UNIVERZITA KARLOVA V PRAZE Fakulta sociálních věd Disertační práce rok 2005: Kateřina Kašová UNIVERZITA KARLOVA V PRAZE Fakulta sociálních věd Institut ekonomických studií SOCIOEKONOMICKÉ DOPADY HIV/AIDS V JIŽNÍ NAMÍBII Vypracovala: Školitel: Mgr. MPhil. Kateřina Kašová Doc. Ing. Tomáš Cahlík, CSc. 2005 CHARLES UNIVERSITY, PRAGUE Faculty of Social Sciences Institute of Economic Studies THE SOCIO-ECONOMIC IMPACT OF HIV/AIDS IN SOUTHERN NAMIBIA Compiled by Supervisor Kateřina Kašová Doc.Ing. Tomáš Cahlík, CSc. 2005 Prohlašuji, že jsem disertační práci vypracovala samostatně s použitím pramenů, které uvádím v přiloženém seznamu literatury. Ve Windhoeku, dne 22. srpna 2005 Kateřina Kašová I hereby declare that the thesis was compiled individually by me, using only the indicated literature and resources. In Windhoek, on the 22nd day of August, 2005 Kateřina Kašová M ACKNOWLEDGEMENTS I thank Doc. Ing. Tomáš Cahlík, CSc. for his guidance during my research, and also for his great patience. I also thank People in Need and the Ministry of Health and Social Services of the Republic of Namibia for the opportunity to carry out the research presented in this paper. I thank the Ministry of Foreign Affairs of the Czech Republic and the Faculty of Health and Social Studies at the University of South Bohemia for financial support for my research. I thank people living with HIV/AIDS for their courage to participate in the research, and their willingness to share their life stories with me. I thank Dr. Vyacheslav Verkhusha from the Keetmanshoop Hospital for information regarding the medical side of HIV/AIDS. I thank Julinda Gomaxas, without her help I could not have done the fieldwork. I am thankful to my colleagues Martin Konečný and Jakub Dvořáček for the interesting information, which they provided me with, and for their support. I am also thankful to Filip Hájek and Dita Votavová for assisting in data transfer. I thank Amara Sacco for making improvements to my English. Finally, I would like to thank my family and the Effenberger family for their moral support and care, without which I could not have done the research presented in this paper. 1 TABLE OF CONTENTS ACKNOWLEDGEMENTS 1 TABLE OF CONTENTS 2 FOREWORD 4 CHAPTER 1: Introduction HIV/AIDS Infection and Epidemic 6 CHAPTER 2: Literature Review Social and Economic Aspects of the HIV/AIDS Epidemic and Methodology 16 CHAPTER 3: Conceptual Framework and Research Design 70 CHAPTER 4: Description of General Settings Facts on Namibia and Karas Region 76 CHAPTER 5: Results Epidemiology and Demographic Impacts of HIV/AIDS 108 CHAPTER 6: Results Risk Environment and Susceptibility to HIV/AIDS in Namibia 123 CHAPTER 7: Results Susceptibility to HIV/AIDS and Impacts on Disadvantaged Communities of the Karas Region 154 CHAPTER 8: Conclusions and Policy Recommendations 203 RESUMÉ: Socio-ekonomické dopady HIV/AIDS v jižní Namíbii 214 BIBLIOGRAPHY 216 ENCLOSURES 230 2 Motto: It is crucial to approach AIDS as a disease of society, of political economy and culture - both of which can change – rather than simply as a virus spread by individuals. B.G.Schoepf (1991) The main asset of most poor people is their bodies...at a sudden blow, the body, the poor person’s greatest and uninsured asset, is devalued or ruined. From being an asset, at one stroke it becomes a liability that has to be fed, clothed, housed, and treated. A livelihood is destroyed, and a household made permanently poorer. R.Chambers (1989) 3 M FOREWORD Namibia is one of six countries facing the worst epidemic of HIV/AIDS in the world. HIV prevalence in the adult population of the Karas Region, the site of the study, in the southern part of Namibia, was estimated at 19 % in 2004. Since HIV/AIDS is a fatal sexually transmitted disease, for which there is still no cure, which kills people in their prime productive and reproductive age, it has many social and economic implications. The aim of this study is to identify the socio-economic factors of susceptibility to HIV infection and the determinants of vulnerability to the impact of HIV/AIDS in Namibia, with a special focus on the marginalized communities of the Karas region. The research will be concluded by a policy recommendation based on the findings on how to prevent the spread of the infection and to mitigate the impact of AIDS. Finally, the study in its entirety should help to clarify the relationship between the HIV/AIDS epidemic and poverty in Namibia. The research is driven by the need to analyze the social and economic determinants and impacts of HIV/AIDS in order to plan and focus the prevention and mitigation interventions in the area of HIV/AIDS in Namibian marginalized communities that are struck by the epidemic. Moreover, the research presented here should contribute to a higher awareness among Czech scholars and decision makers about HIV/AIDS, which represents one of the biggest developmental and public health threats in human history and the prevention and mitigation of which was identified as one of the development priorities of Czech foreign policy. Because HIV/AIDS is still a relatively unknown disease in the Czech Republic, the introductory chapter summarizes the information about the disease, its spread and provides the basic facts about the global epidemic of HIV/AIDS. Chapter 2 reviews the existing literature on the socio-economic impact of HIV/AIDS and provides the theoretical background for studying the epidemic. As HIV/AIDS, due to its special nature affects not only the bodies of infected people but also their families, society and economy, it requires a broad multidisciplinary approach. Therefore attention is also paid to the conceptualization of HIV/AIDS research. Chapter 3 includes the conceptual framework of the study, including the definition of the principal research questions, and provides detailed information on the rationale of this 4 research project, the applied methodology and the research design. The following section, Chapter 4, introduces Namibia and the Karas Region, mainly from a historical, social and economic point of view. It includes information on the public health care system in Namibia and a brief summary of existing HIV/AIDS programs as implemented by the Namibian government. In the Chapter 5, the epidemiology and demographic impacts of the HIV/AIDS epidemic in Namibia are analyzed to provide necessary background for the following socio-economic research. Chapter 6 presents findings on the macro-determinants of susceptibility to HIV/AIDS in Namibia, with a special focus on the role of income inequalities in the spread of the epidemic, while Chapter 7 summarizes results obtained from the research conducted in the marginalized communities of the Karas region, studying the factors determining the spread and impact of the disease at micro-level. Finally, Chapter 8 summarizes the conclusions obtained from the research and includes a broader discussion of the findings, as well as policy recommendations and suggestions for future research. 5 I. Chapter INTRODUCTION: HIV/AIDS INFECTION AND EPIDEMIC 1. 1. HIV/AIDS INFECTION AIDS is used as an abbreviation for the Acquired Immune Deficiency Syndrome. This disease was diagnosed for the first time in the United States in 1981. A retro-virus which causes the AIDS disease, called HIV (Human Immunodeficiency Virus), was identified two years later in 1983. While entering the blood system, the retrovirus attacks T-lymphocytes CD4 (a type of white blood cells), which co-ordinate the formation of antibodies and the immune system of a human body, and at the same time the retrovirus changes the DNA structure of the T- lymphocytes. Existing anti retroviral medicines such as AZT (Azidothymidin) can decelerate a process of replication of mutated white blood cells. However, they are not able to prevent the final failure of the immune system. Figure 1-1 The usual course of HIV/AIDS, from infection to death (CD4 cells are measured by the number of cells per cubic milliliter of blood, while the viral load is expressed as the number of copies of HIV counted per milliliter of plasma) 6 At the beginning, an HIV infection causes a pyretic illness, lasting between one to two weeks. After the first acute period lasting for about three months, the human body produces enough antibodies to temporarily reduce the amount of the virus in the blood (Figure 1-1). During the next chronic stage infected people may stay without any symptoms for many years. However, after this period, the number of antibodies finally begins to drop while the amount of the HIV virus gradually increases. The patient then suffers for about two years from the so-called AIDS- related complex, which typically includes high fever, gastroenteritis, weight loss, lymphadenopathy and weakness. This is later followed by more severe opportunistic infections finally causing death. The experience in Southern Africa is similar to that in most African countries:1 the most common opportunistic infections are typically TB (see Box 1-1), acute pneumonia, herpes infections (especially Herpes zoster), oral and lung candidiasis, Kaposi’s sarcoma, cancer and other severe bacterial infections. While in developed countries HIV/AIDS is becoming a chronic disease, due to antiretroviral treatment and holistic medical care, with which a patient can live for over ten or twenty years, in the countries of the global South, the span between infection and death is usually only five to eight years.2 Two major strains of the HIV retrovirus, which differ by virulence and infection pattern, were identified so far. The HIV-1 strain is responsible for the majority of infections world-wide and it is the most common type of HIV retrovirus in Southern Africa. The HIV-2 strain is often diagnosed in West Africa and a smaller number of cases were also identified in Angola, Mozambique, Zimbabwe and South Africa.