 2006, companies and their approach to managing their exposures to the around 20% of working-age adults in South Africa had HIV.
disease in sub-Saharan Africa. These studies will serve as useful Approximately 25 million people in sub-Saharan Africa are HIV reference for comparison of the approaches taken by multinationals positive - almost 63% of global cases.
operating in similarly affected areas, be that sub-Saharan Africa orother low-income, high disease-rate regions.
• In the Middle East and North Africa, recorded HIV infection rates are very low, not exceeding 0.1%. However, available data Political Response
suggests that the epidemics are growing in several countries In 2001, at a session of the UN General Assembly, leaders from 189 including Algeria, Iran, Libya and Morocco.
Member States committed to targets for delivering effective HIVprevention, treatment, care and support. The aim is to start a reversal • In Asia, around 8 million people are HIV positive and recent of the global epidemic by 2015. This Declaration of Commitment on increases in infection rates are particularly evident in Indonesia, HIV/AIDS requires members to report regularly to the General Papua New Guinea, Vietnam, China, Bangladesh and Pakistan.
Assembly on progress, using indicators developed by The Joint United However, nearly two-thirds of all HIV cases in Asia are in India, Nations Programme on HIV/AIDS (UNAIDS).
due to the sheer size of the population rather than a highprevalence rate. Both India and China have the potential for The UNAIDS programme brings together the resources of ten UN major epidemics, driven in part by their growing mobility.
system organisations. Co-sponsors include UNICEF, InternationalLabour Organisation, World Health Organisation and the World Bank.
• The Caribbean region remains the second most affected region in As the directing and coordinating authority on international health the world. National adult HIV prevalence exceeds 2% in Trinidad work, the World Health Organisation (WHO) takes the lead in the UN and Tobago and 3% in Haiti and the Bahamas.
system on the global health sector response to AIDS.
• In Latin America, 1.6 million people are living with HIV, one-third Overall, leadership and political action on AIDS have increased of whom live in Brazil (the region’s largest country). However, significantly since 2001. Around 90% of reporting countries now have the most intense epidemics are in Belize and Honduras, both national AIDS strategies and 85% have a national body to coordinate with 1.5% of the population HIV positive.
AIDS efforts, while 50% have evaluation/monitoring frameworks.1 • In Eastern Europe, there are indications that infection rates have However, prevention programmes still reach only a small minority of increased sharply since 2004. The Russian Federation has the those in need. According to UNAIDS, in low and middle income largest epidemic in Europe, with estimates suggesting that 1% of countries HIV prevention programmes are failing to reach many of the population have contracted the disease.
those at greatest risk. Surveys indicate that fewer than 50% of youngpeople have comprehensive knowledge levels on HIV. Only about 10% • Even in North America and Western Europe things have stalled, of homosexual men and fewer than 20% of injecting drug users with the number of new infections not improving in the last two received any type of HIV prevention services in 2006. Between 2001 years, particularly among homosexual men, suggesting that HIV and 2006, the number of people on anti-retroviral therapy in low and middle income countries increased from 240,000 to almost 1.5million. Globally, however, anti-retroviral drugs still reach only one in Overall, 4.3 million new infections occurred in 2006; approximately five who need them. Ongoing obstacles to expanding treatment include the concentration of treatment sites in urban areas (ie. lack ofprovision to dispersed populations) and inadequate efforts to address The UNAIDS Executive Director, Dr Piot, summed up the above vulnerable populations such as sex workers, homosexuals, drug figures saying “It appears that countries are not moving at the addicts, prisoners and refugees. Another barrier is the number of HIV positive individuals who are unaware that they are infected, as they donot request testing. Testing must be voluntary and this is a majorweakness in the global fight against AIDS. However, the alternative inmany countries could be systemic discrimination. In China, forexample, the lack of guaranteed confidentiality is a potential problem. Company Response Examples
Anglo American
The company has 121,000 employees in Southern Africa and they Short-term trends in absenteeism
estimate the prevalence of the disease in the workforce is 23%(28,000 employees). Voluntary HIV testing and counselling is offered, and in 2006, 63% of their workforce took this up. Around 8,500 (30%) of their HIV positive employees have enrolled in disease management programmes of which some 4,500 are on anti- Anglo American has made a formal commitment to promoting HIV education and awareness in the areas where they operate, working with government authorities, NGOs and religious groups. They seek partnerships with donor organisations as a way of extending access to treatment to dependants and local communities. They also lobby national governments about the need to raiseawareness of the risks associated with HIV/AIDS at a national level. A proactive government prevention and education strategy will likelyreduce the burden on companies and improve the effectiveness of a Savings resulting from this reduction in absenteeism are “somewhere in the range of 20% to 60% of the treatment provision costs”according to Anglo, depending on the business involved. This The main challenge for Anglo American is to get all of their excludes any additional savings related to increased labour employees to know their HIV status voluntarily. This is not easily achieved as there is a fear that if they are HIV positive they will facediscrimination. Anglo American have attempted to address this fear The resultant reduction in hospitalisation costs has also produced through policies that prohibit discrimination against potential savings “within a range of 45% to 70% of the costs over the first 18 employment candidates based on HIV status, and also discrimination months of a worker’s anti-retroviral treatment provision” according against existing employees. The company had targeted 50% of employees to be voluntarily tested by the end of 2006, but after aslow start they actually achieved 63%.
Anglo American conclude from the analysis to date that, in the shortrun, the cost of ART is more than covered by the reduction in Once HIV infection has taken place, it typically takes 8 to 11 years absenteeism, reduced healthcare costs (particularly hospitalisation), before the onset of AIDS. Treatment can delay this onset. Companies retention of skilled employees and improved productivity. They such as Anglo American have developed ‘wellness programmes’ to report that 94% of employees taking medications are capable of a prolong the health of their HIV positive workers for as long as possible. These programmes include regular monitoring (CD4counts), the provision of anti-retroviral therapy (ART) for those at the A welcome side effect of the company’s efforts to tackle HIV is that relevant stage of infection, nutritional and psychological support. Of far fewer Anglo Coal employees are contracting tuberculosis (TB).
course, this requires voluntary testing to have taken place.
The number of new cases of TB has dropped by almost 75% since2001. Increased health awareness and medical testing as a result of Anglo American have been carrying out an economic evaluation of HIV programmes have led to early diagnosis and treatment of those the impact of HIV/AIDS since 2003 with the Aurum Institute for with TB. Because their immune system is weakened, people with HIV Health Research. The study has evaluated the impact of HIV and are at a much higher risk of developing active TB. Anti-retroviral AIDS without ART, and also the costs and benefits from treatment for HIV can help to prevent TB and other opportunistic Results to date show that HIV/AIDS costs to Anglo companies wouldconstitute 2% of payroll (range 0.12-2.55% based on 2003-2005 Dr Brink, who implemented Anglo American’s policy on making data) if ART was not available. The projected costs would peak treatment available to their employees, points out that despite the cost savings from less employee absence and avoidance of costs for Costs per patient on ART have been declining over time, due to death in service and pensions for dependents, “at the end of the day falling drug prices and the spreading of fixed costs over a greater it was a moral decision – it’s something that no employer in South number of patients. Two years of implementation cost between R915 (approx. £144) and R 1,700 (£267) per patient per month.
The cost of HIV testing is estimated at R116 (£8) per employee.
Offset against this treatment cost are short-term savings achievedthrough a reduction in absenteeism. Across business units,absenteeism shows a continual decline from 6-12 and 18 monthsafter commencing treatment, levelling off in later months. This isillustrated in the graph below.
Company Response Examples (continued)
The issue facing pharmaceutical companies such as GSK is a very Unilever have business operations throughout the world, and different one to those facing mining companies in areas of high therefore have businesses and local employees in areas of high incidence of HIV/AIDS. For GSK the main issue is access to their product. Before 2001, when the leading HIV drug companies set up They acknowledge that countries differ greatly in the quality of a partnership to tackle the issue, they received a lot of criticism from clinical infrastructure and the cultural attitudes to the disease.
NGOs about lack of HIV drug provision to developing countries. This Therefore, the role of the private sector must vary accordingly.
has been addressed by establishing an initiative with relevant UN Where public health systems prevail, Unilever’s contribution will agencies, called the Accelerating Access Initiative (AAI). The other concentrate on schemes of education and prevention. Elsewhere, members of this initiative are Abbott, Bristol Myers Squibb, Roche, direct involvement in treatment and care may be necessary. Their Merck, Boehringer-Ingelheim and Gilead.
policies are most advanced in sub-Saharan Africa where thecompany’s programmes have been developed over many years and Lack of political will and insufficient medical infrastructure are cited are shared widely with other companies and in society.
by GSK as the biggest barriers to accessing appropriate healthcare in The framework to manage HIV/AIDS addresses the needs of developing countries such as those in sub-Saharan Africa. However, individuals at key stages of prevention and treatment:- they are making efforts to help by making their essential medicinesas cheap as possible. For example their HIV/AIDS drugs are available • Awareness through educational programmes for all employees.
at not-for-profit prices to public sector customers and non-profitorganisations in these areas.
• Prevention (including prevention of occupational exposures; Shipments of Preferentially Priced Combivir, Epivir and GSK-Licensed • Establishing the HIV status of individuals through voluntary testing.
• Encouraging HIV positive individuals to receive treatment. (Access Unilever Kenya has had this framework in place for the last 15 years or so, operating a long running campaign to communicate to its employees about the disease. Initially this was a brave step as the condition was still a taboo subject. Early on in the campaign,Unilever Kenya recognised that the problem of HIV/AIDS stretched 126.3 206.3
beyond their own operations, and that working in partnership was the only way to tackle the causes. It therefore approached othermajor companies to pool their efforts in fighting the pandemic. This Combivir, their leading anti-retroviral is available for $0.65 a day.
coalition, called Neighbours Against AIDS meets regularly to share These not-for-profit prices include delivery and insurance costs.
ideas and experiences. It includes companies such as GSK, GM and Orders may be of any size, and the drugs will be available Partly as a result of the coalition, awareness of HIV/AIDS is now In 2006 they shipped fewer Combivir and Epivir than in the previous almost total among the Kenyan population, according to the year (see table above) because of more customers purchasing anti- Corporate Relations Manager. The Neighbours Against AIDS coalition retrovirals from generic manufacturers licensed by GSK. This, GSK is now concentrating on encouraging people to go for HIV tests and point out, demonstrates that their licencing policy is working.
to think about the risks associated with their sexual relationships.
In the last year, the generic manufacturers licenced by GSK havesignificantly increased their manufacturing capacity and ability to Unilever share their learning with other businesses, making their supply larger quantities of anti-retrovirals at lower prices. The programmes available as models on both the ‘Global Business company estimates that their licensed generic companies supplied Coalition’ and ‘Global Health Initiative’ websites.7 over 120 million tablets of their versions of Epivir and Combivir tosub-Saharan Africa.
The World Health Organisation has recently included abacavir as arecommended first line treatment. GSK subsequently managed toreduce the not-for-profit price of abacavir-containing anti-retroviralsby 30% and made their two new anti-retrovirals, Kivexa and Telzir,available at not-for-profit prices.
Product diversion has historically been a problem for pharmaceuticalcompanies, with not-for-profit medicines being illegally shipped backfor sale in wealthier countries. This denies treatment to patients inpoorer countries. In response, GSK has introduced anti-diversionmeasures such as supplying red rather than white Combivir andEpivir tablets.
A report from the Accelerating Access Initiative suggests that by theend of 2006 more than 738,000 people living with HIV/AIDS indeveloping countries were receiving treatment with at least one anti-retroviral supplied by the seven pharmaceutical companies in the AAI(compared to 220,000 people on treatment in 2004 and 600,000in 2005).6 Economic Impact
The macroeconomic impact of HIV/AIDS is difficult to accurately HIV/AIDS has most certainly not gone away, as evidenced by the predict, but there has been analysis of the issue. The disease numbers published by UNAIDS which are reported in this paper.
principally affects people in their most productive years of life Data quality on the prevalence, prevention and treatment of the (young adulthood) and thus has a negative impact on productivity, disease is not perfect, but has improved immensely since the 2001 healthcare expenditure, care demands, disposable income and UN Declaration of Commitment on HIV/AIDS, and serves to savings. In the long term this reduces the market size, reduces illustrate the size of the epidemic and the current situation of the human resources for production and investment and thus leads to various responses to it. Geographically, sub-Saharan Africa remains lower economic growth. Ongoing estimates by the World Bank the worst hit area, but growing numbers with the disease in other suggest that the macroeconomic impacts of the disease may be areas, particularly India, China and Russia, are cause for concern.
significant enough to reduce growth of national income by up to a The macro and micro impacts of the disease are of relevance to the third in countries with adult prevalence rates over 10%. companies in which we invest, to varying degrees and in differentways. The three examples demonstrate how different companies Beyond the macro impacts on companies (impact on markets, manage the impact that HIV/AIDS has on their particular business.
labour, savings and investments), there are two broad areas where These should serve as reference for the analysis of other companies HIV/AIDS is likely to impact on individual business operations: with significant operations in areas of high disease incidence,particularly in lower income regions.
(i) Declining productivity – increased absenteeism, increased organisational disruption (staff turnover, skills loss, declining morale) (ii) Increased costs – recruitment, training, insurance cover, health costs, funeral costs (where businesses provide this), supplying cheap/free aid (e.g. pharmaceutical companies).3 Another concern for companies is that they may be forced tocompensate for government policy shortcomings. Those businessesthat are affected by HIV/AIDS will need to have different responsesdepending on the quality of government response to the problemby the countries in which they operate. As a result of the importanceof a country’s response to the issue, many companies are attemptingto include the domestic government in their HIV/AIDS strategies.
They understand that they need to work with the government toensure an effective, holistic response to the disease. Many companiesare weighing up the benefits of internal programmes against relianceon public health programmes in the host country of their operations.
However, while 50% of business leaders expect the disease to havean effect on their operations within five years, less than 10% havetaken steps to conduct a quantitative HIV/AIDS risk assessment.4 Responses which have been identified as recommended action forcompanies operating in areas of high disease incidence include3:- • Create workplace policies to ensure help for infected employees • Provide grants to HIV/AIDS organisations; • Encourage other key players (public and business sectors) to get “2006 Report on the Global AIDS Epidemic”, UNAIDS, 2006.
“AIDS Epidemic Update 2006”, World Health Organisation & UNAIDS, 2006.
“The Business Response to HIV/AIDS: Impacts and Lessons Learned”, The Global Business Council on AIDS, The Prince of Wales Business Leaders Forum and UNAIDS, 2000.
“Business and HIV/AIDS: A Healthier Partnership?”, World Economic Forum, 2006.
“Update on Anglo American’s Response to the AIDS Epidemic in South Africa”, Dr Brian Brink, 2006.
“Corporate Responsibility Report 2006”, GlaxoSmithKline, 2007 “Combating HIV/AIDS in sub-Saharan Africa”, Unilever, 2006, and “Kenya: Fighting HIV/AIDS”, Unilever, 2006.
Standard Life Investments Limited, tel. +44 131 225 2345, a company registered in Scotland (SC 123321) Registered Office 1 George Street Edinburgh EH2 2LL.
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