HIV/AIDS could cost region up to 35 percent of GDP

World Bank report urges immediate action to stem spread

From The Daily Star in Beirut, Lebanon

WASHINGTON: The threat of an expanding HIV/AIDS epidemic that could cause extensive human, social and economic costs is looming large on the Mideast horizon, a new World Bank report says.

Although still benefiting from relatively low prevalence rates by international standards, with 0.3 percent of the population infected, the region risks a significant spread of the virus, which so far has largely remained unchecked. In 2002 alone, 83,000 people were infected with the HIV virus in the region.
Even by conservative estimates, the countries in the Middle East and North Africa (MENA) region will be facing a loss of up to 35 percent of today’s GDP by 2025, should the spread of HIV/AIDS persist.

“The present level of HIV is not high in most of the MENA region, with the exception of Djibouti,” says Carol Jenkins, World Bank consultant and author of the report HIV/AIDS in the Middle East and North Africa: The Costs of Inaction.

“But the threat seems real, given that the number of infections keeps rising. I personally believe the social and political stress in the region at this time could contribute to heightened vulnerability, particularly of young people. It is extremely important that the region’s leaders put AIDS on their agenda now.”
Since the early 1990s, the incidence of sexually transmitted infections, including HIV/AIDS, has been on the rise in the Middle East, and the total number of AIDS deaths has increased almost six fold.
Djibouti stands out as the most hard-hit country in the MENA region, with 2.8 percent of its adult population infected.

Inadequate surveillance methods and thereby poor data availability challenge an accurate assessment of the extent of the epidemic, and in turn, makes it difficult to develop prevention programs that are adapted to local needs. Further impeding initiative to prevent the spread of HIV/AIDS is the overly confident belief the governments have in the protective effects of social and cultural conservatism.
“The epidemic is still at the very early stages, and therefore there isn’t much awareness among the general public about the risk they are facing,” says Francisca Ayodeji Akala, public health specialist at the World Bank’s Human Development Group for the MENA region.

“There is also a lot of denial and this will create problems for the region, as it is in this sort of environment that the infection spreads most rapidly. Overestimating the protective effects of traditions and religion gives people a false sense of safety, thereby putting them at a higher risk. Furthermore, this denial results in HIV/AIDS not being very high on the development agenda of the MENA countries. When policymakers do not recognize it as a serious threat, it means that you will have insufficient resources channeled to combat the disease, such as resources for adequate surveillance systems. It’s a vicious cycle.”
Following the pattern of other regions, the HIV/AIDS virus finds breeding ground in the rapid social and economic changes that are underway throughout the Middle East. Migration, poverty, conflict, high unemployment rates, the low status of women, and the marginalization of certain groups are conducive to the spread of the disease, which translates itself into pockets of vulnerability throughout the region if care is not taken. This vulnerability, coupled with very little sexual health or HIV/AIDS education, creates a dangerous situation.
The primary groups of concern, are those that engage in risky behavior, such as sex workers and their clients, injecting drug users and men who have sex with men. Although these groups represent a minority, it is sufficient to spread the disease throughout society.

“Right now, nobody has any real information as to what is going on in these high-risk groups with regards to HIV/AIDS and how they interact with the general population,” says Akala. “We need to implement behavioral surveys, to understand how they put themselves at risk, as well as how they interact with the general population, thereby putting them also at risk.”
Most vulnerable to the transmission of the disease from the high-risk groups are migrants going to work abroad, refugees, prisoners, soldiers, mobile workers such as truck drivers, tourist industry workers, travelers, non-injecting drug users, and young people in general, who engage in pre-marital sex.
Vulnerability among youth is great, a fact revealed by the case of Tunisia, where 21 percent of all people infected with HIV are between 15 and 24 years. With migration playing a pivotal role in the economy of the Middle East, the risk of rapid spread is also high. In Lebanon, infected return migrants have often been businessmen trading with or residing in West or Central Africa, whereas in Egypt, many were workers returning from Gulf States.

The Bank report paints a dismal picture of the region’s future, should resources not be mobilized immediately to stem the tide of HIV. Rising poverty and unemployment, reduced investment in health and education services, orphaned children, are but a few of the many impacts on societies left in the wake of the HIV epidemic.
“Economic impact will differ by country, as there are vast differences in economic well-being across the region,” Jenkins explains. “As usual, the burden of providing health care to infected people is more easily borne by wealthier countries. When HIV reaches detectable levels in the general population, poor people get poorer and those on the edge of poverty often slip into true poverty. My report’s co-author, David Robalino, has shown that if left unchecked over the next 25 years, HIV could lead to as much as 35 percent decline in GDP.”
As a result, up to 30 million poor in the region could fail to escape poverty over the coming years.
First and foremost on the agenda for action to stop HIV/AIDS is the need to raise awareness of the disease in the region, so as to gather resources and political will to develop a national policy to combat it.

“The region as a whole needs information,” says Jenkins. “Proper surveillance for trends in prevalence levels of HIV and sexually transmitted infections and behavioral risks is essential. This requires openness about socially and religiously disapproved behaviors. Many people in the region don’t want to admit these practices are present, but will have to change if there is to be any progress. Second, where information indicates a concentration of infections in a defined group, as for example among injecting drug users and probably prostitutes in Iran, there must be immediate investment in prevention programs based on proven methods.”
The Bank’s report shows that the costs of investing in multi-sectoral interventions to reduce and mitigate the risk of an HIV/AIDS epidemic are significantly lower than the costs incurred by a full-blown epidemic.

“The region should stop considering the problem of HIV/AIDS as merely a health issue,” Anne Maryse Pierre-Louis, Lead Health, Nutrition and Population Specialist at the World Bank’s Africa Human Development Team, who directed the preparation of the report, adds. “It’s a multi-sectoral problem that requires us to work in partnerships. This is a change in attitude that is needed from all parties involved in the region, including the World Bank, if they want to mobilize the resources needed to address this issue seriously.”
A few positive developments are already on the way. Over the past two years, a number of countries have initiated strategic planning on HIV/AIDS, involving both health sectors and others. Following in the footsteps of Morocco, one of the earliest in the region to develop a national HIV/AIDS strategy, Egypt, Jordan, Lebanon, and Syria are planning or conducting an assessment of HIV/AIDS in their countries, while Algeria, Djibouti, Iran, Yemen and Sudan have already formulated their strategic frameworks.

“The region has a very good chance of slowing down the number of new infections,” Jenkins says. “But it has to make a move quickly. Having low HIV prevalence is a kind of blinder- it blinds people from seeing what could happen and puts HIV low on the list of priorities.”

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