Prevention without cure

affects 40m people worldwide. Not only is it potentially fatal for individuals,
it also wields a devastating blow for HR operations. What can companies in
high-risk countries do to educate their workforce on ways of catching and
passing on the HIV virus? Our global correspondents report

For many years, businesses in South Africa considered AIDS to be a
humanitarian issue. While they couldn’t ignore the overflowing hospital wards
filled with emaciated AIDS sufferers, exploding graveyards, or tens of
thousands of orphaned children, for most companies the disease belonged on
charity agendas, not in HR departments.

Now, two decades after the first cases were discovered, businesses are
beginning to realise AIDS is their problem too.

Because AIDS is primarily a sexually transmitted disease, it tends to infect
young and middle-aged individuals who are most sexually active. The South
African workforce is one of the highest risk segments. As an increasing number
of infected employees become ill, companies are seeing rising costs from AIDS
absenteeism, higher burial costs and employee replacement.

With AIDS already hitting bottom lines, the worst of the epidemic is yet to
come. Companies are getting serious about AIDS prevention programmes and the
treatment of sick employees. Hoping to keep healthy workers from contracting
the disease and infected employees at work longer, companies are implementing a
whole range of programmes, from peer education to special AIDS-oriented
healthcare schemes, in the hope that investment now will stave off the worst of
the crisis.

"People are starting to understand the financial impact of the HIV/AIDS
pandemic on their companies, markets and productivity," says Brian
Wasmuth, head of the HIV/AIDS programme at the South African Chamber of
Commerce. "They are realising that investing money into managing the issue
will probably be cheaper than addressing the aftermath of AIDS in their
companies. It sounds rather mercenary, but it’s pure economic rationale."

For HR, AIDS is adding a whole host of extra burdens. Particularly in
hardest hit companies, HR is having to evaluate expensive benefit and insurance
packages and address rising absentee rates by changing the way they manage
labour. On a less tangible level, it is also beginning to look at how AIDS
deaths are affecting morale and productivity.

Charles Kendall, HR manager at Lonplats – a platinum mining company with
about 20,000 employees – says AIDS is forcing the company to make a number of
changes in the way it manages and allocates its workforce. In addition to
launching a whole host of AIDS education and health programmes, it is fast-tracking
training efforts to ensure it has enough skilled workers to run its mines,
trying to find ways to convert hard labour positions into less strenuous ‘smart
jobs’, and looking at new methods of mechanisation.

"It’s certainly a challenge, but it also offers new
opportunities," he says. "We’re being forced to come up with new
ideas and policies to make our operations more effective."

The AIDS statistics for South Africa, the continent’s economic giant and a
country among the most AIDS-ravaged in the world, are certainly grim. The UN
estimates more than 4m adult South Africans between 15 and 49 years old – or 20
per cent of all South African adults – are HIV-positive. Government statistics
show that AIDS is now the country’s number one killer. By 2010, one AIDS
researcher estimates the disease will cut the life expectancy of South Africans
by more than 10 years, to below 40.

Many South African companies are finding infection rates among their own
workforces are in line with, or above, countrywide projections.

Hardest hit are companies with largely unskilled labour forces such as
mining, construction, manufacturing and trucking. Companies with more highly
skilled workforces, particularly in the IT sector, are also reporting increases
in HIV rates among well-educated, mobile, young professionals.

On a macroeconomic level, the effect of these statistics on the South
African economy will be devastating. ING Barings predicts AIDS will reduce
South Africa’s growth by 0.4 per cent a year. The Bureau of Economic Affairs
offers slightly starker statistics. It estimates South Africa’s real GDP will
be 5.7 per cent by 2015.

Quantifying the economic impact of these AIDS statistics can be difficult
and varies from company to company, based on variables such as infection rate,
skill level of employees and the quality of healthcare offered. No company will
emerge unscathed. Although organisations with more highly skilled labour forces
may lose fewer employees, the cost of replacing them and of lost productivity
due to sick leave may be higher.

Alan Whiteside, director of the Health Economic and AIDS Research Department
at the University of Natal believes the highest expense to companies will stem
from increased absenteeism and burial costs. Expenses due to funeral attendance,
labour turnover, training, recruitment and healthcare will also contribute to
increased payroll costs.

Because it can take several years for AIDS symptoms to appear, analysts also
estimate the economic effects on companies will increase in coming years,
peaking around 2010.

As HIV-positive individuals become increasingly ill over a period of many
years and South African law prevents the dismissal of employees for medical
conditions such as AIDS, companies will be left with a workforce increasingly
unable to perform its duties.

Sugar giant Illovo found that in one South African mill with a 26 per cent
infection rate, HIV-positive employees missed an average of 55 extra days to
illness during their last two years of life. Absentee rates at another manufacturing
company with a 66 per cent infection rate are already so high the company has
been forced to hire two employees for every factory position to keep the
company running.

"If HIV/AIDS was a disease that killed people quickly, it wouldn’t be
such a big problem for companies," says Dr Jack van Niftrik, medical
officer for Lifeworks, a specialised healthcare network that helps companies
manage AIDS among their employees.

No-one argues that stopping the spread of the disease is the best solution.
But even if companies can stem infection rates, the economic toll of caring
for, and replacing, already infected employees will be high. An increasing
number of companies are finding they can reduce AIDS-related costs by investing
in medical care that will keep their employees at work longer.

Large companies such as Anglo-American, Illovo and DeBeers, which already
offer their employees onsite medical treatment, are in the best position to
effectively treat AIDS and AIDS-related illnesses. Most of these companies have
already begun specialised AIDS training for their healthcare professionals and
a few, including Anglo, are considering offering expensive antiretroviral drugs
to infected employees.

Antiretroviral regimes are commonly used to extend the lives of HIV-positive
individuals in first-world countries, but remain too expensive for people in
the developing world. In South Africa, access to such drugs has become a major
political battleground and AIDS activists have been pressuring the government
to provide them in public health clinics.

Since the government continues to doubt the efficacy of such drugs, however,
it will likely be business which first makes them readily available to large
numbers of poor South Africans.

The price of such drugs – which once cost well over $1,000 a month – is
decreasing dramatically as pharmaceutical companies drop their developing world
prices. And new laws are paving the way for the sale and manufacture of generic

"There is the hypothesis that the cost of providing antiretroviral
treatment will be offset by the benefits gained by people being well rather
than sick," says Brian Brink, Anglo-American’s vice-president of medical
affairs. "But price has, and always will be, a huge obstacle."

Anglo announced last year it plans to offer antiretrovirals to its 32,000
employees, but it has not yet said when that programme will begin.

Healthcare professionals emphasise, however, that even without
antiretrovirals, many less expensive kinds of healthcare can extend the life of
someone who is HIV-positive. Simply providing early intervention, good
nutrition and rapid treatment of opportunistic diseases, for example, can keep
people productive for an additional five to 10 years.

Still wary of investing in expensive antiretroviral programmes that are
difficult to monitor, many of South Africa’s largest companies have chosen to
simply create specialised healthcare programmes for people with AIDS within
their existing healthcare structures.

Illovo Sugar, for example, has created a "wellness programme"
within its healthcare structure, designed to reduce a patient’s susceptibility
to opportunistic diseases. Companies believe one advantage to programmes like
this is it makes it clear to employees that there is an incentive for getting tested.

"Really what it is saying to the workforce is, if you have a problem,
here are channels you can go to for help," said Nigel Hawley, Illovo’s HR
director. "We were finding that initially a lot of people were hesitant to
come forward, but that is changing now."

Even smaller companies which currently offer little or no healthcare to
their employees are finding the cost of the AIDS crisis may force them to begin
offering some sort of treatment, even if antiretrovirals remain too expensive.
As few of these companies have the infrastructure to provide healthcare and
most insurance companies will not insure HIV-positive individuals, a host of
new companies have developed to meet this need.

Lifeworks, for example, offers AIDS medical care to companies at a monthly
cost of between 10 and 60 rand (approximately $1-5) per employee, with
programmes at the high end including antiretrovirals. The South African Chamber
of Commerce is also working on developing an AIDS healthcare network that would
be available to 40,000 member companies, most of which have fewer than 100

Many companies, however, are finding that no matter how generous the
healthcare options they offer employees, without education, the
best-intentioned AIDS programmes will yield few results. Since companies cannot
force staff to get tested and the results are confidential, employers can do
little to help them unless employees come forward with their HIV-status

"We don’t know who is HIV-positive," says Brink. "We don’t
want to know from a management perspective, but we want our healthcare services
to know."

In 1997, Pick ‘n Pay, a South African supermarket chain with 30,000
employees, began offering free antiretroviral treatment to rape victims and
HIV-positive pregnant women. Short regimes of these drugs, such as AZT,can
reduce the chance of an infected mother passing the disease on to her child and
can prevent women exposed to the disease, such as rape victims, from becoming

Despite widespread publicity about the programmes, however, few women
stepped forward to take advantage of them. Pick ‘n Pay realised it needed to be
more proactive about AIDS awareness and change its employees’ attitudes towards
the disease.

"For two years we battled to get people to come forward and say they
needed these programmes," said Raziya Girie, director of the company’s
AIDS training programme. "They were worried about being ostracised and
believed if they told people their status, their co-workers wouldn’t speak to
them anymore."

Last year, the company began training peer AIDS educators in each of their
more than 100 stores. Drawn from rank and file employees, the peer educators
were taught about how AIDS is transmitted, safe sex, where employees can get
tested and what healthcare schemes and counselling are available to those who
test positive.

Girie says the peer education programme has dramatically changed employees’
attitudes towards AIDS and made Pick ‘n Pay stores a more open environment for
those who do test positive. The number of employees taking advantage of the
antiretroviral programme has skyrocketed and an increasing number of workers
have revealed their HIV status. In one store, for example, six out of 20
employees participating in a peer education session admitted they were
HIV-positive and asked how they could get help.

Susan Hyde, a consultant who helps companies create HIV programmes, said
peer education can be an incredibly effective way of changing employee
attitudes about AIDS. She warned, however, that for such programmes to be
successful on a long-term basis, companies need to give peer educators
institutional support in the form of budgets, ongoing training and managerial
and emotional support. Since only a handful of large companies have created
departments specifically to deal with HIV/AIDS, much of that burden often falls
on HR.

"You can’t just train peer educators and then leave them unsupported
and expect the programmes to keep running," she said. "You wouldn’t
take a diamond miner, teach him how to run a diamond mine, and then let him do
it alone. You can’t do that with peer educators either."

Hyde also said effective peer education programmes must target employees’
specific beliefs about AIDS. In one company she worked with, for example, a
survey indicated that 30 per cent of employees believed AIDS is caused by
enchantment from witch doctors.

"Unless you create a peer education programme that addresses
enchantment as a form of transmission, you’re going to miss the boat," she

Dealing with touchy cultural issues can be difficult, especially in South
Africa, where most managers are white and most rank and file employees are
black. Hyde and other AIDS consultants counsel companies to get various
stakeholders, such as unions, involved in AIDS programmes from the beginning.

There are no easy answers for South African companies grappling with AIDS
and no company claims to have the perfect prevention and treatment programme.
But as the economic costs of the disease increase, few companies can afford to
ignore the coming crisis.

As a sign of how seriously most companies are taking the HIV/AIDS issue, the
impetus for the majority of AIDS programmes is coming right from the top of
company structures, the CEOs and company presidents.

Although much of the burden of managing AIDS programmes will continue to
fall largely on HR, an increasing number of companies are realising AIDS is
more than a labour issue. It’s something that will affect long-term profits and

A US snapshot
By Liz Simpson

Although some 800,000-900,000 people
now live with HIV in the US, and over 750,000 have full-blown AIDS*, it is
impossible to put an accurate figure on the extent of HIV/AIDS in the
workplace. Under the terms of the Americans with Disabilities Act (ADA),
employers with more than 15 staff members are prohibited from making
disability-related enquiries or medical examinations before making a job offer,
to prevent discrimination against those with ‘unapparent disabilities’ such as
cancer, mental illness or HIV/AIDS.

Only when an employee requests a ‘reasonable accommodation’,
requiring job restructuring, reassignment or a modified work schedule, for
example, would someone with HIV or AIDS have to disclose their condition at
work – hence many thousands may be working for employers who have no idea these
workers are

The US – and in particular states such as California, Florida
and New York that report the highest number of AIDS cases among residents –
has, for 20 years, been ahead of the wave in terms of research, education and
legislation about this issue. This was largely spearheaded by the very large
and sophisticated gay communities in California and New York, which prompted
the US government to instigate a massive public health education effort,
including a brochure about AIDS transmission that went to every household.

Dr Kathleen Montgomery teaches diversity management courses at
the University of California at Riverside. AIDS in the workplace, which she has
studied since the mid-80s, is a major component of her course. She recognises
three distinct stages in the manner in which this issue has progressed in the

"Early on – before the ADA was passed – there was an
assumption among employers that someone who got infected with HIV would quickly
progress to AIDS and soon become too sick to work. Therefore many believed that
while this was a social issue, it wasn’t a workplace issue because such people
would quickly die," reports Montgomery.

"When the ADA was passed in 1990 we experienced a swing to
the other extreme with employers believing they had to have non-discriminatory
policies specific to HIV/AIDS. However, today we’ve seen the number of specific
HIV/AIDS-related policies drop back as organisations find their standard
policies cover this issue sufficiently."

Despite educational and legislative advances, US HR
professionals still grapple with challenges around HIV/AIDS.

"One issue here that is, I believe, unique to HIV/AIDS and
isn’t being covered well is what to do about the career development of
employees who formerly asked to go part time, take on less demanding work or
maybe a leave of absence and now, because of advances in their medication, feel
much better and want their employers to invest in their training and
development," says Montgomery.

"Under the terms of the ADA, companies are not supposed to
discriminate in any employment decision on the basis of illness, but this is a
new issue that hasn’t been thought about before by managers."

Another challenge for HR comes from trying to balance the
interests of employees with HIV or AIDS while addressing the concerns of
co-workers who worry about workplace risk. This is where workplace training can
pay dividends. One American Airlines executive states in a recent Business
Responds to AIDS programme document: "As a result of our HIV/AIDS in the
workplace efforts, our workforce is much more at ease with addressing these
issues. That in turn has reduced lost time and increased productivity. In that
sense, it’s a real bottom-line plus."

One inspiring example of what can be done to support and
reassure all employees comes from San Francisco-based law firm Heller Ehrman,
which has had a long tradition of hiring and advancing minorities, including
self-identified gay men and lesbians, to reflect the diversity of the community
in which it practices.

HR director David Sanders explains: "For the past six or
seven years, we’ve brought in a company called Life Theatre which put on
interactive plays about reactions to people with HIV and AIDS. The material
approaches the issue from a number of perspectives in a fun, informative,
sympathetic and memorable way.

"People’s knowledge about HIV and AIDS needs to be
reinforced regularly. Doing something like this once a year is not too
much," adds Sanders. His colleague, Pat Gillette, who co-chairs the firm’s
Labor & Employment National Practice Group, believes HIV/AIDS will always
be treated differently to other disabilities in the workplace until the
attendant prejudice is stamped out.

"Dealing effectively with this issue goes hand-in-hand
with the elimination of prejudice," says Gillette. "Employees need to
be educated to realise they can’t just ‘catch’ HIV/AIDS, but also that just
because it can be more prevalent among members of certain sexual orientation or
lifestyle it doesn’t mean co-workers should be treated differently to any other
person in the workplace."

Twenty years on, the US still needs to get over both hurdles.

*According to latest figures (to December 2000) from the
Center for Disease Control and Prevention

By Ed Peters

August, Thailand’s Public Health Ministry reported that AIDS is now the leading
cause of death in Thailand, overtaking accidents, heart disease and cancer. The
ministry also admitted that the figure of 1m AIDS deaths to date is probably
incorrect, as many families are reluctant to report the real cause. More
worryingly, the United Nations Programme on HIV-AIDS (UNAIDS) office estimates
that Thais who were infected at the beginning of the epidemic 10 years ago, would
now start to sicken and die in large numbers, creating a potentially disastrous
AIDS "bubble".

"Thailand is trying to make an international name for
itself in the IT and related fields, promoting its growing expertise and the
relatively low cost of doing business here," said one HR professional.

"But do the maths. If the so-called ‘AIDS bubble’ is
coming, it is going to hit the late 20- and 30-somethings who became sexually
active in the early 1990s."

After initial reluctance, the Thai government, prompted in part
by international health organisations and lone crusaders such as former Health
Minister Mechai Viravaidya, have been attempting to tackle the problem with
some success.

For instance, don’t expect to be offered an after-dinner mint
at any of the outlets of the C&C restaurant chain in Thailand. Instead, the
bill comes with a saucerful of condoms.

The chain – Cabbages & Condoms – is Viravaidya’s
brainchild, who has linked one of Thailand’s most popular vegetables with
something he thinks should be equally commonplace. Profits from the restaurants
fund his Population and Community Development Association, set up in 1974.
Other promotional stunts include handing out condoms to aghast CEOs at World
Bank meetings and paying Thai farmers to paint condom adverts on their water

It is therefore no surprise that Mechai has become the slang
term for condom in Thailand, yet his high-profile tub-thumping is a rarity
among the country’s employers. But while he has made great strides in promoting
condom use, according to the UNAIDS office in Bangkok more than 1m people have
been infected with AIDS in this kingdom of 60m.

Tourism is a major foreign currency earner and the sex trade
remains undiminished, despite recent government regulations curbing opening
hours in the red lightdistricts.

But AIDS and HIV are by no means restricted to tourists or sex
workers. Traditionally, many Thai males keep mistresses and visit prostitutes
as a matter of course, practices to which wives and girlfriends are expected to
turn a blind eye. Coupled with this is a general public reluctance to
acknowledge the presence of AIDS, which means that those afflicted may be
shunned by family and friends. And of course employers.

"Many of the sex workers are poorly educated and poverty
stricken, so they may well not know about preventing sexually transmitted
diseases. They may also be seduced by extra cash not to use condoms," said
one HR professional, who tellingly asked not to be identified.

"Once it becomes evident a worker has contracted HIV, they
will probably be thrown out of the bar or brothel where they work, and there is
no question of any benefit or compensation.

"Customers who contract the disease are likely to cut
themselves off from their job and family as its effects take their toll, but as
yet this has not impacted the workforce significantly."

While prostitution remains illegal, the Thai government has
launched a pragmatic initiative to promote condom use in commercial sex

As a result, according to research monitored by the World
Health Organisation, condom use has increased to a reported 90%, while HIV
infection rates among 21-year-old military recruits is down to below 1.5%.

Mechai Viravaidya is fond of saying that nowadays condoms – not
diamonds – are a girl’s (and presumably a boy’s) best friend. While he and many
like him have done enormous amounts to combat AIDS, it remains to be seen
whether the disease is now under some measure of control, or whether over the
next decade it will wreak havoc with the Thai workforce.

Russia’s silent danger
By Ben Hooson

Russia has the fastest growing rate
of HIV in the world. Registered cases have skyrocketed from around 1,000 to
nearly 200,000 in six years due to an epidemic among intravenous drug users,
which is now spreading outwards through sexual contact. But national provisions
governing HIV prevention, the status of HIV-positive citizens and their rights
to employment, reflect an acute state of denial in Russian society and the
political establishment.

The country has effectively built a Potemkin village for its
AIDS patients. Count Potemkin was an 18th century Russian grandee, who built
fake ideal villages to ensure the success of provincial tours by the Empress,
Catherine the Great – a lady whose sex life would have put her in a high-risk
group if AIDS had existed in those times.

Russia’s HIV Potemkin village is reflected in a finely worded
law and government resolution from 1995. According to law articles, people do
not have to quit their jobs due to HIV unless their performance is seriously
impaired (blindness for bus drivers and so on) and do not need to test for HIV
when applying for a job – unless it involves laboratory or medical work with
human blood.

The reality is quite different. According to international
professional services firm Deloitte Touche & Tohmatsu, foreigners must take
an HIV test to obtain a Russian work permit, and the result submitted cannot be
more than three months old. A photograph of the applicant, the work permit
request, the test result and a fee are then provided to the authorities issuing
the work permit.

Non-Russians must also have an HIV test to obtain a multi-entry
visa, which is valid for one year and must be renewed abroad. This means every
year the applicant must obtain another HIV test, leave Russia to go to another
country with a Russian consulate/embassy and provide them with pictures, HIV
test, passport, forms and money.

Gennady Roshupkin, one of Russia’s top AIDS activists, has
worked in the Moscow office of Medecins sans Frontieres and helped set up the
leading Russian AIDS support organisation, AIDS Infoshare. He says 99 per cent
of people who are known to be HIV-positive cannot find or hold down a job.

"The boss invites the person into his office and says
‘either you quit, or we find a legal excuse to fire you’. I do not know of a
single case where the employee has contested that treatment in court:
application of the law is difficult because necessary rules on implementation
do not exist, and the person could not go on working in such an environment
anyway," Roshupkin says.

Sites in the, Russia’s rich world of Internet
resources, contain complaints from HIV sufferers about the employment dead-end.
One woman with a work history in retail says she was turned away by McDonalds
in Moscow: "They told me I had to get tested. I know for certain McDonalds
does not employ HIV-positive people."

It proved impossible to track down a McDonalds representative
who would answer questions, but Natalia Shukina, a representative of another
big employer in Russia, Procter & Gamble, was brusque in reply to an
enquiry about the company’s HIV policy: "We have not come across the
problem and I cannot give any comment."

The job situation is one of the reasons why the AIDS epidemic
in Russia stays hush-hush, and why the official HIV positive figure of 200,000
is probably a gross underestimate. Roshupkin explains: "People do not want
to get tested because as long as they do not know for sure whether they are HIV
positive, nobody else knows either, and they can go on living and working

Indeed, Arek Majszyk, the UN AIDS representative for Russia,
makes no secret of his scepticism about official statistics on HIV infection:
"Our specialists multiply the official figures by minimum two times and
maximum five times – nobody really knows how many cases there are."

Due to a lack of open debate and information campaigns, public
attitudes to HIV have remained where they were in the US and Europe at the
start of the 1980s. AIDS is seen as limited to homosexuals and social
inadequates. Recruitment agencies in Moscow refer to the letter of the law but
claim no direct experience with HIV-positive job seekers. Artyom Denisyuk of
Coleman Services, an international agency working in Moscow, says employers
have never specifically asked for non-HIV candidates, and the question has not
arisen for any of the 8,000 personnel placed over the last two years.

That could be due to the current profile of many HIV-positive
Russians – young drug users, often living at home and unwilling to press their
claim to rights and independence. Unfortunately, recruiters may have soon have
to grapple the problem as HIV moves into broader sections of Russian society.

Further informatiom – AIDS in
South Africa  – The Centers for Disease Control &
– AIDS cases by US state – the
‘Business Responds to AIDS’ and ‘Labor responds to AIDS’ site includes ‘the
manager’s kit’ and ‘Labor leaders kit’ – information
on sexual orientation

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