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Hiv/aids workplace interventions in south africa and the united states


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Hiv/aids workplace interventions in south africa and the united states
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Reed, Joel Christian
University of South Florida
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ABSTRACT: This thesis focuses on the private sector response to the human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) in the Republic of South Africa (RSA) and the United States (US) in multinational businesses and corporations. From an epidemiological perspective HIV/AIDS and its co infections cause acute and chronic illness in the workforce leading to programs and interventions of various complexity and effectiveness. Workforce HIV/AIDS epidemiology in South Africa and the US is reviewed and discussed. From a critical medical anthropology perspective multinational corporations are political and economic entities with immense resources and power over people, communities, and governments globally. Corporate culture becomes important in the design of prevention and treatment strategies.
Thesis (M.A.)--University of South Florida, 2005.
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HIV/AIDS Workplace Interventions in South Africa and the United States Joel Christian Reed A thesis submitted in partial fulfillment of the requirements for the degrees of Master of Arts Department of Anthropology College of Arts and Sciences And Master of Public Health Department of Epidemiology College of Public Health University of South Florida Major Professor: Nancy Romero-Daza, Ph.D. David Himmelgreen, Ph.D. Skai Schwartz, Ph.D. Date of Approval: April 15, 2005 Keywords: HIV/AIDS, business, monitoring and evaluation, multinational corporation, medical anthropology, epidemiology Copyright, 2005, Joel Christian Reed


i Table of Contents List of tables iii List of figures iv Abstract v Introduction 1 Literature Review HIV/AIDS epidemiology overview 3 HIV/AIDS epidemiology in the workplace 9 HIV/AIDS in multinational companiesthe economic impacts 18 Legislationdiscrimination in the workplace 29 The business response to AIDS 36 Workplace intervention evaluation 48 Medical anthropology; relevant theories and perspectives 55 Critical medical anthropology, political economy, and participatory action research 60 Political ecology 75 Multinational companies, urbanization, and HIV/AIDS 78 Research Setting The Global AIDS Program 88 Internship goals and objectiv es 90 Experiences and events 93 Methods 96 Results Company Profiles 101 Policy development 105


ii Prevention, education, and awareness 108 Peer education 115 Care, support, and treatment 120 Voluntary Counseling and Testing 124 Anti-Retroviral Therapy 128 Community Involvement 131 Discussion Implementation and Success 137 Ways Forward-lessons learned from stigma 144 Involving people with AIDS and other unique initiatives 146 Conclusion 148 References 153 Appendices 169 Appendix I Appendix I-A: PWHAs in the labor force 170 Appendix I-B: GDPs and losses due to AIDS 171 Appendix I-C: PWHAs unable to work because of HIV/AIDS 172 Appendix I-D: Cumulative mortality losses in workforces due to HIV/AIDS 173 Appendix I-E: Orphans and annual working age deaths due to HIV/AIDS 174 Appendix I-F: Economic and Social Burden increases due to HIV/AIDS 175 Appendix I-G: Current impact of HIV/AIDS on businesses 176 Appendix I-H: Future Impact of HIV/AIDS on businesses 177 Appendix I-I: Businesses with and wit hout HIV/AIDS policies 178 Appendix I-J: Urban households with piped water, LDCs by Region, 1990s 179 Appendix II-Abbreviations used in th is document 181


iii LIST OF TABLES Table 1 Global summary of the HI V/AIDS pandemic 4 Table 2 Regional HIV and AIDS statistics 5 Table 3 Costs of HIV/AIDS to business 20 Table 4 Doubling time for the human population 84


iv LIST OF FIGURES Figure 1 Flow Chart-HIV/AI DS Economic Impacts on Business 21 Figure 2 Population Growth Rates in Urban and Rural Areas, 83 Less and More Developed Countries, 1975 to 2000 and 2000 to 2025 Figure 3 Percent of Population Li ving in Urban Areas in Major World 85 Regions, 1950, 1975, 2000, and 2025


v HIV/AIDS Workplace Interventions in South Africa and the United States Joel Christian Reed ABSTRACT This thesis focuses on the private sector response to the human immunodeficiency virus and acquired immune deficiency syndr ome (HIV/AIDS) in th e Republic of South Africa (RSA) and the United States (US) in multinational businesses and corporations. From an epidemiological perspective HIV/AI DS and its co infections cause acute and chronic illness in the workforce leading to programs and interventions of various complexity and effectiveness. Workforce HIV/AIDS epidemiology in South Africa and the US is reviewed and discussed. From a critical medical anthropology perspective multinational corporations are political and economic entities with immense resources and power over people, communities, and gove rnments globally. Corporate culture becomes important in the design of preventi on and treatment strategies. Working with the Centers for Disease Control and Prev entions (CDC) global AIDS program (GAP) allowed the researcher to conduct key informan t interviews and part icipant observation in five multinational businesses in South Africa. Important issues are raised regarding workforce education, stigma, workplace and co mmunity relationships, rapid-saliva versus


vi blood sample testing, and the need for more disclosure and involvement of people with HIV/AIDS (PWHAs) in the workplace. In li ght of increasing globa l capitalization, poor government services for prevention and tr eatment, and the fact that HIV/AIDS discrimination is a human rights abuse, from a collective standpoint businesses have been slow to respond to HIV/AIDS, in southern Africa as well as in the United States, and should make it a core component of corporate social responsibility (CSR) strategies regardless of disease prevalence in the workforce.


1 INTRODUCTION Corporations, businesses, and other priv ate sector enterprises possess enormous resources globally often to th e point of rivaling host c ountry governments. On-site clinics or hospitals, the staff needed to run them, dependable transport and communications capabilities, and the availabil ity of secure warehouses for storage place many large businesses in less developed countri es (LDCs) in an excellent position to cooperate with and participate in public health surveillance and prevention efforts. In more developed countries (MDCs) the private sector offers medical benefits packages which can shelter an individual from personal economic ruin due to HIV. In many cases the actions and influences of large busi nesses are far-reaching and long lasting. Corporations draw individuals into situat ions where HIV may be more prevalent, such as urban areas, and certain industries directly increa se vulnerability. Townships spring up around factories in Africa and migrants travel and leave family in order to participate in wage earning activities. U.S. citizens often move to metropolitan areas pursuing work as well, in places such as New York City, Los Angeles, and Miami, cities which have the highest HIV infection rates in the US. Multinational corporations are able to develop and nurture the partnerships necessary to produce and obtain educational materials, lab tests, and drugs on a consiste nt basis through global contacts. They are


2 capable of supporting many of their workers in a variety of ways. This paper focuses on the private sector response to HIV/AIDS in multinational corporations and workplace initiatives to combat the disease, in the Re public of South Africa (RSA) and in the United States (US). These countries are the only two industrialized countries failing to record mortality data by socioeconomic status (Navarro 1990). Workers spend a significant amount of tim e at work and are captive participants for prevention campaigns as well as treatmen t regimens. There are direct costs for businesses that are unavoidable and signi ficantly less damaging if HIV/AIDS is addressed rather than ignored, and businesse s have the option of inaction or taking the lead in the promotion of non-discrimination a nd human rights. Labor unions, investors, governments, and societies in general are incr easingly searching for ways to compare and evaluate the business response to HIV and AIDS This is occurring against a backdrop of transnational business reform known as corporate governance which is bringing about a move from the single to the triple bottom line, which embraces the economic, environmental and social aspects of a comp anys activities (King Committee: 9). To consider what businesses have done to combat HIV/AIDS I focus on five major areas: policy development, education and awareness, voluntary counseling and testing services, provision of medical services and community involvement.


3 LITERATURE REVIEW HIV/AIDS Epidemiology Overview The Joint United Nations Program on HIV/AIDS (UNAIDS) estimates 39.4 million people living with HIV/AIDS at the end of 2004, with 4.9 million new infections that year and 3.1 million deaths (see table 1) Current estimates of regional rates (see table 2) show that Africa claims 60% of PWHAs as well as 63% of new infections and 74% of those killed by the disease in 2004. In spite of some claims that Africas pandemic is beginning to slow more improved estimates indicate that incidence levels continue to remain roughly the same while mo rtality rates increase. Southern Africa alone contains 30% of HIV/AIDS cases but only 2% of the worlds population (ILO 2002; UNAIDS 2004).


4 Table 1 Global summary of the HIV a nd AIDS pandemic, December 2004 Number of people living with HIV in 2004 Total Adults Women Children under 15 years 39.4 million (35.9 44.3 million) 37.2 million (33.8 41.7 million) 17.6 million (16.3 19.5 million) 2.2 million (2.0 2.6 million) People newly infected with HIV in 2004 Total Adults Children under 15 years 4.9 million (4.3 6.4 million) 4.3 million (3.7 5.7 million) 640 000 (570 000 750 000) AIDS deaths in 2004 Total Adults Children under 15 years 3.1 million (2.8 3.5 million) 2.6 million (2.3 2.9 million) 510 000 (460 000 600 000) Source: UNAIDS, 2004


5 Table 2 Regional AIDS Statistics, end 2004 Adults & children living with HIV Adults & children newly infected with HIV Adult prevalence [%] Adult & child deaths due to AIDS Sub-Saharan Africa 25.4 million [23.4 28.4 million] 3.1 million [2.7 3.8 million 7.4 [6.9 8.3] 2.3 million [2.1 2.6 million North Africa & Middle East 540,000 [230,000 1.5 million] 92,000 [34,000 350,000] 0.3 [0.1 0.7] 28,000 [12,000 72,000] South and South-East Asia 7.1 million [4.4 10.6 million] 890,000 [480,000 2.0 million] 0.6 [0.4 0.9] 490,000 [300,000 750,000] East Asia 1.1 million [560,000 1.8 million] 290 000 [84,000 830,000] 0.1 [0.1 0.2] 51,000 [25,000 86,000] Latin America 1.7 million [1.3 2.2 million] 240,000 [170,000 430,000] 0.6 [0.5 0.8] 95,000 [73,000 120,000] Caribbean 440,000 [270,000 780 000] 53,000 [27,000 140,000] 2.3 [1.5 4.1] 36,000 [24,000 61,000] Eastern Europe & Central Asia 1.4 million [920,000 2.1 million] 210,000 [110,000 480,000] 0.8 [0.5 1.2] 60,000 [39,000 87,000] Western & Central Europe 610,000 [480,000 760,000] 21,000 [14,000 38,000] 0.3 [0.2 0.3] 6,500 [ <8,500]


6 Regional AIDS Statistics, end 2004, continued Adults & children living with HIV Adults & children newly infected with HIV Adult prevalence [%] Adult & child deaths due to AIDS North America 1.0 million [540,000 1.6 million] 44,000 [16,000 120,000] 0.6 [0.3 1.0] 16,000 [8,400 25,000] Oceania 35,000 [25,000 48,000] 5,000 [2,100 13,000] 0.2 [0.1 0.3] 700 [<1 700] Source: UNAIDS, 2004 In the US between 850,000 and 950,000 people were living with HIV in 2003 and about 43,000 were diagnosed that year (CDC 2003a). From 1991 to 2001 the rate increased from 0.33% to 0.43% (KFF 2005a). Re gional variation exists between states and the three topping th e list are New York, California, and Florida (CDC 2003a). The U.S. epidemic has changed drastically in recent years as minorities and women, in particular African-Americans, are increasingl y the victims of infection (UNAIDS 2004). Rates in blacks in the U.S. doubled from 1991 to 2001, from 1.1% to 2.14% while infection rates for whites remained the sa me at about 0.2%, making U.S. AIDS rates thirteen times higher in the bl ack population than in the wh ite. This is likely an


7 underestimate because the sample used in this particular survey did not include the homeless or prison populations (KFF 2005a). AIDS diagnoses increased in women from 1999 to 2003 by 15% but only 1% in men, and infected women are 12% less likely to receive prescriptions for the best treatm ents (CDC 2003d). The number of infected persons receiving treatment in the U.S. is estimated at 268,000 or about 55% of those who are medically recommended to receive it (KFF 2005a). In spite of years of prevention education and a re latively high number of test ing facilities, up to 280,000 people (almost one-third of thos e infected in the U.S.) do not realize they are infected (CDC 2003a). South Africa contains 5.3 million PWHAs (2.9 are women), and prevalence levels are still increasing in all age groups, and show there is immense regional variation. Prevalence exceeds 30% in Mpumalanga, the Free State, and Kwa-Zul u Natal. Recent studies point out that official AIDS rate estim ates in RSA are three times lower than they should be due to cause of death misclassifi cation (Groenewald 2005). Variation across ethnicities is apparent as well. Like in the US, rates in blacks are thirteen times higher than in the white population (Basyurt 2005). Currently considerable concern exists regarding a consistently de layed anti-retroviral drug (ARV ) rollout program planned by the government. The number of people on ARVs by March 2005 was supposed to be 53,000 but current estimates st and at only 30,000, or about 0. 3% of those infected. Activists in the Treatment Action Campaign (T AC) note that while over half of the total health budget for the next five years will be spent on the program its reliance on doctors and hospitals will limit distribution efforts and major changes will have to occur in health infrastructure in order for the program to be successful (IRIN PlusNews 2005b)


8 The worst is supposedly still to come for Africa. About US $200 billion is necessary to save 16 million people from death and 43 million people from infection in the next 20 years. If current policies and f unding levels continue Af rica can expect to see 80 million deaths from HIV/AIDS by the year 2025. 6,500 people die each day from HIV or AIDS related complications in nine highly affected African countries (IRIN PlusNews 2005a).


9 HIV/AIDS Epidemiology in the Workplace The term workforce is defined here as persons of working age who are in paid employment or productive self employment. Informal sector employment is included in some statistics but is mostly outside the scope of this paper. The informal sectors importance is well established however sinc e many households, especially in LDCs, survive through members working in both th e formal and informal sectors. A workplace, is defined in this document as an office, factory, farm, or any holding of a multinational corporation where significant production or managerial processes occur. Again, the importance of small and medium sized enterprises (SMEs) should not be underestimated but is outside the scope of this paper. The term multinational corporation is used in this document as a ge neral term for a transnational businesses. It may mean that a given business has multiple workplaces in various countries, but a common trend is for corporate head offices to be located in one country (or the capital of a country) and production factories in anothe r (often where labor is cheapest). Finally, while it is widely recognized that HIV/AIDS is technically a pandemic, or present in nearly every country at above acceptable levels, I use the term syndemic originating in anthropology (B aer, et al. 2003; Singer 1998) to better portray the multiple facets of the disease. Because of the synerg istic relationship between tuberculosis (TB),


10 malaria, and other opportunistic infections and HIV/AIDS, and also because of the social and political factors which play into its transmission and prevention, syndemic is a more appropriate reflection of the many sma ller epidemics that contribute to the global pandemic. Syndemic refers not simply to co -occurring epidemic rate s of disease within the same population but the interaction of all potentially relevant health conditions including malnutrition, TB, and threatening environmental conditions such as migrant labor camps and poverty-stricken urban areas. The mutually enhancing nature of the factors involved in the HIV/AIDS syndemic must be appreciated in order to combat common reductionist conceptions of PWHAs and to consider local contexts and structural inequality on a level equal to the bi ology of the disease (B aer, et al. 2003). In the world of HIV/AIDS prevention and treatment, institutions, organizations, and governments often use modeling to determ ine the number of infections averted by a particular intervention or economic costs saved or gained from HIV initiatives (Farnham 1994; ILO 2004a; Olson 2000). UNAIDS and th e World Health Organization (WHO) estimate that 29 million new infections could be prevented by 2010 if 12 necessary interventions are undertaken by 2005. A thr ee year delay would reduce this potential gain by 50%. Bringing these programs up to scale would cost US $27 billion and a multi-pronged approach including mass media campaigns, public sector condom promotion and distribution, condom social ma rketing, voluntary c ounseling and testing programs (VCT), prevention of mother-tochild transmission (PMTCT), school-based programs, programs for out-of-school youth, workplace programs, treatment of sexually transmitted infections, peer counseling for se x workers, outreach to men who have sex


11 with men (MSMs), and harm reduction programs for injecting drug users (IDUs) (PR 2002). As I write this thesis in 2005, it is obvious that the th ree year delay has already occurred. It seems as if the very organizat ions that are supposed to be solidifying a response to the disease engage in more talk than action. Projectio ns are consistently made but goals remain unachieved. Ber nhard Schwartlander, director of WHOs Department of HIV/AIDS, stat ed in 2002 that a reduction in prevalence levels of 25% by 2010 is achievable and this goal was adopted by all governments at the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS in 2001. Infection rates have continued to rise since that time. Most of the effect of HIV/AIDS will be felt in Africa, where the average age of the workfor ce is expected to decline by 2 years (Olson 2000). Many studies in sub-Saharan Africa draw on sentinel surveill ance of pregnant women attending antenatal clinics, numbers wh ich are not representative of the private sector workforce. One survey of 34 businesses in South Africa, Botswana, and Zambia found an average prevalence rate of 16.6%, with country specifi c rates at 14.5%, 17.9%, and 24.6% respectively. Mining and metal pr ocessing industries had the highest rates concentrated more in the uns killed labor force than in upper management or skilled workers (Evian, et al. 2004). The most sexually active segment of th e US population is in the work force (Pickering 1995) but many companies in the US are still unwilling to hire HIV positive workers and reasonable accommodations are regularly denied to PWHAs in companies, which has lead to lawsuits. About 2,100 complaints alleging discrimination over


12 HIV/AIDS issues were filed with the Equal Employment Opportunity Commission (EEOC) between 1992 and 1999., but it wasnt until 1998 when the US Supreme Court ruled that federal laws against discrimina tion protect people infected with HIV (Armour 2000). US employers in general are compl acent about HIV/AIDS workplace issues and there has been a recent decline in employer re quests for such technical assistance in spite of rising infection rates (Vaughn 2001). By the end of the year 2000 it was estimated that AIDS costs American business about $55 billion in lost productivity, disability insurance and higher health premiums, and additiona l expenditures for hiring and training new employees (Miller 2000). The International Labor Organization (ILO) recently produced HIV/AIDS and work: global estimates, impact and response (ILO 2004a), which highlights statistical modeling of the pandemic in the working world. Much of the remainder of this section is based on that report due primarily to the de ficiency in epidemiological studies on the subject, many of which have low sample si zes, measure very diffe rent indicators, and differ in assumptions, country samples, met hodology, and temporal focus. A number of studies have been important in laying the foundation for understanding, however, and have been helpful in making the case for HI V education and treatment in the workplace (Bloom 1997; Bonnel 2000; Coulibaly 2004; Dixon 2001; Evian, et al. 2004; Farnham 1994; GHI 2005a; Liu, et al. 2004; Over 1992; Rosen 2003). The ILO report assumes a lack of ARV therapy in the st atistical models, surv eys a total of 50 countries varying in prevalence rates from 1%-40%, and measures many indicators at 5 year intervals from 1995 to 2005 to 2015. The complete report can be viewed and technical notes on


13 statistical models accessed inde pendently by the reader, but for the purposes of this paper relevant data is mentioned primarily for the US and the RSA. The ILO estimates that more than 26 million workforce participants are HIV positive worldwide with over 70% of them living in Africa. Kenya has 1 million, Mozambique 1.1 million, Ethiopia and Zimbabwe 1.3 million, Tanzania 1.4 million, and Nigeria 2.4 million HIV positive workers. South Africa, with a 2003 prevalence rate of 21.5%, has 3,698,827 HIV positive workers between th e ages of 15 to 64 years old. The US, by stark contrast, had a 2003 prevalence ra te of 0.6% which translates into 928,800 HIV positive workers between the ages of 15 to 64 years old. These estimates were obtained by summing the products of ILO estim ated economic activity rates for each age and sex group and the population weight s of those groups (see appendix I-A). The estimated impact of HIV/AIDS on economic growth depends on prevalence and economic activity. In the US and other low prevalence countries economic impact is difficult to quantify and the ILO records a negligible direct domestic impact from the disease. The 2002 US gross domestic product (GDP) was US $9,221,212 million (i.e. add six more zeros) and per capita GDP wa s US $31,660. In South Africa, on the other hand, the economic impact of HIV/AIDS is mo re easily measurable. With a GDP of US $392,380 million and a per capita GDP of $8,923, South Africa lost 2.1% of its GDP to HIV/AIDS costs on an annual basis fr om 1992-2002 which equals about US $7,230 million every single year. In the countries included in the ILOs analysis there was a global loss of US $25 billion per year from 1992-2002 because of HIVs impact in the business world (see appendix I-B).


14 In the absence of treatment, and once symptomatic AIDS develops, the disease runs its course in 18-24 months. Worker s who catch the disease inevitably show diminished capacity to work partially and inte rmittently at first, before total incapacity occurs. Measuring this impact globally shows that by 1995 there were already 500,000 people unable to work because of HIV/AIDS and 300,000 were in Africa. In the US this statistic stands at 58,610 people and 8,090 peopl e in the RSA. By the end of 2005 it is predicted that 2 million workforce participants will be unable to work with 78% of them in Africa. The impact has decreased by this time in the US with 14,880 people unable to work but in South Africa there is a huge increase to 298,280 people. In the absence of treatment by 2015 estimates indicate that 4 m illion workforce participants will be unable to work because of HIV. Even with predic ted increases in HIV rates in Asia those who are unable to work (6 out of 10) will still be in Africa. By that year the U.S. can expect to see about 20,740 people unable to work due to HIV and South Africa can expect another increase as well, of up to 481,740 people (see appendix I-C). Another frightening indicator is the total cumulative AIDS deaths in workforces. The ILO measured this at 5 year intervals a nd in the absence of treatment. In 1995 about 5 million people had died because of HIV/AIDS, and both South Africa (at 64,900 workers) and the US (at 506,000 workers) had lo st 0.4% of their workforce to AIDS. By 2000 the global estimate stood at 13 million people, with the U.S. losing 922,000 people (0.6%) of its workforce and South Africa e xperiencing losses of about 500,000 people or (2.5%) of its workforce. By 2005 these numbers will stand at about 27 million people globally (1.5%), 1.3 million (0.8%) in the US, and 2.07 million (9.2%) in South Africa. In the year 2015 the ILO predicts that globally we will have lost 74 million workers


15 (3.2%) to HIV/AIDS, and that 2.14 million ( 1.3%) workers will have died from the disease in the US and 4.4 million (18.2%) in South Africa (see appendix I-D). These measurements are even more staggering in some other countries. For example by 2015 Zimbabwe will have lost more than 40% of its workforce to HIV/AIDS. Keep in mind the above numbers repr esent men and women who are actually working in the formal sector and are unrepre sentative of the informal sector including subsistence or small income generating agri culture, domestic house work, small personal or family businesses, or craft or goods produc tion for home use. All working age family members are important to household function, for example, in many nations a working age parent or sibling often stays home with the young children. The death of parents not only leaves children with no ho me care but robs them of a livelihood as well. Orphaned children as a result of HIV/AIDS represent a human rights concern but also may lead to a less educated and less able workforce in the fu ture along with an increase in child labor. Again the impact will be more felt in Africa and other low resource areas. In 2003 there were already nearly 15 million orphans (children ages 0-17) and 12 million were in Africa. In the US AIDS orphan estimates are negligible but stood at 1.1 million in RSA (see appendix I-E). Estimates of men and women of worki ng age who died because of HIV/AIDS during the year 1995 stood at almost 735,000 pe ople, 78,860 of them in the U.S. and 10,880 in RSA. In 2005 3.2 million men and wome n of working age will die-20,020 in the US and 401,330 in RSA. That annual mortal ity estimate, which is current as I write this, will rise in the future. In 2015 almost 6 million people of working age will die in the


16 50 countries included, and 27,920 will be in th e U.S. and 648,160 in South Africa. Half of that 6 million will be women and 72% of them will be in Africa (ILO 2004a). The impact of deaths and illness related to HIV/AIDS was measured using an economic burden ratio and a social burden ratio estimated in 5 year intervals. Economic burden tells us how much more productive responsibili ty an economically active person (in the formal sector) will ha ve compared to dependents or non-productive members, old or young, living in the househol d as a result of HIV/AIDS. In 1995 few countries were feeling an ec onomic burden at all due to AI DS, but in 2005 the U.S. had an economic burden of 0.2% and South Africas stood at 3.5%. By 2015 this ratio will jump to 0.7% in the U.S. and 12.5% in South Africa. The social burden indicator takes into account all economically active persons, in the formal and informal sectors, and describes the change in dependency caused by the deaths and illness of all working age persons as well as circumstances involvi ng caregivers increased investment in previously working adults w ho are now home dying of AIDS. In 1995 the U.S. had a social burden of 0.3% and South Africa 0.0%. In 2005 these numbers will stand at 0.6% and 7.2% respectively, increasing to 0.8% and 18.3% by 2015 (see appendix I-F). Based on these numbers, the impact HIV will have on the world of work will be increasingly destructiv e and incapacitating, particularly in the absence of treatment and at the current level of education and prevention programs. It would be extremely nave of businesses to assume that labor in developing nations is infinite especially considering the costs of training workforces from what will be increasingly educationally-deficient countries. Businesses may be forced to dow nsize and restructure and may find shrinking


17 markets among their consumer base (Groenewald 2005; ILO 2004a; UNAIDS 1998; UNAIDS 2000). HIV in the United States workforce peaked in 1995 in terms of PWHAs unable to work, and the advent of anti -retroviral therapy (ART) in a country with access for many workers provides those victims a path to continued productivity. Existing literature reflects this since many businesses were spur ned to action in the mid 1990s. The effect of HIV on the economy and social fabric in the US at this point, according to published studies, will be negligible when compared with South Africas plight and any other highly affected area (GHI 2005a; ILO 2004a). Also, the effects of the epidemic go deeper than the numbers presented here impl y. The cumulative impact over the years of HIV has been underestimated considering th e loss of institutional memory regarding locale-specific best practices (especially in the agriculture sector) and the weakening of institutions, organizations, ne tworks, unions, and individual human capacity to sustain productive activities (Evian, et al 2004; FAO 2005; ILO 2004a).


18 HIV/AIDS in multinational companiesthe economic impacts In 2002 in the US an HIV positive worker would cost companies an estimated $37,320 US dollars for asymptomatics and $50,374 US dollars for workers with symptomatic AIDS per person-year. This st udy by Liu et al (2004) suggests that HIV costs to businesses are mostly due to higher costs for insurance premiums, welfare benefits, less productivity, new recruitmen t and training, and downsized economies and labor markets. The authors also state that little guidance exists regarding examples of well designed, validated, and easily replicable co st analyses (Liu, et al. 2004). Economic costs to businesses will be even higher if employees are not treated with ARVs (Liu, et al. 2002). It is difficult to convince businesses in the US that HIV/AIDS will affect their businesses because economic impacts are unde r the radar (see appendix I, table 4), and there is consequently a dearth of literature and research about workplace HIV issues in the US (Newberger-Lowenstein 2001). US companies are concerned about their investments in Africa and some formed a Corporate Task Force on AIDS in Africa in the year 2000. This group was formed to examine and propose courses of action for Amer ican corporations with investments in Africa. Offering a unified bus iness approach for American companies to respond to the epidemic, this task forces impact is ye t to be documented (AIDS Weekly 2000).


19 HIV/AIDS in Africa can be likened to the plague (Caldwell 1997: 169). The disease takes the most productive members of society causing families to lose income, decrease agricultural output, suffer greater malnutrition, increase funeral costs, and increase health care costs, just to name a few associated problems (UNDP, 2002). Nearly everyone who is infected is doomed to die more quickly than usual, but the latency period allows the disease to move undetected within populations, particularly considering that less that 5% of Africans know th ey are infected until late stag es of the disease are reached (Caldwell 1997). About half of infected Americans dont realize it as well, in spite of more extensive testing and di sease surveillance (CDC 2003a). Given the nature of the disease it needs to be regarded not only as a pandemic but also as a development issue. Even if there were no new cases from now on, the repercussions of HIV will be felt economically in Africa for generations (Reid 199 7a). In LDCs the crisis as a whole has roots in colonialism, exacerbated poverty due to Structural Adjustment Programs (SAPs), limited products on a world market, war, and heavy debt burdens (Schoepf 1995). Politics play into corruption a nd mismanagement of funds and in the US also limits what information is available to the public part icularly regarding co ntroversial prevention programs (KFF 2003a). Not too long ago companies were disc riminating against PWHAs openly and few had policies or educational mate rials, especially in developi ng countries (Baggaley, et al. 1995). As it became more and more clear that this disease is not lim ited to marginalized populations, businesses began paying more atten tion to the consequences of HIV in their workforces (Bassett, et al. 1996; Mbizvo 1996) Now the problem is well recognized and


20 steps are being made to mitigate the negative consequences of the disease in the business world. The impact of HIV on business is classifi ed into two broad ar eas: direct and indirect costs (see table 3). Another way to conceptualize th is is as external and internal impacts (see figure 1). Both of these ar eas refer to structural, political, economic, cultural, and ecological issues outside and w ithin companies or businesses. External impacts may be couched in terms of market s, resources available for production and investment and subsequent decreases in gro ss domestic products (GDP) of the countries in which businesses operate. Per capita growth in half of sub-Saharan African countries is dropping at about 1% ever y year due to HIV/AIDS (Brookings Institution 2001). Conservative estimates for GDP losses in Kenya for 2000-2020 range from 20 to 30% (Robalino 2002). However, if Africa could ach ieve a 1% increase in its share of world exports, then net annual financial inflow to the continent would be $70 billion or 7 times its current aid level. This will depend more on the private sector than on official development assistance (De Waal 2002). Table 3 Costs of HIV/AIDS to business Direct Costs Indirect Costs Individual costs from one employee with HIV/AIDS Medical care Benefit payments Recruitment and training of replacements Reduced productivity due to absenteeism/sickness Supervisors time dealing with productivity losses Turnover costs Organizational costs from many employers with HIV/AIDS Insurance premiums Accidents related to sickness or inexperience Costs of litigation Senior management time Production disruptions Depressed morale and motivation Loss of experienced workers Strain on labor relations Source: ILO, 2004


Figure 1 Flow Chart-HIV/AIDS Economic Impacts on Business (Compiled from various sources) HIV/AIDS Internal Impacts External Impacts absenteeism markets & fewer consumers staff turnove r Education capital skills and knowledge insurance, retirement, & funeral costs need for training & recruitment foreign investment & GDP Total productivity declining reinvestmen t total costs total profits 21


22 Education is affected and thus quality of future labor supplies is compromised by HIV/AIDS. Primary school attendance will d ecrease by 20% in Zambia and nearly 25% in Zimbabwe by 2010 and education sector growth will be less than half of what it should be without the disease (World Bank 2000). In Zambia teachers have been dying faster than they can be trained and replaced (IO E 2002). In 1998 the World Bank had already estimated that over 40% of education personne l in urban parts of the country would be dead because of HIV by 2005, and in Tanzan ia 100 primary school teachers die every month because of the disease. South Africas teacher-stude nt ratio rose from 1:27 in 1990 to 1:34 in 2001 and Botswanas teacher death rates increased from 0.7/1,000 in 1994 to 7.1/1,000 in 1999 (ILO 2004a). While Africa as a continent is expected to maintain a positive growth rate during the AIDS pandemic, expected fertility reduc tions formerly attributed to condom and contraceptive use are now attributable to biological mechanisms which will bring about reductions in future youth populations (Caldw ell 1997). AIDS is also expected to increase child mortality by 20% overtaking malaria and measles as a prime killer of children under 5 (Hope 1999). Orphan populations are expect ed to skyrocket, with 15 million uninfected children losing their parents to AIDS already, and 40 million expected by 2010 (Foster 2000). In spite of notions th at traditional extended families could handle this burden, studies have show n that breakdown of family st ructure is occurring due to AIDS care giving (Jacques 1999). The implicati ons for numbers of street children are staggering, especially considering that the fa mily network breaks down more quickly in urban areas as opposed to rural villages, and fostering by non-relatives is uncommon (Foster 2000). Child labor will be on the incr ease as well as survival crime and survival


23 sex among street kids. Foreign direct invest ment may be damaged as outside investors recognize these challenges. In LDCs with low financial capital, th e primary economic asset is human capital and the size and quality of labor forces is drastically affected by HIV/AIDS. A drop in life expectancy of up to 27% is expected in southern Africa and adult mortality rates have tripled over the last 15 years. The age group of most working populations places them at risk and consists of the most productive segment of society. Deaths occur mainly in the 20 to 39 age group, which represents 42 percent of the total workforce. Five countries in southern Africa will lose one -third of their labor for ce by 2020 (Aventin 1999). Unskilled and skilled labor forces are both a ffected. In Zambia two-thirds of the deaths are among managers (d'Adesky 2003). One study of pregnant women in Rwanda found prevalence rates of 38% for women w hose husbands worked for the government, 32% for those with white collar working husbands, 22% for army families, and 9% for farmers (Bloom 2001). This presents a distinct problem in places where HIV is conceptually linked with social status and r ace, molding false perceptions of who is and is not vulnerable. Sufferer stories, such as the one about Acphie in Haiti who acquires the disease because she marries a soldier for survival purposes, conjure concepts of structural violence which are best underst ood in context (Farmer 2003). In many cases people have no choice about preventing transm ission in their personal lives because of the way power in society is wielded or abused. As families spend more time and money caring for AIDS patients in their final years, household savings diminish, livelihood st rategies (formal and informal) are more elusive, income decreases, and so does cons equent investment and expenditure. Other


24 family members may enter the labor force in cluding children who are forced to leave school reducing human resources in the futu re and for the collective economy. The effects of HIV on a business are similar to those on a household (ILO 2004a). The internal impacts and direct costs of HIV are evident through decreased productivity and increased costs to businesses. Declining pr oductivity is financial suicide when production costs are not declining as well. Ill employees lead to greater absenteeism, the costs of which are visibl e through the use of temporary staff and impaired potential to meet production dead lines and market demand. Employees in certain situations and cultural contexts may be called on to care for sick family members and attend or sponsor funerals. Household inco me in Thailand and Cote dIvoire declines by 40-60% when any family member is in fected (UNAIDS 1998) indicating that education for the families of workers is equa lly important as for workers themselves. Most infections occur among people before they reach the age of 25 and many will suffer symptoms before 35 indicating th at AIDS affects the most productive and economically active members of societies. It is through loss of this workforce population that the most detrimental social and econom ic effects of HIV are felt. While it has become a manageable disease in high-income countries the potential to provide care and prevention is difficult in LDCs where 95% of those infected dwell and the realities of health care have always been dismal (Hope 1999). Decreased life expectancies and a reversal of recent development gains are direct results of the epidemic, and the resurgence of opportunistic infections associated with HIV are significantly debilitating as well. Ignorance, stigma, and denial exacerbate transmission and discourage efforts to fight the disease.


25 Deaths within a company generate disorg anization obvious in staff turnover, the loss of skills and institutional memory or experience, and decreasing morale. While turnover is easily quantifiable, economists a nd other analysts are less likely to emphasize the devastation of losing intelle ctual capital and the ability of a workforce to share and transfer skills among one another. Empl oyee morale and motivation does not improve under these circumstances. Businesses must compensate by incr easing recruiting and training efforts as well as stepping up pens ion and insurance plan s affecting the overall level of benefits available to the workforce. In South Africa where worker deaths have increased threefold the total co sts of employee benefits will rise from 7% to 19% by 2005 (UNAIDS 1998). The increased cost of funera ls, a common benefit to workers in Africa, is particularly evident. Some companies put dollar amounts on inte rventions in cost-benefit analyses. One study in South Africa found that workers with AIDS take over 27 more sick days than the average worker and each death from AIDS equals 4 days of a managers time. Life insurance payouts increased seven times a nd 60% of the deaths were due to AIDS in Zimbabwe in the early 1990s (d'Adesky 2003). In Kenya AIDS was estimated as costing US $25 per employee per year and will increase to US $56 by 2005, however a prevention program costs a one-time fee of US $15 per employee. A small company in Thailand found that AIDS cost US $80,000 annually while a prevention program would cost US $11,500. One large company in Zambia reported AIDS related illness and death costing more than entire profits for the year (UNAIDS 2000). Many have found that providing education and drugs can be expensive but pays off in the long run. DaimlerChrysler estima tes that averting one new infection in the


26 employee population saves the equivalent cost of 3 to 4 annual salaries. AngloGold found that gold prices would be US $3 great er per ounce if nothing was done to combat HIV in that company and has since initi ated an ARV program for all employees (d'Adesky 2003). If an epidemic becomes devastating it is because either prevention techniques are difficult or because of complacency and inacti on during the early stages. A study in India found that 75% of employees were unaware that condoms prevent sexually transmitted diseases (STDs) and only 5% used condo ms properly (UNAIDS 1998). HIV is easily preventable and avoidable but is subject to cultural taboos because transmission routes tend to be primarily through sexual contact in sub-Saharan Africa. Because of this the issues and realities of HIV/AIDS are fre quently difficult to discuss from a cultural standpoint. Mobility and migrant work consistently in crease vulnerability to HIV. Studies have consistently found that HIV infection is higher in migrants compared to nonmigrants in South Africa (Evian 1995; Lurie, et al. 2003), that those who have recently changed residence are more likely than th e general population to be HIV positive (Karim 1992), and that migration is an independent risk factor for HIV infection (Lurie 1997; Lurie, et al. 2003). Migratory work is ofte n linked with increase d sexual networking not only for men but for women as well (Chirwa 1997; Romero-Daza 1998a). Moreover, the legacy of apartheid in South Africa has left a culture of migration and severed familial ties (Chapman 1998). Stigma is now attached to migrant labor in the African public consciousness for example in Swaziland wher e authorities recently banned a same-sex


27 workers hostel in an up market suburb for f ear it would attract pros titutes and exacerbate disease transmission (IRIN News 2005d). One huge challenge for programs remains uptake of VCT programs among workforces. While the level of knowledge about the disease may be high, perceived personal risk is low. Health complications are motivating factors for individuals to get tested but fear and stigmatization of HIV is still very high (Day 2003). Fear of a positive result seems to be the major barrier for HI V testing (Ginwalla 2002). Testing for other STDs is important as well and may decrea se HIV incidence even without behavior change (Machekano 1998). In addition, treati ng a core group of hi gh risk individuals (such as commercial sex workers) reduces community prevalence of STDs and can subsequently reduce STDs and HIV among a workforce (Steen 2000). Demands of the workforce and economy require that impact assessments on HIV/AIDS continue to become more targeted (Forsythe 1998; Forsyt he 1995). Universities can help with this effort (Crewe 2000), and the cooperation of traditional healers and community health workers is necessary as well (Green 1999). HIV is significantly different from what most businesses are used to dealing with in terms of occupational exposure. Worker s do not generally acquire HIV at work but some industries increase the vulne rability of the workforce. This is linked with increased exposure through sexual transmissi on. Industries most affected include mining, tourism, transport, security, agriculture, and construction (d'Adesky 2003). The difference between HIV and other types of occupationa l health hazards requires that HIV be handled less through engineering, administrative, or personal controls in the workplace. One study found that in South Africa occupati onal health services should be making


28 better contributions to AIDS control and prevention part icularly by improving worker participation, empowering women, and focusi ng on a critical understanding of related behavioral issues (London 1998). While all of the typical workplace protections related to traditional heal th threats are necessary and helpful (especially for immunocompromised individuals) a sh ift toward heavy medical su rveillance and protection for the worker when he or she is not at work becomes necessary as well in the world of HIV/AIDS, highlighting the importance of co mmunity and public sector partnerships with the private sector.


29 Legislation-discrimination in the workplace Workplace discrimination continues everywhe re as is the case in El Salvador where recent legislation allows workplaces to screen out applicants with HIV. The measure comes under wider legislation which gua rantees rights to those with HIV, but the reality could be much different if the policies are used to k eep PWHAs out of the workforce (Elton 2002). Also, the issue of la rge companies disenfranchising lower tiers of the workforce must be rectified. At the start of its initiatives Coca-Cola defined its African workforce as upper management and designed programs for this segment of its workforce while leaving bottlers and s uppliers without support (Melvin 2001). The Americans with Disabilities Act ( ADA) protects HIV positive Americans in the workplace from unfair discrimination, based on the three main pillars of the act: nondiscrimination, reasonable accommodations, and confidentiality of me dical information. One lawsuit awarded $360,000 to an HIV positive bartender in Atlanta who was fired because of his disease (AIDS Policy & Law 1997). Another case resulted from one business owner who switched insurance carri ers and forced exclusion of a positive employee from coverage (AIDS Policy & Law 1996a). One fast food manager who was stripped of his managerial dutie s after disclosing his status received a settle ment of US$5 million (Petesch 2003). Still another case, in times before the Health Insurance


30 Portability and Accountability Act (HIPAA) was implemented, found an employer guilty of demanding prescription drug records from employees in violation of the ADA (AIDS Policy & Law 1996b). However, ADA does not always apply when a PWHA is asymptomatic. PWHAs may still be fired for excessive tardiness or poor performance at work (AIDS Policy & Law 1995a). Two separate hair salons in Texas fired HIV positive employees after learning of their status but were forced to re-hire them and pay back wages and punitive damages (AIDS Policy & Law 1995b). Bragdon v. Abbott found that one persons asymptomatic HIV is a disability under ADA because it limits the major life activity of reproduction. Blanks v. Southwestern Bell Corporation found an HIV positive man was not covered in similar circumstances because he and his wife had decided not to have any more children. The ADA does, how ever, permit action for disability-based harassment under in hostile environment, and in general most persons with HIV are likely protected under the act (Petesch 2003). While far from being ignored in the Unite d States the business community mostly pays lip service to workplace AIDS educati on (Marc 2004). Pseudoscience and myth still surround the HIV pandemic in social cons cience (Makgoba 2002). Wrongful firing practices still occur consistently, such as wh en a grocery bagger at a small grocery store was fired for his own good (Petesch 2003). More recently this occurred with a Cirquedu-Soleil performer who was fired by Cirque which openly admitted doing so due to his HIV status (Romney 2004a). They also stated that employment pos itions "which would be suited to an individual with HIV include dishwashers, dining room attendants, prep cooks, [and] box office staff. An activist remark ed that this case is extremely disturbing because a number of Americans are navigati ng the workplace with HIV and this case has


31 bearing beyond the individuals situation. Prot ests have been carried out against Cirque and the San Francisco Human Rights Commissi on is heading up the complaint litigation (Romney 2004b). Employers may defend a discrimination charge if they can prove a clear risk to others, through medically proven methods of transmission, because of a PWHA in the workplace. This is generally not easy to pr ove but certain jobs involving blood to blood contact may pose a risk. In one case a dental hygienist was a ri sk to patient safety due to the potential for sticks or cuts during treatment. In another a surgeon performing invasive surgery was proven to be a risk to patients as well. However, the Chattanooga Police Department was charged with discrimina tion against an HIV positive applicant, as was the Attorney General of the US, when a suspected HIV positive medical facility director was qualified to perfor m routine physical exams of FB I agents due to no risk of infecting others. In such cases a reasonabl e probability of substa ntial harm must be demonstrated supported by medical evidence. There may be some issues regarding the side effects of certain medications for PWHAs on the job in the futu re (Petesch 2003) Three people applying for employment with American Airlines were rejected, after being conditionally approved for jobs pending background checks, blood tests, and medical exams. None revealed their HIV stat us voluntarily but were denied jobs based on blood tests. Protection under the ADA in cludes that medical exams be performed only after initial scr eenings and background checks, maki ng the process transparent and making it obvious that these three people were denied the final job offer based on their HIV status (Azulay 2005). The case is currentl y in litigation. Obviously the concept of


32 HIV/AIDS as a disease like any other has st ill not completely replaced ignorance, or outdated attitudes of discri mination and uncaring. Under the ADA employee or customer fears are not a defense for discrimination. Employee PWHAs are also entitled to r easonable accommodations and employers refusing to attempt reasonable accommodations will subject themselv es to litigation. This entire concept is flexible and in the case of HIV/AIDS displays a couple of interesting characteristics. First, due to th e hidden nature of the disease, employees may have to bring the disability to the notice of superiors supported by medical evidence of a disability. Second, the progressive nature of HIV requires constant dialogue and evaluation regarding what accommodations ar e necessary and reasonable. This may include reassignment, providing special equipment, adjusting work schedules, and being flexible about leaves of absence (Petesch 2003). While the National Labor Relations Act (NLRA) gives a group of workers the right to engage in concerte d action for mutual protection, the refusal to wo rk must be grounded in objectively reasonable terms regarding dangers to health a nd safety (Petesch 2003). There are no mentioned examples of this occurring in the literature related to HIV/AIDS in the workplace. In South Africa, PWHAs are covered unde r legislation very similar to the ADA but which is more sensitive to their needs specifically. The Employment Equity Act (EEA) of 1998 prohibits di scrimination by employers for many reasons including HIV/AIDS status. The Acts provisions are interpreted by South Africas Labour Court, are designed in part to protect women, and also cover issues related to sexual harassment, affirmative action, pay scale differentials, a nd training offered to employees. The Code of Good Practices on key aspects of HIV/AI DS was added to the EEA on December 1,


33 2000 but does not impose any specific legal ob ligations. Instead it addresses broader goals including eliminating unfair discrimi nation in the workplace based on HIV status, promoting a non-discriminatory workplace in which people living with HIV or AIDS are able to be open about their HIV status without fear of stigma or rejection, promoting appropriate and effective ways of managi ng HIV in the workplace, creating a balance between the rights and responsibil ities of all parties, and givi ng effect to the regional obligations of the Republic as a member of the Southern African Development Community (SADC) (ILO 2004b). The Code also recognizes women as more vulnerable to infection due to culture and material economic situations. Core principles of the Code include: to promote equality and non-discrimination between individuals with HIV infection and those without, and between HIV/AIDS and other comparable health/medical conditions; to create a supportive environment so that HIV infected employees are able to conti nue working under normal conditions in their current employment for as long as they are medically fit to do so; to protect the human rights and dignity of people li ving with HIV/AIDS as that is essential to the prevention and control of HIV/AIDS; to ensure the fact that HIV/AI DS impacts disproportionately on women is taken into account in th e development of workplace policies and programmes; and to ensure that consulta tion, inclusivity and encouragement of full participation of all stakehol ders remain the key principl es which should underpin every HIV/AIDS policy and programme (ILO 2004b). The Code has major policy implications related to the Constitution of South Africa of 1996, the Labour Relations Act of 1995, the Occupational Health and Safety Act of 1993, the Mine Health and Safety Act of 1996, the Compensation for Occupationa l Injuries and Diseases Act of 1993, the


34 Basic Conditions of Employment Act of 1997, the Medical Schemes Act of 1998, and the Promotion of Equality and Prevention of Unfair Discrimination Act of 2000. Also, it provides a broad definition of workplace that includes the informal sector economy (ILO 2004b). The AIDS Law Project (ALP), at Wits University Centre for Applied Legal Studies in Johannesburg, is an organization that helps people w ith HIV/AIDS to deal with their problems. They research the social, lega l, and human rights implications of AIDS in order to develop law, policies and recomme ndations on questions related to HIV/AIDS and employment. They have a legal depart ment which provides advice and resource links, three qualified attorneys capable of initiating legal ac tion, and are one of the few organizations in Africa working primarily to promote equal rights for PWHAs. The ALP is also in partnership with the Canadian HIV/AIDS Legal Network, working together to promote a better understanding of the legal and human rights issues re lated to the global impact of HIV/AIDS, and are joining together for events and activities including creating conferences and undertaking research (ALP 2005). A brief search for organizations similar to the ALP in the US returned few results. Much information touching on US legislation and human rights is found on the Canadian HIV/AIDS Legal Network website ( ) which underscores the complex relationship between federal and state govern ments. Areas in the US with higher concentrations of PWHAs have more extensive local resources such as San Franciscos AIDS Law Referral Panel (ALRP). The US le gal system has been called on to address social disputes on a regular basis and at leas t since the early 1990s, as a litigation survey from the years 1991 to 1997 shows over 550 cas es appearing in the federal and state


35 courts, which is an underestimate (Gostin 1997). Therefore, the lack of something similar to South Africas ALP here in the US may represent disinterest, lack of profitability for lawyers, or the fact that the largest segment of infected individuals traditionally in the US (i.e., MSMs) have generally been able to fend for themselves in the legal arena. Increasing prevalence rates in minority populations suggest that an ALPlike project(s) may be very necessary here fo r infected and affected US citizens in the near future.


36 The business response to AIDS In the US and in South Africa the busine ss response to AIDS has been too slow and lacking in focus (Dickinson 2004; St uddert 2002). Many programs have been ineffective, politically motivated, reactive and poorly designed, and limited to low cost programs (Versteeg 2004). Multinational companies are adept at maximizing efficiency and minimizing losses, monitoring production, de veloping advertising, and assuring that bottom line profits can be reinvested in order to grow as a business. In highly affected areas a response to HIV should be equally well organized and in clude an HIV/AIDS policy and strategy, a preparedness and c ontingency plan, monitoring and reporting, internal epidemiological indicators such as morbidity and prevalence rates, company specific costs and losses due to HIV as well as future projections, a specific HIV/AIDS budget, VCT and counseling/support programs, education and awareness programs, condom and femidom distribution, health care provisions, and benefits for dying employees or family members (Fourie 2004). Reports should be prepared yearly for release and review in public forums. The Global Health Initiative (GHI) r un by the World Economic Forum (WEF) recently published Business and HIV/AIDS : Commitment and Action? (GHI 2005a) which presents the findings of a global business survey cond ucted among about 9,000


37 business executives in 104 countries. Becau se the report is based on the opinions of corporate elites I will leave it up to the reader to judge the validity of the responses but would like to highlight the fact that these are decision makers in companies capable of making significant changes. The survey incl uded similar questions about malaria and tuberculosis, which interact significantly with HIV/AIDS and are part of the syndemic in developing nations especially. Again, the RSA and the US statistics are of primary interest in this document. Globally, howeve r, about 30% of respondents to the survey indicated some current impact in their busin ess from HIV/AIDS and 37% expect impacts in the future. About 67% of the respondent s said that impacts on their businesses are minimal but only 55% thought the same about the communities in wh ich their businesses are located, suggesting that some businesses feel they are shielded from the worst impacts of the virus. In addition 45% reported that workforce prevalence rates are lower than community rates in spite of a lack of clear evidence in most cases Many more South African business leaders expect current serious impacts than in the US. The survey shows that 41% of RS A businesses expect serious impacts, 88% expect some impacts, and 8% expect no impact. With corresponding numbers in the US at 6%, 39% and 61% respectively it is no surprise that there are fewer workplace programs in that country (see appendix I-G). When questioned about the future impact of the disease on their businesses responses in the US remained the same, however responses from RSA indicate that 51% of th e companies surveyed expect a serious impact in the future (see appendix I-H). In general it can be assumed that mo st companies have not evaluated how HIV will impact their business and do not disti nguish the effect of HIV on aspects of


38 operations or finance, although awareness is immensely greater in high-prevalence countries. Decisions are being made regarding whether and how to respond to AIDS without information on how it affects businesse s. Globally, 71% of companies have no specific written policy to deal with HIV/AI DS. Companies in the health and social sectors are more likely to have written policies as well as the mining, hotel and restaurant, fishing, manufacturi ng, and transport industries. Industries more often lacking policies include agriculture, c onstruction, real estate, and retail. In the US surveyed companies lacking written policies stand at 45% compared to 7% in the RSA. South African companies surveyed were more like ly to have a writte n HIV specific policy (77%) than US companies (15%) (see appendi x I-I). However, North American and subSaharan African companies have the most co mprehensive policies when compared to other regions of the world. In addition, comp anies that had carried out formal risk or prevalence assessments were more likely to have a written policy (GHI 2005a). In low income countries programs are focused on prevention. In countries with greater than a 20% prevalence rate 82% of the companies provide information about HIV/AIDS, 69% provide condoms, and 57% VCT services. In terms of treatment, however, the picture is quite di fferent. Only 17% of companies surveyed in low income settings provide ARVs versus 30% in MDCs. Many businesses in Africa provide treatment primarily through the care of sexua lly transmitted infections (STIs) (40%) and opportunistic infections (OIs) (32%) while only 24% provide ARVs and 11% home based care (HBC). African companies are also 48% more likely to repor t serious negative effects on their HIV/AIDS programs due to st igma and discrimination, which is nearly double the global survey average (GHI 2005a).


39 Various industries and enterprises ar e affected differently by HIV but one universal issue is skilled worker loss, whic h represents the main problem for companies particularly when such workers have job or location specific competencies that are difficult to replace. Certain i ndustries increase vulnerability to the disease particularly when it involves migratory/mobile work or activities that separate families (ILO 2004a). For example, about 56% of the truck driver s in the RSAs Kwa-Zu lu Natal province are HIV positive (News24 2005). Contract worker s are more vulnerable as well as the mining and metal processing industries in Africa n nations (Evian, et al 2004). In the US workers in the travel and tourism industry are more vulnerable to infection. While concern over HIV/AIDS, as well as perceptions of its impact, vari es little between industries, many large sector high risk i ndustries such as mining and transportation perceive no greater threat than industries th at do not as greatly exacerbate the risk of infection for employees (GHI 2005a). According to the GHI, more companies are responding to the epidemic in 20042005 than in 2003-2004 and also reporting higher workplace prevalence rates. Confidence in high prevalence countries is increasing and more aspects of disease prevention and treatment are bei ng covered in the business world than in previous years. A lot remains to be done, however, particularly in the area of public-pri vate partnerships. Globally, 72% of business pr evention programs do not provide condoms, over half provide no information about HIV/AIDS, and even in heavily affected areas many companies have failed to act on their concerns about the viru s. There seems to be an information gap in spite of the plethora of online tools and technical assistance, and the GHI suggests that governments and internati onal donors should fill th is gap even to the


40 point of helping with the costs of programs. The GHI report advocates raising company awareness of the impacts of HIV/AIDS as one important path to stimulating more and sustaining current responses. Effective mon itoring systems must be developed for this purpose (GHI 2005a). Size, industry type, and available resources help determine which responses are effective, relevant, and appropriate. In many cases, businesses develop responses centered on advocacy or philanthropy rather th an a specific workplace, which is more common in the US. Due to the fact that some representative South African business programs are described in detail in the primar y data collection sections of this thesis, I have included some examples of HIV/AIDS programs in US-based companies here to highlight some of the public and private se ctor partnerships and the diversity in approaches. The Bill and Melinda Gates Foundation, which serves as a philanthropic arm of Microsoft, Inc. founder Bill Gates has donated since its inception in 1994 more than 3.6 billion to organizations in global health gr ants alone. HIV/AIDS priorities include improving voluntary counseling a nd testing programs as well as STI treatment, funding for research to reduce transmission such as vaccines and microbicides, as well as expanding access to treatment and prevention education. This includes $50 million to support an HIV prevention and treatment pr ogram in Botswana known as the African Comprehensive HIV/AIDS Partnership (ACHAP). The Gates Foundation provided enough ARVs to treat the entire population of Botswana but many of the medications expired because of stigma and lack of acce ss to testing sites. Avahan, a $200 million initiative, is a project intended to expand acces s to HIV prevention programs for high-risk


41 populations and to combat stigma in India. The foundation also donated $100 million to the Global Fund to Fight AIDS, Tuberculosis and Malaria at the country level. To accelerate the global effort to create and distribute an HIV vaccine the International AIDS Vaccine Initiative was given $126 milli on. Another $60 million was awarded to the International Partnership for Microbicide s to help develop that prevention method (Gates Foundation 2005). Black Entertainment Televisions (BET) Rap-It-Up campaign is now in its 7 th season. Launched in 1998 in partnership with Kaiser Family Foundation (KFF), the campaign claims to be the nations larges t public education cam paign focusing on the African-American community in the U.S. The television stations efforts include programming related to sexual issues and HIV, a road tour that c onducts on site testing and sponsors concerts featuring popular hiphop artists, a comprehensive web site with public service announcements (PSAs) and other multimedia and news resources, a toll free hotline that has handled over 900,000 calls printed materials about HIV and sexual issues, teen forums featur ing students and AIDS activists, and a comprehensive curriculum for high school teachers to info rm their students a bout the disease (BET 2005). Music Televisions (MTV) campaign, Fight for Your Rights: Protect Yourself is intended to empower and inform youth on issues of sexual health. Like BETs initiative this is in partnership with Ka iser Family Foundation, and the campaign helps provide recent information on HIV and other sexually transmitted diseases, as well as unintended pregnancy to its target youth audience. It includes special programming, PSAs, a website with comprehensive informa tion and links (including VCT sites), and a


42 resource and referral service. Partners in clude the CDC and Advocates for Youth (MTV 2005). MTV supports a similar campaign thr ough their international affiliates that includes regional specific hotlines, websites and PSAs in 164 countries. This campaign is known as Staying Alive (KFF 2005b). Since 2001 the National Basketball Association (NBA) has been conducting annual Basketball without Borders camps a ll over the world. The program is a summer camp format for youth which promotes goodw ill and friendship through the sport of basketball, bringing NBA player s from different teams to act as coaches. In the former Soviet Bloc European players also attempt to smooth over ethnic barriers, while in South Africa African players have coached camps w ith kids from all over the continent. Sponsored by Algida, American Airlines Champion, Gatorade, Nike, Spalding and United Colors of Benetton the program also partnered with UNICEF in 2004 to include HIV/AIDS prevention education. The Fdration Internationale de Ba sketball (FIBA) is responsible for the selection of kids which hinges on basketball abil ity and dedication. UNICEF conducted seminars with the kids in Brazil, Italy, and Johannesburg, South Africa which focused on HIV and drug abuse, living with the disease, and prevention. The NBA and FIBA donated items like basketballs, nets, books, and computers to local basketball federations and have refurbished recreation facilities as well (NBA 2004). Home Depot, which has a workfo rce of over 250,000 employees, began HIV/AIDS initiatives in 1991 by hosting quart erly health promotion talks on HIV, partnering with Red Cross to provide education to managers and employees at each Home Depot site across the country. By 1999, the program had conducted more than 60 education sessions for about 1008 managers at a cost of $19 per employee. The program


43 focuses on raising awareness, supporting PWHA s, and alleviating the impact of the virus. The partnership with Red Cross f acilitates access to their existing 26,000 trained HIV/AIDS instructors acro ss the US (GBC 2005b). The Red Cross Workplace Program is a modular format which makes it flexible to the needs of a variety of workplaces. The program includes facts about transmission and prevention, employee and employer rights an d responsibilities such as legislation and medical concerns, and decreases stigma by explaining why employees can work safely with PWHAs. The Red Cross program claims to promote a compassionate environment for workers living with HIV, or those whose fa mily members, friends, or partners may be HIV-positive. It also helps those who are in terested to identify local resources and services related to the disease (Red Cross 2005). PepsiCo, makers of Pepsi-Cola as well as Gatorade, Tropicana, Frito-Lay, and Quaker products, supports employee PWHAs w ith access to a medical plan with no preexisting condition clause, prescription drug cove rage for ARVs, help with clinical trial enrollment, and comprehensive case management for affected employees. They also provide services for seriously ill employees su ch as end-of-life provisions regarding wills and post-death benefits. There is, howeve r, no mention of prevention or education initiatives (PepsiCo 2005). In 2001 and 2002 at least eight US corporat ions were important HIV/AIDS grant makers giving more than US$600,000 in HIV/AI DS related grants both years, and 15 others made grants of more than US$100,000. In kind donations were also common including information technology application and resources in communications or marketing. Partly because philanthropic efforts are tied to a companys profit margins


44 the state of US corporate giving was diminished in the early 21 st century compared to the 1990s. In addition governmental cuts for the non-profit sector have lead to cuts in services for communities; therefore, this is a time when partnerships from the private sector would provide a huge boost for HIV/AIDS related programs. The current atmosphere displays a number of other char acteristics including increasing needs in the US as the number of infected individuals continues to rise, an increasing need for services and programs in poor and minority co mmunities, as well as politically loaded debates about the efficacy of prevention. One expert asks corporations to focus on marginalized, underserved communities and the non-profits that serve them (Di Donato 2004). Stigma continues to be a serious barrie r to workplace programs and PWHAs in the US. Some groups commonly stigmatized as HIV positive include racial minorities, MSMs, IDUs and other substance abusers, women with multiple sexual partners, sexually active young people, and former prisoners. In the workplace some of these groups are obvious and some are not. Stigma can directly lead to firing or rejection in the workplace and discriminatory workplace environments. PWHAs are often concerned about being seen as receiving special tr eatment due to their disability and people who have been affected by the virus may not want to discuss, for example, how their son, daughter, or father died from the disease. For a business to not have a policy on HIV/AIDS discrimination prohibition, to not address HIV/ AIDS in wellness and benefits programs, and to not encourage employees to learn their status implies that s ilence about the disease is acceptable in the workplace. Someone w ith HIV may fear losing their job or being treated unfairly by an employer be cause of this lack of focu s, and the workplace without


45 HIV/AIDS initiatives may be rejecting qualifie d individuals based on an issue that is as pervasive as the rejec tion of someone based on color, ge nder, sexual orie ntation, religion, or age. Businesses may not be responsible fo r the beliefs of their employees but they can foster fair work environments. In most cases the prejudices held by employers and employees can be overcome by training, clear and obvious policies th at support tolerance for PWHAs and intolerance fo r discrimination, and enhancements such as awareness posters, VCT, AIDS charities, and widesp read prevention inform ation (Milan 2004). The business world felt the impacts of HIV in the US particularly in the 1990s through discrimination issues, rising health care costs, as well as in creased life insurance and disability costs. Many people in the work force died because of AIDS (see table 6) and many left the workplace altogether, walki ng away from potential benefits because they did not understand how they worked or fa iled to apply for them because of stigma. A supportive work environment for PWHAs in cludes an appropriate benefits package which can help a business see reduced turnove r, lower health plan costs and premiums, and increased respect from employees (Franzoi 2005). Some ways that employers can provide a ppropriate benefits at reasonable costs include health savings accounts, which are designed to accumulate non-taxable savings for health care services and can be effective when paired with a high-deductible health care plan. Businesses also can establish part nerships with a disease management firm able to offer PWHAs clear explanations of their rights and provisions while helping them navigate through the complex medical envi ronment of being positive. Short term disability benefits are important as well fo r salary continuation and extended life or health insurance. Even if a business cannot help provide short term benefits the Social


46 Security Administration may find the indivi dual eligible for Consolidated Omnibus Budget Reconciliation Act (COBRA ) benefits which can help to bridge the gap before Medicare programs kick in. Life insurance is important as well and many PWHAs cash out these settlements at a loss. Companies ca n offer accelerated deat h benefits, such as a living benefit option, under group life insurance at no extra premium costs but which allow a portion of life insuran ce to be given out to a bene ficiary when an employee is expected to die in less than 12 months. Em ployers can also provide continuation of life insurance coverage after a PW HA ceases to work allowing the employee to convert to an individual policy without providing evidence of good health. Long term disability plans are also available in case of total disability and allow an employer to combine successive periods of disability common in PWHAs into one period, which keeps an employee from losing benefits. Certain plans also allow em ployers to safeguard employees benefits so they are not reduced until work salary reaches the typical level. Long term care, also known as HBC, can also be offered by employers which allows a positive person to secure future help in daily living activities and maintenance for chronically ill persons. Employee assistance plans (EAPs) offer PWHAs and their household members the option to obtain assistance for personal problems such as confidential counseling, family problems, stress, and chemical dependency. Whether it is a dependent or employee who needs this assistance EAPs, particularly when combined with disease management programs, help an employee stay focused at work. Pension plans, while providing more obvious benefits for married couples, provide monetary compensation for spouses when they die at work or in retirement. Howeve r, a lump sum benefit for single employees (such as higher death benefits) or a plan which allows an employee to designate a


47 beneficiary under a contingent annuitant bene fit can be developed in lieu of access to pension (Franzoi 2005).


48 Workplace intervention evaluation Evaluating responses requires data and other relevant information. In spite of legislation and codes designed to foster co rporate responsibility in the US (NYSE 2002; OECD 2004; US Congress 2002) and in South Africa (ILO 2004b; King Committee 2002) companies have options when it comes to how much information they choose to share with researchers. Th e source of the request can make a difference as well as whether or not the requesting individual or or ganization invokes laws or codes in order to facilitate the process. Uniform reporting guidelines are necessary but cannot always be enforced and laws designed to promote corporate governance vary in context and interpretation (Sorenson 2004), and AIDS servic e providers in South Africa are playing a key role in legislative interpretation even for some businesses (Vass 2004). Again, more evaluation literature comes out of South Africa rather than the US, and US based interventions do not possess the same characteristics as South African interventions such as repeated KAP or prevalence assessment s, peer education, and VCT services for example. Many companies feel under pressure to act and in South Africa this has resulted in a competitive environment, one in which quality is being sacrificed for quantity with businesses jostling for awards and so forth (Vass 2004: 10). This should not be viewed


49 as a principle motivator and the presence of a sympathetic key individual with some authority in the company greatly facilitates an effective response, as well as pressure from employees themselves and the visible effects of AIDS in the workforce. Many companies are under pressure to be seen doing something. Having a policy, even a plagiarized version taken from another comp any, is seen to be sufficient. Often companies fail to move into the implementa tion phase after developing a policy and if they do often only satisfy mini mum legal requirements in order to avoid sanctions. There are often notable failures to follow up initial peer educator trainings, and codes or guidelines are not well understood and conseque ntly not used as effective leverage to build and sustain a successf ul response (Vass 2004). In regard to M&E activities specifically, a general lack of standard effectiveness criteria relating to program co mponents like peer education and awareness raising exists. Peer education, while recognized as an effec tive tool, is being hamstrung due to a lack of operational support at shopfloor level (V ass 2004: 11). VCT services are sometimes used to screen out HIV negative employees from prevention and awareness activities presumably to save money and the effi cacy of counseling and confidentiality maintenance have been called into question. In short, the high leve l of self-regulation in the workplace HIV/AIDS management cont ext (Vass 2004: 12) with no noticeable intervention from Departments of Health or ot her formal structures calls into question the validity of any M&E data whatsoever. The abundance of literature on the econom ic impacts of HIV on business has spurned action globally, however, the results of such action are not well studied and are difficult to assess (Wilson, et al. 1996). Moreover, many businesses may not conduct


50 program evaluations at all and/or may decide no t to report their results As close back as 2003 little literature ex isted on workplace programs but this is changing quickly. Several publications and advances have occurred in the area of monitoring and evaluation (M&E) of HIV/AIDS programs in recent years. The Global Health In itiative has done several case studies in cooperation with specific businesses. Responses are varied and difficult to compare due in part to regional and industrial differences. However, explan ations are bulleted and easy to skim and information regarding numbers of employees and varieties of insurance/medical schemes is available as well as businesses motivations for initial and conti nued action. Also, one may get an idea of exactly what companies are doing such as how HIV affects particular industries in different ways. Prevalence surv eys, results from know ledge, attitudes, and practices (KAP) surveys, economic impact assessments, money spent on prevention and medical efforts, key successes, self-evaluations, and future goals of the companies are examples of other reported information about company specific programs. This is the most comprehensive and consistently structured resource available to discern impacts of workplace programs, and includes best practice s sections specific to Africa and Asia (GHI 2005b). Case studies are written by Peter DeY oung in collaboration with the company, thus, the studies can not be judged as unbiase d. A causal link between specific programs and selected company indicators cannot be esta blished but these case studies are the basis for appendix I and the statistical analysis contained in the resu lts section of this document. Notably, none of the case studies is on a busines s in the US but many of the


51 businesses are US based, further indicating th e lack of response or interest in that countrys workplaces and more of an inte rest in the diseases impacts abroad. The Global Reporting Initiative (GRI), based in South Africa but operating globally, represents one attempt at esta blishing a unified a nd universal reporting framework for businesses. Guidelines have been developed, and are currently in their 3 rd phase of revision, which addre ss the lack of consistency in case studies about corporate or business responses to HIV. This initia tive acknowledges that la bor unions, society in general, governments, and investors are look ing more toward how and if businesses are attempting to turn the tide of the disease and looking to make corporations accountable for turning awareness into action. Guidelines are component based and participation is completely voluntary. GRI was started in 1997, became independent in 2002, and collaborates with the United Nations Environm ent Program (UNEP) as an official center as well as with the UNs Global Compact (GRI 2005). The GRI accepts sustainability reports from companies and provides information necessary for businesses to dete rmine their own reporti ng indicators within the guideline framework. Companies that have used the guidelines include the Ford Foundation, General Motors, Deutsche Bank, Hein eken International, Shell, Starbucks, McDonalds, Anglo-American, Microsoft, Bayer, and Nike (GRI 2005). Much like the GHI reports these are approved by the company and therefore contain biases related to information which may harm asp ects of company operations. The International Labor Orga nization is a UN agency that seeks the promotion of social justice and interna tionally recognized human a nd labor rights (ILO 2005). Founded in 1919, the ILO is the only surviving creation of the Treaty of Versailles and


52 became the first specialized agency of the UN in 1946. The organization forms standards for international labor th rough conventions, recommendati ons, and setting minimum rights standards. It also provi des technical assistance in the fields of vocational training and vocational rehabilitation, employment policy, labor administration, labor law and industrial relations, working c onditions, management development, cooperatives, social security, labor statistics, and occupati onal safety and health (ILO 2005). The International Labor Organization provides case studies and exercises for program coordinators to use and adapt to thei r own needs and has provided the most comprehensive account of HIV workplace epidem iology to date (ILO 2002; ILO 2004a). Family Health International (FHI) publis hed an action guide for managers which focuses on policy development, prevention and care programs, managing impacts on companies, and company leadership (Rau 2002). In addition the organization has published a training resource designed to build skills for conducting monitoring and evaluation activities including data collection and analysis and developing an M&E work plan. Additional modules exist for differe nt contexts including HBC, VCT, orphan programs, and clinical care. Based on a dult learning theory the module combines lectures, discussions, group wor k, and role-plays (FHI 2005) The Global Business Coal ition on HIV/AIDS (GBC) was established in 1997 to increase the numbers of businesses that fight AIDS, profile their responses and advocate for changes, fundraise for HIV/AIDS pr ograms around the world, and to increase the quality of business sector programs in th e workplace and in the wider community. Funding came from Bill Gates, George Soro s, and Ted Turner to help start this organization, and additional funding and technical help has been provided by other


53 corporate executives and companies. The GBC provides technical advice and advocacy support for business organizations and helps to develop formal partnerships. The GBC acts as a liaison between governments, busines ses, the UN, the media, and civil society organizations (GBC 2005a). There are now 180 corporate members of the GBC. This is up from less than 20 in 2001. The board of directors includes repr esentatives from Virgin Group Companies, Standard Chartered Bank, Viropharma, Est e Lauder, Edelman, GlaxoSmithKline, Merck Inc., Coca-Cola, Haco Industries, Getty Im ages, AREVA, Care Capital, Home Box Office (HBO), MTV Networks, Heineken Brew eries, DaimlerChrysler, and the NBA to name a few. African employers are heavily represented, particularly the mining industry, and ties have been formed with the Asian a nd Thai Business Coalitions on HIV/AIDS (d'Adesky 2003). The GBC is an advocacy gr oup and urges employers not to pre-screen candidates for jobs and not to discriminate against HIV positive employees. A five-step action plan calls for a risk assessment, the development of a non-di scriminatory policy, prevention and awareness programs, a VCT program, and care and treatment for positive employees. While the GBC had accomplished almost nothing prior to 2001, it has had recent success recruiting multinationals to its cau se, however, its true effectiveness is still somewhat questionable (Schoofs 2001). The tools and materials necessary for busin esses to take action are at this point well developed and available. The Center s for Disease Control and Prevention (CDC) pioneered the Business and Labor Responds to AIDS (BRTA/LRTA) Programs that include five pillars for businesses and em ployees to consider: policy development, training for managers and labor leaders, employee education, education for employees


54 families, and community service and philanthropy (CDC 1993; CDC 2005a). Global strategies for global companies has been a dded recently as a concern which includes a few case studies and a section on global policy and law (CDC 2005b). BRTA/LRTA interests are represented as wo rkplace interventions or privat e-public partnerships within the CDCs international global AIDS program, which utilizes a variet y of strategies to combat HIV (CDC 2003c). Dating back to 1991, the BRTA/LRTA program hasnt been as successful as originally intended, however, the systems it seeks to put in place in the form of private-public partnerships is still very valid (CDC 1993; Williams, et al. 1991). Companies and businesses all over the wo rld have developed booklets, manuals, and tools specific to their own workplaces and intended for their own workforces and their family members. Nearly every multin ational business operating in highly affected areas have such materials and many go further in developing posters, screen savers, other photographic resources, as well as clot hing and other a-wear-ables.


55 Medical anthropology; relevant theories and perspectives HIV/AIDS, like all illnesses, should be viewed in social as well as medical terms. The poor are disproportionately affected by HIV in every region, and in sub-Saharan Africa the effects are near catastrophic. Pr evention remains extremely relevant and important since the majority of people in the world have not been infected. Education is necessary and anthropolo gical research can help to insure that education is conducted in culturally sensitive ways and that prevention methods are possible given the social and economic constraints on indivi duals. The importance of local context is a key to successful HIV/AIDS programs. An African solution must be widely implemented on that continent in order to see change and anthropologists have the training to help facilitate this process. In many ways AIDS is a fragile disease. It is unable to repr oduce outside of its host and even laboratory-high concentrati ons of the virus lose 90-99 percent of pathogenicity in only a few hours (CDC 2003b). It is impossible to contract HIV through casual daily contact, virtually impossible through kissing, and rather difficult to do so through oral sex. AIDS is even so fragile that if caught within 72 hours of invading the human body a post-exposure prophylaxis coul d prevent permanent infection (CDC 2003a). Workplaces practicing universal pr ecautions regarding blood and bio-hazardous


56 waste have little concern over the virus being transmitted in the workplace itself (with the exception of certain industries like health care). Therefore many businesses, including billion dollar corpor ations, see no reason to be concerned. Coca-Cola, an Atlanta based company that has enjoyed years of cheap labor and high profits in Africa, issued a policy in June 2001 which provided treatment for upper tier staff (about 1,200 people) but left 100,000 bo ttlers and distributors with nothing. The situation received considerable attention from activists and Coca-Cola has since formed a partnership with its bottlers costing the co mpany about US$11 million per year. The plan requires Coke to pay 50% of related costs, bottlers to pay 40%, and employees to pay 10% of their ARV costs. It is unclear how far the plan has rolled out following an announcement on March 31, 2003 by the company st ating that 100% of its bottlers and employees (including dependents) are now able to access ARVs in 54 of 56 African countries. Getting Coca-Cola involved in pub lic sector treatment should now be a focus given that one finds the product in even so me of the most remote parts of Africa, including crisis areas (Coca-Cola Africa Foundation 2003; Lynch 2002). Similar examples of activism playing a positive role occurred when African mining giants Anglo-American, Anglo-Gold, a nd De Beers agreed to provide treatment for their workers, but there are still many cor porations not doing their part to fight the disease. McDonalds, the transnational fast food chain, ha s a significant market in the US and the RSA. The company refuses to prov ide transportation to late shift workers in South Africa and employees are ambushed re gularly. One woman was raped after her late shift and subsequently contracted HIV/AIDS. Refusing to provide her with ARVs


57 the regions human resources di rector stated we cant just give money to everyone who asks for it and the company instead offered her a short-term loan (IRIN News 2001). Nike continues to differentiate between its Thai workforce (230 direct hires with access to benefits) from workers in factories (who number about 50,000 and receive no benefits) (GHI 2003d). The company is thus able to claim that it provides education and treatment for its workforce, when in reality it pays a number of individuals a pittance without providing healthcare or AIDS education. In the same way Coca-Cola defined their workforce to protect the elites companies all over th e world continue to differentiate between skilled staff and expendabl e unskilled workers, who get paid next to nothing and receive no benefits packages. C ontractors, who consistently show higher infection rates (Versteeg 2004) ar e also often left out of tr eatment access. Nestle, in Brazil, has 15,000 direct hires with access to benefits and 220,000 workers without (GHI 2003c). Timberland in China has about 5,400 direct hires worldwide and 33,000 factory workers in China alone. While 45% of th em have received workplace prevention education, Timberland has no HIV/AIDS polic y and refuses to share its HIV/AIDS budget figures publicly (GHI 2003e). Modicare in India defines its staff as 250 people, yet employs 950,000 consultants (GHI 2003b) The businesses and workplaces mentioned above are not high risk industries where occupational exposure to HIV is co mmon, but the situations in which some industries and businesses place their workers can exacerbate spr ead of the disease. CocaCola truck drivers travel large distances spending long periods of time away from regular sexual partners. Timberland and Nike fact ory workers tend to be women who have migrated to earn work. Worki ng the late shift at McDonalds in South Africa can even be


58 a risk factor for HIV. In this world of risk groups and labeling, is it fair to define specific workforces as HIV/AIDS risk groups? In general, researchers have mislabel ed risk groups since the start of the syndemic. For example, CDC categories included sex partners of injecting drug users. As Kane (1991) points out this is not a valid social identity or natural category. Sex partners of drug users may not even know that their partner uses drugs (Kane 1991). Herdt (1990) notes that though the notion of sexual partner may seem obvious, it varies across cultures and is probab ly the source of significant error in research design. Whether a partnership is sexual and/or social, culturally approved or disapproved, voluntary or coercive, is of real import (Herdt 1990). Using words such as prostitute or commercial sex worker can introduce bias in to a study as well because in spite of financial or material transactions wome n who are involved often conceptualize the exchange differently, seeing the man as a customer or even a boyfriend (Baer, et al. 2003). If a commercial sex worker actually wo rks in a brothel or established facility specifically for prostitution she/he may be more likely to define themselves as such. In that sense the workplace provides so cial identity. Anyone participating in wage earning activities in the formal sector will in most circumstances claim his/her workplace as a defining part of him/hersel f. The workplace can be viewed as a geographical unit and analyzed on a group level like a school, prison, or hospital. It can also be conceptualized as a social and po litical unit with a government-like structure complete with hierarchy and class-based divisions. When wo rkplaces initiate HIV/AIDS programs they transcend blame-assigning risk group categories, allowing diverse groups of people to learn together, and lend legitimacy in the eyes of employees to the full


59 weight of the syndemic as a discrimination a nd human rights issue as well as a medical one.


60 Critical Medical Anthropology, political eco nomy, and participatory action research Frederick Engels study The Condition of the Working Class in England examined the oppressive hierarchy of factory conditions in that country as far back as 1840 including accounts of poor health among wo rkers such as TB, STDs, and alcohol addiction. He relates specifi c health problems with fact ory conditions and the class structured, oppressive societ y. Merrill Singer notes how this study had an effect on Rudolph Virchow, a pathologist who developed the cell theory in 1858, as he examined a typhus outbreak in Prussia. Virchows accounts indicate that hunger was the primary means through which typhus spread but he also spoke of local physicia ns failures to take care of poor people due to thei r love for money as well as linguistic differences with Polish speaking patients. Virchow and Engels are credited by Singer with setting the foundation for a political economy of health l ong before the recent struggle to relate macro-social conditions to diseases on a causa l scale (Singer 1998). Just as the political economy of health model has ebbed and flowed through history, the idea of the workplace as an analyzable unit may or may not have been pioneered by Engels but is certainly nothing new. Neither the discipline of epidemiology nor medical anthropology focuses enough research on the ways in which larger global, political, and social structures define


61 individual behaviors on the local level (B aer, et al. 2003; Doyal 1979; Farmer 1999). Among the biggest contributors to HIV/AI DS research, prevention, and treatment programs are the U.S. Agency for Interna tional Development (USAID), WHO, and the United Nations Development Program (UNDP) as well as UNAIDS. However, the type of assistance given is in gene ral inconsistent with known hea lth problems associated with the disease and does not take in to account ever worsening health services, particularly in African countries. Poor governance in highly af fected countries, lack of participation on the part of the poor, and a less than clear understanding of the de tails of a countrys specific crises all contribute to failed programs and wasted money. Most programs receiving international support are top-down techni cal measures not designed to facilitate community involvement (Schoepf 1991; Turshen 1997). In Africa, such projects are integrated into family planning measures, promoting population control rather than tr eatment or prevention of HIV, in a region where birth is part and parcel of sexual and social fulfillment and the pressure to prevent pregnancy is not strong (Preston-Whyte 1995). Condom use has been the focus of prevention accompanied by a dialogue of cultural barr iers. Funding directed toward local approaches and responses to high rates of HIV may reveal more effective methods of prevention, but at this point the preoccupati on with condoms has left little room for holism (LeClerc-Madlala 2002; Susser 2000). Vaccine tria ls tend to receive more funding than prevention efforts in Africa but these require high risk or infected cohorts (Schoepf 1991). Ethical dilemmas continue to arise in clinical trials in Africa, particularly regarding particip ants access to care if the beco me sick as well as quality control and informed consent cross-cultural understanding (IRIN News 2005b).


62 Considering that Africas infrastructure, phys ical and medical, is insufficiently developed enough to cope with proper delivery of and patient adherence to ARVs, vaccine intervention will not be Africas most important weapon against AIDS in the near future (see Ezzell 2000). Another major concept researchers shoul d convey about sub-Saharan Africa is that most women are dependent on men economi cally and multi-partner sex is normal in the region. Many men feel they cannot be sa tisfied by one woman and feel it is their right to have many partners Many women exchange sex for food, clothing, gifts, or school grades as well as money in preand extra-marital relationships. Prostitution is also common in Africa in a variety of forms (LeClerc-Madlala 2002; Preston-Whyte 1995; Schoepf 1995) but those unfamiliar with lo cal concepts of resource exchange may not fully understand the importance and func tion of economic relationships such as multiple sexual partners among the Basotho (Romero-Daza 1998a). Mens earning power, local ideology favoring men, a nd a large background of infected persons combine to make the subSaharan African environment particularly dangerous for women. Condom usage is rare in relationships in general and most women do not have the skill to protect themselves th is way. Even so 60 to 80% of all infected women have only one sexual partner (Reid 1997b ), and mens sexual behavior needs to be addressed on an equal footing. Often, ol der men attempt sexual relations with younger girls because they are assumed to be HIV negative. In addition, due to the myth of a virgin rape cure many men believe that follo wing through with this act will cure them of AIDS, consequently, almost one-third of Sout h African teenage girls report being forced into sex (Tracey 2000). The situ ation is no less dire in th e US, where survival sex and


63 sex for drugs contribute signi ficantly to the syndemic (Singer 1994). Commercial sex workers in the States, for example, are consis tently taken advantage of due to their low social status and struggle for survival on the streets. In many cases selling sex is not a personal choice but a forced one because of drug addiction and cycles of poverty (Romero-Daza 1998b). An important component of HIV in general is the stigma attached to carriers of the disease. Particularly in areas where social belonging to a group or family is critical to ones personhood, a spoiled iden tity is greatly feared by all but the most heroic individuals (Herdt 2001: 144). Given the now inherent Chris tianity brought to Africa by missionaries, being infected with HIV implies the stigmata of sin, especially for women. In the US this stigma has been target ed toward MSM populations. Many African prevention campaigns in the past focused on men avoiding prostitutes, another stigmatized group (Schoepf 1995). Having a condom ready for sex in many situations implies being promiscuous, or a lack of trus t with a partner. Moreover, stigma has aroused very defensive reactions from of ficials and African intellectuals making it difficult to conduct qualitative research (Schoe pf 2001). Stigma affects our ability to address prevention and treatment issues openl y and limits the effectiveness of workplace programs. Historically in Africa the major source of HIV transmission was considered to be through heterosexual sex and from mother to infa nt. This has been viewed as distinctly different from in the US where intravenous drug use and bisexual or homosexual acts have been considered the main tran smission routes (Bond 1997a; Mufune 1999). Researchers of the disease realized early on in the em ergence of HIV that this


64 epidemiology was different, but many had limite d knowledge of the societies or cultures of foreign areas. Much like early discourse on tuberculosis and syphilis in Africa, the search was on to find out why it was different there as opposed to the west and the result was an essentially behavioral paradigm (P ackard 1991). The prevailing notion was that Africans, with their super-potent men and wild, lascivious women (Schoepf 1995: 32) were over promiscuous, much like homosexuals and Haitians. Such stereotypes are misconstrued, place blame on the victims, and supply labels for risk groups with which people in danger may or may not identify. In depth studies of people grouped into epidemiological categories reveal significan t diversity between and among groups. For example IDU comparisons in the US show regional differences including sociodemographic, drug use, and needle use pattern variability as well as relationship status, family involvement, homelessness, occupation and employment history, and education (Singer 1998). Risk categories pertaining to this dise ase, in every society, limit the scope of viable research and subsequent policy by limiting the research questions that are originally asked. Research employing classi cal epidemiological methods to HIV places risk and individual behavior as the main determinant, giving little note to social context and cultural barriers or motivat ors (Schoepf 2001). Power structures may ban research that challenges authority or exposes vulnerabi lities (Farmer 2003). St ill, studies that are epidemiological in nature are the main source of authority on the transmission of HIV/AIDS. However, sexuality is a cultura lly constructed phenomenon and in the case of HIV, numbers of partners ar e less indicative of risk than the social context in which sex takes place. Many such studies rely on data that is self-r eported and few give


65 information on how questions were formulated for questionnaires, who carried out the interviews, and under what conditions (Standing 1992). Schoepf argues that from the beginning of the HIV/AIDS pandemic the social sciences were marginalized, that governmentally employed epidemiologists labeled entire populations as risk groups, a nd that such methods and approaches are part of a hegemonic process that helps dominant groups to maintain, reinforce, re-construct, and obscure the workings of the established social order (2001: 337). While early HIV research drew on the existing ethnographi c record such knowledge was misused by analysts and policy makers. The problem in general was that anthropologists themselves were not involved from the beginning, but we re called on to fill gaps in the knowledge of other researchers (Packard 1991; Schoepf 1991; Standing 1992). The focus on HIV as a gay disease in the early 1980s in the US lead to the misclassification of a number of IDU deaths and illnesses, at which an epidemiology skewed by class and racial bias failed to begin to look until 1987 (Baer 2003: 239) and continues to limit our ability to reach those cu rrently in the most danger such as minority communities and women in particular. There was also debate over which countrys scientists actually isolated the blood borne pathogen first with the US taking the credit for the discovery over the French in 1984, whic h some have criticized as imperialism through rights obtained to develop blood test s and vaccines. The stigma initiated by researchers pre-emptively labeling the diseas e gay related immune deficiency (GRID) persists in the form of a blame-the-victim mentality for all those infected well into the present period, and extends past the gay i ssue to affect even more oppressed and marginalized populations.


66 In general in the developed world, the pol itical economy of AIDS has analyzed the syndemic in terms of class inequalit y, gender, sexual preference, and ethnic differences. In the developing world the fo cus has been on AIDS as a disease which exacerbates underdevelopment and has frustrated recent development gains in LDCs. The segregation between these two ideals is outdated in th at AIDS strikes more often in those already suffering discrimination, neighborhood decline, less th an adequate housing, poor sanitation, hunger, lack of access to medi cal care, and navet or disregard from decision and policy makers. The fact that AI DS spreads along the fa ult lines of society (Farmer 1999) and the vectors of disadvantag e (Singer 1998) is in this researchers opinion a more realistic way to frame di scussions about the disease. In recent years, anthropologists have become extremely involved in the HIV/AIDS field in many wa ys including surveys of population knowledge and attitudes, analyses of AIDS discourse evaluations of existing AIDS programs, discourse on societal responses to the ep idemic, ethnographies of high risk groups, discussions of ethical and methodological issues, studies of sexual networking, and discourse on vulnerability. Such studies have broadened our understanding of the epidemic in general (Bolton 1992). Given the deadly nature of HI V, I recommend an approach that allows us to contribute to the private sector response to HIV/AIDS and claim that anthropology is well suited for it. I view the following statem ent as equally applicable to treatment as it is to prevention: Prevention works best when it promotes change through individual and community empowerment strategies informed by holistic understandings of the local context, when it acknowledges the positive contributions of local cultural values to the process of change, and when it incorporates an array of options that permit individuals to transform their lives in ways that enhance their physical, emotional, and material well-being. [Bolton and Singer 1992: 142]


67 Schoepf (2001) provides an overview of pa rticipatory action research (PAR). This is a transdisciplinary me thod designed to foster social ch ange (344). It is linked to the empowerment of communities in that it enhan ces people to be socially responsible for their own well being. This method has a history going back to Rapoport who claimed that : Action research aims to contribute both to the practical concerns of people in an immediate problematic situation and to the goals of social science by joint collaboration within a mutually acceptable ethical framework (Ra poport 1970). The method itself uses ethnographic data gatheri ng techniques as a basis for participatory action against a problem or situ ation. At the same time, it contributes to the knowledge base of the social science community (Clark 1972), which is different from applied social science, where this is not al ways the case (Myers 2002). Such an approach is useful for developing workplace programs. It allows researchers to discover how the workers in a business socially constr uct disease and risk, and how they might go about molding their ow n protective strategies By involving the recipients of the programs (workers and comm unities) in design strategies it is more certain that all of the work and money put into the effort will have a sustainable and positive effect. PAR allows us to combine research with our own personal concerns about the health of the populations and indi viduals we are studying so that we give something back to them. My own experience in Zambia among th e Lunda-Ndembu, the same tribe studied on a long term basis by Victor Turner and his wi fe Edith, initially piqu ed my interest in reducing the impacts of HIV/AIDS through app lied and participatory methods. I came to the country as a Peace Corps volunteer in Januar y of 2000 as a health outreach worker.


68 Because Zambia is one of the countries hardest hit by the epidemic I knew that HIV would have to be a focus during my two year work stint. What I didnt know was that Zambians themselves were mostly unknow ledgeable about the disease modes of transmission, methods of prevention, and its vast potential to disrupt their lives. Also, I could not have expected the intense atmosphere of silence that made prevention and education efforts so difficult. I certainly did not expect the level of denial that I faced among government health workers as well as among the rural villagers with whom I worked. The apparent apathy was startling. Zero AI DS deaths were reco rded in the clinic records. During needs assessments the last th ing to be addressed by locals was HIV. The school was full of educational materials in th e local language that ha d never been used. Funerals occurred regularly of young people who had traveled to towns for work, returned sick, and died suddenly, with no explanation of death from the family members other than shrugged shoulders. At the loca l clinic, teens were refused condoms while young children made homemade latex soccer balls from them. Downcast and bored faces were the only reactions I received to my early attempts to address the issue of Kapokota, the thinning disease. I was a development worker and health e ducator and most of the people could not read. I floundered for a while wondering how to address HIV, and spent a better portion of eight months before I had made en ough friends and was comfortable enough with social customs and local understandings of the disease to begin addressing it directly. Along with local volunteers (my in formants/friends) we used lect ures, fill in the gap story pictures, participatory games, and drama to educate on prevention. This took place in


69 schools with kids and young adults as well as with adults in the vi llages. We always asked for questions from the audience afterwar d and their questions re vealed gaps in our teaching which allowed us to improve, in esse nce, a simple and basic form of monitoring and evaluation. The prevalence rate in Zamb ia has been decreasing steadily for years now and hopefully will continue to fall. Businesses in Zambia have begun to addr ess the pandemic, some starting as far back as the early 1990 s (Baggaley, et al. 1995). K onkola Copper Mines has had a policy as far back as 2001 (GHI 2001) and LaFarg e Construction has implemented awareness raising campaigns (GHI 2003a) but neither co mpany is able to provide ARVs for the workforce. The economic climate in Zambia and the continually falling price of copper leaves many mines and other companies with negative profits and will probably prevent any organized action on a scale parallel to South Africas. Parker and Ehrhardt (2001) give us examples of how ethnographic knowledge can uncover hidden aspects of social life as well as misunderstood epidemiological risk behavior patterns, especially in places where denial, di scrimination, or stigma exist heavily. They talk about ways in whic h HIV has challenged ethnography to document and analyze why prevention programs are not al ways transferable from one setting to another, how political and social processes affect what may be achieved by individuals, and to contribute to more effective and multilayered approaches to prevention. It has shed new light on the cross-cultural diversity of sexual exchanges, provided descriptive data for the triangulation of data sets, a nd expanded investigation efforts through oral histories and in-depth interviews contributing to community mobilization. The ethnographic lens has much to offer researchers (Parker 2001).


70 Herdt (2001) recommends the study of stigma to enhance HIV/AIDS interventions. Differences across sexual cultures and within communities are important if we want to generate improved anthropological studies. Stigma can focus our attention to the vulnerabilities of communitie s, particularly when cons idering social exclusion. People attempt to pass for normal so that they are not stigmatized as an other, because if this occurs then blame is placed. In real istic contexts this can lead to loss of belonging and therefore loss of personhood (Herdt 2001). The closeness of the anthropologist-informa nt relationship is stressed in PrestonWhytes style of action-research in Kwa-Zulu Natal, South Africa (1995). When mutual cultural understanding occurs, both parties are empowered, and the resulting trust can be used as a basis for intervention. She found th at through the process of interviews with young people they often made good suggestions on how to battle HIV in their communities. Simply being in the community and gaining their trust meant that she and her team were half-way to interventi on. Informants began asking for condoms themselves and decided to put together drama pieces for performance. The research team helped in all these endeavors, but the ideas came from the community. Research led directly to effective HIV/AIDS programmatic concepts inspired by locals (Preston-Whyte 1995). Schoepf (1995) gives us examples of appropriate intervention techniques which are easily implemented by teachers, but which would not be obvious to outsiders of local culture. Based on her own ethnography in Zair e she notes that misunderstanding leads to neglect of protection (38) and participatory lear ning methods can help groups understand the facts of transmission quickly. Using local knowledge and metaphors to


71 create role plays, puppet perfor mances, and pictures that tell stories can open up dialogue among the group. It is lack of such dial ogue that underscores the silence surrounding HIV. Also, since family is important in Africa it is more helpful to construct prevention messages in terms of family survival rather than as a betrayal of the spouse or as Christian immorality. In a ddition, condom use can be disc ussed as a way of family planning rather than as a way to prevent AIDS. Such indirect talk is characteristic of discussions relating to taboo subj ects in Africa (Schoepf 1995). Knowing a culture through ethnography provided the grounds for a study of beer halls in Zimbabwe by Fritz et al (2002), who note th at drinking is a large part of many African mens social lives and this behavior has been positively correlated to HIV/AIDS rates, because it often leads to unprotected se xual intercourse. Focus groups and in-depth interviews were conducted at beer halls to determine whether prevention methods would be appropriate in this forum. They found that acceptability wa s high among patrons and managers, and the mere presence of the study team steered conversations toward sharing information about HIV. Free condoms were distributed, proper use was demonstrated, and pamphlets were distributed about HIV. Patrons of the beer halls also expressed interest in having further pr evention related activities at their drinking establishments (Fritz 2002). Mataure et al ( 2002) also studied beer halls using participan t observation, key informant interviews, and focus groups and found that opportunities exist there for outreach education particularly with th e adolescent crowd (Mataure 2002). An article based on ethnographic resear ch, which involved a multi-disciplinary team of anthropologists and South African politicians, f ound that womens level of political mobilization affected their ability to adopt preventi on strategies (Susser 2001).


72 In an earlier study involving communities in Namibia and Botswana as well as South Africa, she notes the importance of consid ering access to resources and employment, level of political involvement and awareness, and local perceptions of the boundaries of sexual authority between men and women. Her studies imply that such differences are important when designing fresh HIV/AIDS programs and should be taken into account by policymakers (Susser 2000). HIV/AIDS interventions should also be directed toward the issue of migration, an area anthropologists are especi ally equipped to study due to its international and intertribal implications. Virginia Bond studied migration on a commercial farm in Zambia to develop an educational program for this populat ion. She found there was a lot of hit and run sex between migrant workers and local gi rls. Her study also brings up the ethical implications of anthropologists becoming invol ved in local matters, a consideration for action-researchers (Bond 1997b). Chirwa used interviews spaced 4 years ap art with the same cohort to assess the relationship between migrant labor, multipartnered sex, sexual networking, and HIV/AIDS in Malawian workers returning from South African mines (Chirwa 1997). Government censuses are inadequate when studying migration and further probing is necessary. In many cases assumptions are ma de that returning migrants bring HIV to their home partners, but infection can also be the ot her way around (Lurie 1997). Employers should provide more family-friendly housing options at migrant workcamps as well as interventions for migrants ho me villages. Romero-Daza and Himmelgreen (1998) discuss migrants between the highlands of Lesotho and the mines of South Africa, and is one of the few to even mention homosexuality in Africa.


73 Little is known about this subject and ne xt to no literature is available on it. However, its occurrence cannot be dismisse d (191) and it is reportedly common in the same sex segregated worker compounds of Af rican mines. Teunis (2001) notes that longterm ethnography is invaluable pertaining to th is subject, that diversity in Africa is underreported, and that the dismissal of AIDS as strictly a heterosexual disease on an entire continent is hegemonic. His own st udy took place in Senegal (West Africa), but as one of the only studies on homosexuality in Africa it is worth mentioning that he conducted ethnography on an entire same-sex community whose members engage in sexual relations, which suggest s that similar studies are missing from the ethnographic record in the sub-Saha ran context (Teunis 2001). To date much AIDS prevention has been dominated by psychological models about behavior change such as the Theory of Reasoned Action, the Health Belief Model, Self-Efficacy Theory, and the Stages of Cha nge model, which focus attention at the individual level often ignoring society, commun ity, and family levels of analysis (CDC 2005c). By focusing on how individuals process, value, interpret, and act on information many interventions have ignored larger stru ctural and political influences which may constrain an individuals ability to act on knowledge of HIV and/or increase the vulnerability of certain populations (Singer 1998). Ideally PAR should be long term to avoid the pitfalls of rapid assessment. The research presented in section II of this thesis could best be described as rapid assessment, however, this researcher was constrained by tim e, funding, and the need to attend classes. PAR in multinational companies must be carried out to truly obtain a qualitative understanding of the effectiveness and resu lts of workplace programs on HIV/AIDS. My


74 suggestion is that researchers attend internal company meeti ngs on the subject, participate in health education, grief counseling, preval ence testing, or other pr ogram activities, and if possible become involved in community events and activit ies as well. PAR in critical medical anthropology high lights the client-researcher relationship and the issue of trust, knowle dge of the local context, the role of stigma, empowerment and the adoption of effective strategies, local metaphors to convey meaning, creative places and ways for conducting ethnography, and the overall importance of ethnography and qualitative methodology in AIDS research. It is difficult to i gnore larger societal oppression and obvious human rights abuses when one is well ve rsed in the attitudes and opinions of sufferers. Knowledge of the loca l context inevitably improves the questions we ask as researchers, which has a direct bear ing on reducing lives lost to this epidemic. From this researchers perspective the wo rkplace and the workforce represent relevant settings in which to carry out PAR a nd subsequently design better informed interventions.


75 Political ecology Political ecology is a synthesis of political economy and cultural ecology approaches to researching the human conditi on. It describes the political sources of environmental change as well as associ ated consequences. Critical medical anthropologists are increasingly interested in political ecological perspectives (Baer 1996). Concerned with power differences and th e ways they shape social processes, this branch of the discipline traces roots back to Karl Marx. Current concepts of political ecology vary yet reflect the recent history of human and environment relations and span disciplines, methodology, and many areas of overa ll focus. In many ways it is a loosely defined term but the field is considered a critical social science (Mayer 2000). Julian Steward is credited with coining the term cultural ec ology in the late 1930s and early 40s, but this and many other attempts at defining such a field yielded deterministic and reductionist theories (Hval kof 1998). Still, even including humans in a discussion about ecology challenged more pr evalent modes of thought that strictly separated humans and environmental scie nce (Paulson 2003). Processual ecological anthropology, brought to the surface by Rappa port and Bateson, is where we see more politics included in the framew ork (Hvalkof 1998). The actual term political ecology


76 dates back to the 70s, is credited to jour nalist Alexander Cockburn, anthropologist Eric Wolf, and environmental scientist Grahame Beakhurst. However, there is no main article or publication that heralds the advent of political ecology. The most comprehensive overview (Bryant 1992) is entirely devoted to third world regional political ecology. Geography, as a discipline, contributed significantly through radical development geography, questions surrounding the growing population and ecological crises and increasing involvement and concern for social movements such as feminism and liberation ideology. Today we have socialist ecology, social ecology, ecofeminism, deep ecology, and cultural ecology all as coexisting fields in political ecology (Clark 2001). The inte llectual genealogy of political ecology as a whole stems from Green politics in Europe and ecoanarchism, pur porting that capitalism is inherently self dest ructive due to its productivist ethics (Baer 1996). It is the spread of capitalism and the concentration of wealth and resources that is seen to be a problem and from this stems the need for far reaching changes in political economic processes on local, national, and global levels (Bryant 1992; Mayer 2000). Anal ysis on a variety of levels is essential and important but the que stion of which level to start on and how to move between different scales of analysis can be difficult because of assumptions about history, space, causality, and time (Paulson et al 2003). Neo-Marxism was eventually adopted by political ecology in general, and became the basis of many deeply embedded assumptions, to link social oppression and environmental degradation to wider political and economic processes. This contributed to the focus on how unequal power affects the use of, access to, and conflicts over environmental resources. This brings historic al perspective as well especially in Africa


77 and other colonized areas of the developing world where people are forced to compete on a level of capitalism for which their history a nd social development did not prepare them (Bryant 1998). It is analysis on a variety of levels, historical understanding, and the relationships between social actors that political ecologists fo cus on to achieve results and raise interesting points and perspectives. In Fall 2003 an entire issue of Human Organization was devoted to studies in political ecology but none touc hed on medical or biological anthropology. There seems to be a predisposition toward the traditional focus on land development, degradation, and management which has always been typical of political ecology. The existing literature, in particular anthropological l iterature, reveals little in the way of disease research. In medical geography work has been done on development and disease in Africa (Hughes 1970) and historical impacts on endemic di sease in Tanzania (Turshen 1984). Often studies focus on rural regions and pol itical ecology has rarely been applied to urban settings (Myers 1999). Political eco logists have not yet a ddressed the issue of multinational companies systematically. Also, much work has focused on the role of the state rather than instituti ons such as businesses, NGOs multilateral institutions, or peoples organizations (Bryant 1998). Another area of research th at is lacking is the synt hesis of medical foci and political ecology, particularly in the area of disease causality. Such a conceptual framework would include the combination of traditional disease ecology with political economy. It would also allow a researcher to demonstrate that disease can be caused by humans as well as natural forces and particul arly look at the unintended results of human interaction with the en vironment (Mayer 2000).


78 Multinational Companies, Urbanization, and HIV/AIDS Mayer (2000) takes a polit ical ecology framework in a global analysis of emerging and resurgent infectious diseases. Di sease ecology is just as much the result of political and economic power as it is sma ller scale molecular phenomena. The very cause of a disease can change when consider ed from socio-ecological angles. Mayer uses global interdependency to point out flaws in publ ic health structure and inconsistencies in trade and policy matters. The health transition and the Wests declaration that the battle against infectious dis ease was over in 1969 meant that in developed countries more money and effort is now put into battling non-in fectious diseases rath er than infectious ones. Human-environment interaction has led to disease for example in situations involving Schistosomiasis and dam constructi on, clearing land for r ubber plantations and accompanying increases in malaria, vectored diseases such as HI V/AIDS spreading along transportation roots, and lyme disease due to suburbanization and real estate development in the US. Assumptions that developing countries health problems cannot seriously affect developed nations and that infectious di sease is a problem of the past are false and dangerous. Mayer uses five f actors to describe the flow of disease: cross-species transfer, spatial diffusion, pathogenic evol ution, recognition of a pathogen that was


79 formerly unnoticeable or unrecognized, a nd changes in the human-environment relationship. I would like to poi nt out that HIV serves as a solid example of all five of these factors. The virus may have crossed over from a chimpanzee species during hunting and dressing activities (Gao, et al. 1999), has diffused over the entire globe through travel and war (Smallman-Raynor 1991), evolves for its own survival and protection from ARVs (Lipsi tch and Nowak 1995), was probably harming populations before it was discovered (Discovery Hea lth 2005), and its transmission can be exacerbated by humans and environmental cha nge (Coetzee 1996). In Mayers analysis, public health surveillance measures are assumed to be highly inadequa te and in need of drastic change and increased funding. Urbanization also tends to increase in fectious disease, however, an equally important issue is that transmission patterns a nd interactions of possi ble vectors change in ways that are little understood in urban environments and introduce new problems concerning control. In Africa the spread of HIV is exacerbated by urbanization (Coetzee 1996; Nunn 1996). This is particularly notable in studies looking at pregnancy, birth, and HIV (Mwakagile 1996; Taha 1995) Street prostitution and consequently STDs increase with poverty in urban areas as well (Lockhart 2002). Malaria transmission, while generally believed to decrease in urban areas, has also been shown to increase (Brieger 2001; Campbell 1997; Ladhani 2003; Sethi 1990) and one study in particular demonstrates higher levels in peri-urban townships compared with city centers (Robert 2003). Power is reflected in the ability of one so cial actor to control the environment of another and is often institutionalized (B ryant 1998). In this case, control is


80 institutionalized through the private sector through a gi ven companys actions which have far reaching results in South Africa. On e of the results is that people often leave rural villages to come to the city to work. Power is further consolidated on the part of multinational companies when settlements or camps, formal or informal, spring up around million dollar factories whose executives may hire or fire at a whim due to a seemingly endless available supply of cheap labor. Infrastructure within company grounds is often near flawless, especially the barbed wire fences and security checkpoints, but the immediate surrounding community often l ooks like a desolate urban hellscape to the outsider. Historically limits to movement as we ll as lifestyle changes were imposed on African people by drawing political lines acco rding to the desires of colonial powers. Groups that were mobile were forced to settle and resort solely to agricultural practices. They were exposed to manufactured or im ported goods that often out performed local tools and became favored in most circumstan ces. Traditional practices waned and were forgotten. The Lunda-Ndembu people in Zambia no longer mine and produce their own metal tools, but must go and purchase (for exam ple) an axe head from town to attach to their village-produced wooden handles. In South Africa, workers were funneled fr om rural areas to wo rk in often white owned mines and factories. Urban areas deve loped in this way growing in unplanned and haphazard ways. While the wealthier areas of any South African city are often indistinguishable from wealthy areas of a ny MDC, the townships and mining towns of industry workers remain unhealthy and undeve loped through conditions often directly


81 augmented by the company or industry itself Polluted ambient air, groundwater, and intolerable noise levels are all common results. On a global level, companies search for cheap labor and expanding markets. The reasons for why multinational businesses beco me multinational often revolve around self interest and profit making. Some companies and businesses possess more resources than LDC governments themselves. Ford, Coca-Co la, and Volkswagen are examples of businesses that can enter a foreign market and compete on a level equal to or better than local companies. In this way businesses choose where they will operate, who they will do business with and who they will hire. This translates into consid erable power in South Africa, a country with a 31% unemployment rate (CIA 2003). A village in KwaZuluNatal may lose significant human and social capital to jobs at an auto-manufacturing plant 300 km away in Gauteng Province. On a national level, South Africa has done a poor job at developing rural areas when compared to urban ones. The aparthei d system, which forced many black Africans back onto traditional homelands, also spread illness to rural ar eas on a national scale (Farmer 1999). While a leader in esta blishing corporate governance guidelines companies in South Africa co-exist in an environment where many of the countrys citizens disturbingly remain on the fringes of societys economic benefits (King Committee 2002). As is common in other Africa n nations, rural dwelle rs are forced to make a choice between poor services versus trying their luck and integrating into the wider economy and competing on a more capitalis t level. This usually involves some or all of a family relocating or migrating seas onally in order to add cash income to the household budget. Businesses have been cons ciously located in urban city areas for


82 convenience sake. Specifically, the convenience I refer to is that the rural and semi-urban areas can remain undeveloped. The irony is that when families move they often must survive in worse living conditions in the city th an those they left be hind initially. In the greater African culture and worldview in tense stress is put on communal values, consensus and cooperation, in terdependence, and co-exi stence among and between families and communities (Sorenson 2004) On a local level, poor peopl e are striving for survival. Moving to town for a better life represents an ideological myth that often fails to live up to expected standards. However, people are so desperate for wage la bor that many are willing to relocate to urban areas without any proof th at life will indeed get better working the informal sector economy, begging, or committing crimes. In many cases the government forces displacement of residents from an area into squatter camps. In some case people claim sections of land, squat, and turn it into an informal township, continuing to occupy the land until it is officially r ecognized by the government. This is happening in townships and informal townships all across sub-Saharan Africa (IRIN News 2005c). Communities spring up around factories in South Africa and often begin as informal settlements containing people working for, or who want to work for, the company. Services slowly become availabl e and proper housing is eventually built if growth circumstances warrant that action, but not all reside nts are equally accommodated at any given time. When an informal set tlement becomes a township, more squatter camps immediately appear on the borders of th e new township itself, indicating that this process is a consistent one (Chapman 1998; IRIN News 2005c). Disease surveillance and prevention efforts are not likely to be up to acceptable standards in squatter camps, and


provisions of government service are rarely satisfactory. Nevertheless, many of the people living there would not be doing so if the factory were elsewhere. Growth rates in developed countries have leveled or are negative while developing countries maintain high birth and fertility rates and lower death rates (see figure 2). Even HIV is not expected to negatively affect population growth in Africa (Chamie 2001). Doubling time for the global population has decreased exponentially (see table 4) mostly because of the agricultural and industrial/scientific revolutions. This has resulted in what public health professionals term the incomplete demographic transition or the health transition where 95% of the annual global population growth occurs in less developed countries that already have trouble caring for the majority of citizens (Nadakavukaren 2000). Even using the word incomplete while describing LDCs underscores the continued hegemony and paternalism of governments and researchers in donor nations by assuming that other countries demographics should and will one day evolve and possible even mirror their own. Figure 2 Population Growth Rates in Urban and Rural Areas, Less and More Developed Countries, 1975 to 2000 and 2000 to 2025 Source: (Brockerhoff 2000) 83


84 Table 4-Doubling time for the human population (Nadakavukaren 2000) Date Estimated global population Doubling Time (years) 8000 B.C. 5 million 1500 A.D. 1650 500 million 200 A.D. 1850 1 billion 80 A.D. 1930 2 billion 45 A.D. 1975 4 billion 36 A.D. 1999 6 billion n/a Urbanization rates are also alarming (see figur e 3). This trend is leading to megacities that deplete environmental resources, co ntribute to urban sprawl, acid rain, global warming, and establish large semi-urban slums. Governments must strive to improve and provide services at such quick rates and most often fail in one capacity or another. Africa has the highest urbanization ra te and its population is growin g faster than that of any other continent. By 2030 nearly 800 million people, or a number equivalent to the current population of the whole continent, will be living in urban areas (Mosha 2001). By 2050 it will be three times more populated than Europe (Chamie 2001). Arguably this is due more to natural growth than migration. Such rapid urbanization combined with population growth and economic difficulties is related to deteri orating services in areas like transportation, water, health, and education. Squatter settlements often claim 50% of the inhabitants in African cities,


where people use dirty water and live in polluted areas and fragile environments. Poor municipal management in cities means that vehicle emissions are unchecked and garbage collection is not fully carried out. Many cities lack drainage or sewage systems and the majority of urban dwellers have no indoor plumbing and use simple pit latrines (see appendix I-J) (Mosha 2001). The richer residential and commercial areas are spared such disaster. The conditions in large African cities and particularly in the slums and townships are favorable to disease transmission and outbreak. Moreover, the urban status of residents means an increase in chronic diseases as well (Stephens 1996). Figure 3 Percent of Population Living in Urban Areas in Major World Regions, 1950, 1975, 2000, and 2025 Source: Brocherhoff, 2000 85


86 Several structural relationships are important in this scenario. International Monetary Fund (IMF), World Bank policies, and SAPs geared toward privatization have made their mark on South Africa, preventi ng the country from safeguarding its own economy from foreign investment and takeover. This has helped to establish the push and pull factors typically evid ent in migration patterns. Poor population control in the country and cultural factors valu ing pregnancy and child birth m ean that natural growth is taking place in the cities at alarming rates. Th is growth is equally if not more important than migration issues (Coetzee 1996; Schoepf 1995). The stigmatization of HIV is an important issue as well. Particularly important for workplace intervention issues is the fact that individuals are not willing to get tested and are afraid of losing their jobs if found positive for the infection. This stems from societys imposition of morality on the diseas e, which was further hindered by President Mbekis statement that HIV does not cause AIDS. My main points in this section are that: 1) urbanization is imposed on populations, is unchecked, and will impact our global environment and 2) those who benefit most from urbanization are the compan ies, factories, and bus inesses involved. To solve this we can start with a couple of initiatives: requiring businesses to keep the environment clean and employees healthy, and by putting more effort into rural development. Urbanization can be reversed by groups moving back to villages or rural areas, which is not likely to happen easily, but is an idea that governments and companies could support through rural development. Anot her angle to consider is the development of smaller urbanized areas where unchecked development has not yet occurred. These


87 areas could represent a hybrid of urban and rural benefits and hopefully attract some of the overflow from the cities. Political ecology provides a framework to analyze such complex issues and can help discover solutions to related problems. However, in the real world the radical changes which political ecology often endorses will not be acceptable to those in power. For example, to remedy Africas refug ee crisis Kalipeni and Oppong recommend redrawing national boundaries to reflect tribal or ethnic clas sification (Kalipeni 1998). Businesses and corporations are willing to work with people to solve crises. In most cases the crisis must be one that w ill clearly impact business markets or overhead costs. Not being overly political with political ecologi cal concepts perhaps is a better way to start making significant changes than touting Marxist princi ples as the primary path to success. While I feel that drastic changes are necessary we need to involve as many parties as possible in discussion and measure our successes and fa ilures regularly to determine progress.


88 RESEARCH SETTING The Global AIDS Program I was first introduced to the topic of HIV in the workplace as an intern for a joint program between the Association of Schools of Public Health (ASPH) and the CDC in which I participated from May 7, 2003 until July 29, 2003. ASPH, a non-profit organization, supplies interns with a living st ipend while the intern works with CDC staff using CDC office space, equipment, and other necessary resources. Both organizations are based in Atlanta, Georgi a and this was the primary location of my internship experience. I was given an office for the summ er at the Corporate Square offices of the CDC, in the Division of HIV/AIDS Preven tion (DHAP). My immediate supervisors were Dr. Richard Keenlyside, Associate Di rector for Science in the Global AIDS Program (GAP), and Jennifer Lowenstein, MPH, who works for both GAP and DHAP. My official title was public-private partne rship research assistant and while I was technically working for the Global AIDS Progr am I was privileged also to work with members of DHAP and people involved in the BRTA/LRTA program. Initially started in the year 2000, GAP focuses on prevention, treatment, surveillance, and support for capacity building to address the global aids pandemic by


89 partnering with communities and community or ganizations, governme nts, universities, international health organizations, and priv ate-sector enterprises such as businesses working in low resource countri es. GAP also partners with U.S. government agencies such as the National Institutes of Health (NIH), the Health Resources Services Administration (HRSA), the USAID, the Depart ment of Defense, and the Peace Corps to achieve its goals. GAP includes 25 country programs and four regional programs, focusing in particular on the 15 countries deem ed recipients of the Presidents Emergency Plan for AIDS Relief (PEPFAR). GAP count ries include Angola, Botswana, Brazil, Cambodia, China, Cote dIvoire, the De mocratic Republic of the Congo, Ethiopia, Guyana, Haiti, India, Kenya, Malawi, Mozambi que, Namibia, Nigeria, Rwanda, Senegal, South Africa, Tanzania, Thailand, Uganda, Vietnam, Zambia, and Zimbabwe. GAP uses three broad based technical strategies which include prevention, HIV/AIDS treatment and care, and surveillance and infrastructure development. My role as public-private partnership research a ssistant was subsumed under the prevention strategy, hence the association with DHAP, a nd many of the partnerships nourished by CDC are between public health and private business, usually multinational businesses interested in decreasing the impact of HIV on their workforces. This desire to engage business and labor in HIV/AI DS workplace policy, educatio n, and prevention stemmed in part from the U.S. domestic business pr ogram known as BRTA/LR TA, a program more thoroughly discussed above in the workplace intervention evaluation section.


90 Internship goals and objectives Original goals were decided upon by my supervisors and I. These included: 1) Conduct a literature review of HIV/AIDS international workplace programs in order to establish the effectiveness and validity of su ch programs as well as to identify factors contributing to or discouraging policy formulation, program implementation, success, and monitoring or evaluation. 2) Conduct research and data collection whic h contributes directly to the Business and Labor responds to AIDS (BRTA/LRTA) international agenda as well the Global AIDS Program (GAP). 3) Contribute toward a draft formulation of a sub-Saharan version of the BRTA/LRTA toolkits (manuals) for employers and employees. These goals later became modified and the connection between my research and the BRTA/LRTA program became less clear. My su pervisors were interested in obtaining and analyzing monitoring and evaluation da ta from existing workplace programs, but reality dictated that few businesses had program s at all, even fewer evaluated the progress of programs, and very few indeed published da ta on monitoring/evaluatio n results. It was decided that I would partner with GAP count ry personnel in South Africa, Botswana, and Zimbabwe to conduct interviews with busin esses possessing HIV/AIDS programs in each country. The process and challenge of conduc ting international research nudged goal number 3 off of the agenda. I began to focu s on establishing contacts with businesses to conduct interviews, reviewing lite rature directly related to po tential interviewees, writing a research protocol and key informant que stionnaire, and completing the necessary


91 procedure to conduct human research through the University of South Florida (USF) Institutional Review Board (IRB). The CDC IRB would have been unable to review the potential research within the internship time frame. Th is turned out to be a huge disadvantage in Botswana because the GAP di rector in that count ry would not accept the USF IRB clearance and prevented me from conducting active research in Botswana, although I did visit GAP offices and attend m eetings. Turnover in GAP staff and people taking vacation in Zimbabwe left me w ithout counterparts during the intended time frame, thus this country was dropped from the research entirely. I based my research question on one that my supervisor suggested: in existing workplace programs, what mechanisms and st rategies are working and not working to lower the prevalence of HIV, and what syst ems of support must be in place to sustain effective programs? This central question allu des to the fact that the study falls into a category known as monitoring and evaluation but we avoided those words intentionally, primarily because of the intimidating natu re and implied authority associated with monitoring or evaluating a given project. It is unusual, or less common, for an thropologists to study up or collect ethnographic data from powerful entities in stead of powerless ones. In many cases participants in anthropological research studies have something to gain from the research materialistically, politically, or socially. Apart from being allowed to participate based on rapport, trust, or other relati onship markers, it is the leverage of some type of aid or help being offered to the source community that can cement an anthropologists place as friend and ally. While multinational companie s are powerful entities, their workforces and the economies of the communities purchasing products are ravaged by AIDS


92 particularly in Southern Africa. Companies in the study were approached with an attitude of beneficence and anonymity, because this re search is intended to help the common good and because company names associated with successes and fa ilures of workplace programs are unnecessary and potentially incriminating. Also, I admittedly had some leverage with many of these companies simply because my email address and phone number originated from the CDC, and because GAP is a multinational global health initiative with connections to country level ministries of health and other institutions.

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93 Experiences and Events Within the first two weeks of my internsh ip I attended two conferences. The first was a 2 day BRTA/LRTA conference in Wa shington, D.C. intended to share ideas between CDC and BRTA/LRTA board members or representatives from companies, labor unions, law firms, community groups and pharmaceutical sales. This was a housekeeping meeting where the board decided on goals and priorities for the next year as well as events and activiti es that should be planned to raise awareness of HIV/AIDS issues. During this meeting the head of BRTA /LRTA, Victor Barnes, addressed the board regarding Tommy Thompsons restructur ing of the CDC center which deals with the AIDS epidemic. Most of DHAP was against the restructuring, which places importance on testing and identifying HIV positi ve individuals particularly in minority communities, and effectively de-funds hundreds of community based organizations here in the States that deal with HIV preventi on. The board was equally shocked, noting that asking businesses to start testing employees goes against the standa rd of anonymity and equal opportunity that BRTA/LRTA has been striving for since its inception. Key concepts of this new initiative directly handed down by the Bush administration targets minority communities and high prevalence popula tions for rapid HIV/AIDS testing (IRIN

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94 News 2005b; KFF 2003a; KFF 2003b). Not only do the reductionist risk categories restigmatize the disease as one of Blacks and Latinos in the US, but the governments funding was restricted to programs favored by the administration. In keeping with prolife policies, abstinence is favored while condoms are disregarded as a method which does not provide 100% protection. Not only is the new initiative actually an old initiative, that of stigmatiz ing populations on purpose for pol itical reasons, but policies favoring abstinence have restricted inform ation about condoms on government websites which limits information available to the general public and i gnores science. Far reaching results of this Christian faith-driven policy shift have been observed in Uganda, where the US is the largest si ngle donor, and condoms are gradually being removed from HIV/AIDS strategies. School textbooks there falsely state that latex condoms have microscopic pores which allow HIV through and that pre-marital sex is deviant behavior (IRIN News 2005e). Restricting information about how to protect ones health in case of a sexual encounter is act ually pro-death rather than pro-life. The second conference I attended was the GAP annual conference held in Atlanta, GA. Directors, nurses, social workers, epidemiologists, and lab personnel from each of the 25 GAP countries were presen t to share experiences and th e results of initiatives in their respective countries. This meeting allo wed me to hear presentations on each of the technical strategies GAP utilizes to combat AI DS. It also gave me a clear indication that public-private partnerships, as a strategy, r eceived little attenti on in a room full of biomedical professionals when compared to surveillance, treatment, and even other prevention strategies such as presumptive treatment for commercial sex workers with ARVs. Partnerships with businesses seemed neglected, for example, when few people

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95 turned up for the general session on this issue which happened to be scheduled immediately after lunch, a time when many were likely to show up late. Through meetings and conversations with staff all through my experience with the CDC, I was under the impression that the public-private partnerships strategy of the Global AIDS Program did not receive enough atte ntion in the field offices. The convenient and most memorable aspect of this conference was the privilege of networking with advanced professionals all over the world involved with AIDS treatment and prevention. This happened before Zimbabwe was crossed off of my research list, and I was able to meet the a ppropriate GAP contacts fr om the countries in which I would soon be conducting research, and spoke in length with the GAP staff from Zambia, where I lived for two years. After that week long conference and for the next seven weeks, I continued preparing for research by completing IRB materials, continuing to review literature and summarize information for my background sect ion, and attend internal CDC meetings, conference calls, and workshops sponsored by ASPH to educate interns on how to present research and speak effectively in publ ic. This time was also used to finalize travel arrangements for airfare and hotels as well as for interview appointments with program directors in South Africa.

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96 METHODS This research looks specifically at im pacts of the private sector response to HIV/AIDS in South Africa focusing on large businesses and corporations. The purpose is to obtain a current unders tanding of what is working and not working for HIV/AIDS workplace programs as well as what systems of support must be in place in order to maintain effective and successful programs. Five multinational corporations were singled out, three in the automotive industry, one financ ial services bank, and one company which produces food, chemicals, a nd detergents. One auto manufacturer already working with GAP/CDC agreed to participate and the GBC website and GHI case studies provided contact information for other multinational companies. Companies volunteered to participat e in the study by responding to an email sent from the author at the CDC in Atlanta, Georgia requesting study participants. After emailing more than 25 companies in South Africa, seven responded and five were able to participate. Key informants within these companies were interviewed. Verbal consent was obtained following an e xplanation of the pur pose/intent of the study, which was also provided to participants in a written document. Confidentiality was guaranteed for informants and companies thus company names are not used in this thesis. This data is complemented by direct observation as well as a review of literature.

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97 Literature review began in May 2003 and c ontinued until August. The ethnographic portion of this study could best be described as rapid assessment and was carried out from July 5, 2003 until July 19, 2003, in Johanne sburg and Pretoria, South Africa as well as in Gaborone, Botswana. To compleme nt the literature, I specifically sought supplemental information in the domains of risk and health seeking beliefs and behaviors, knowledge systems, structural and cultural contexts of behavior, symbolism, and communication that could be used to guide the development of appropriate intervention materials and action. The interview schedule was made up of open-e nded questions that allowed for extensive probing. Key informants included 5 HIV/AIDS program coordinators for large, multinational businesses as well as 4 peer educators and 2 government employees in South Africa. The first key informant is a do ctor at the on-site cl inic on factory grounds. She is a white woman in her mid-forties and has worked with the company for about 6 years, and is responsible for the HIV/AIDS program on a full time basis. From what I saw she was very well liked and known by workers. The second key informant had worked with the company, through a partneri ng foreign agency, since the beginning of the project in 1999. She is an ethnically whit e epidemiologist in her mid-forties and our interview occurred in the corporate offices in Pretoria. In another company, I spoke with a human resources manager who was a white woman, probably about 30 years old, who had been with the company for about almost 7 years and also traveled frequently to help with the global rollout of the HIV/AIDS pr ogram. Another key informant was the nurse primarily responsible for the HIV/AIDS progr am in the company who had worked there for over 10 years. She is a white woman in her mid-fifties. In the same company I spoke

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98 with a white, middle-age consultant who worked as a technical advisor on the program. I also received a PowerPoint presentation a bout the program from a younger, black South African man who had worked for the company si nce his entry into a professional career. Another key informant was a white man in his retirement years that had spent the majority of his professional career in human resources for the company. I was able to visit this companys community outreach center where PWHAs from the community come to participate in income generation ac tivities. Four peer educators presented themselves for interviews as well. One was a middle-aged black woman who visited the center regularly and used faith as a t eaching tool and support mechanism for her education. Another was a mid-level, middl e aged black professional working for the company (a desk job). Another middle-aged black man was a factory floor worker for the company for over a decade and a shop stew ard, which is someone responsible for a team of employees. The final peer educator was a middle aged man of Indian heritage who had worked on the factory floor for about 4 years. Two more key informants were one middle-aged black woman and one young black woman who worked for a government AIDS Treatment, Training, and Information Center (ATTIC). During a brief visit in Botswana, the researcher talked with one NGO staff member as well as individuals working for the CDC/ACHAP project in that country. Observations were documented through written field notes. In South Africa this occurred primarily within the workplace and included factory floors, corporate offices, on site health clinics, and one community outreach pr oject site. People and businesses retained the right to remain completely anonymous throughout any interview, conversation, or

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99 observation exercise. No person was asked to disclose his or her HIV status. Questions asked during the interview included the following: 1) What type of intervention(s) is the company carrying out? 2) Are programs effective and useful to wo rkers? Workers famili es? Why or why not? Are workers receptive to the programs? If peer educators/counselors are involved how are they selected? 3) Are there any other obvious results of the program(s)? 4) Is the program cost effici ent for the company? Is the role of HIV educator/program coordinator/peer counselor an added duty to typical work roles? Are such individuals paid or somehow compensated for their efforts? 5) What factors or circumstances contributed to management or other decision makers deciding to implement an HI V/AIDS program and policy? 6) Were there or are there currently barri ers to implementing the program(s)? What circumstances, if any, make implementing the program(s) easier for your company? 7) What role has stigma played in implementation of workplace programs? 8) Do you think workers in other companies should have access to HIV/AIDS programs in the workplace? Are programs more important for skilled or unskilled workers? 9) If you could change something about the programs/interventions available to you and your workers what would it be? Does the co mpany supply ARVs for workers? Spouses or children? Are there co-pays? How does distribution occur (clinic, mail) and how does this affect participation? 10) Do you have any suggestions for small businesses that may be interested in becoming more involved in workplace interv entions? Would your company work with small businesses during education sessions or in any other capacity? Data collected from the interviews and from observation were coded into five main areas of analysis: (1) policy deve lopment, (2) prevention, education, and awareness, (3) care, counseling, and treatm ent, (4) community involvement, and (5) implementation and success. The research attempts to identify reasons for success or failure beyond what information is availa ble in documented research and program evaluation literature to this da te. Program coordinators, work ers, and peer counselors had the opportunity to express thei r opinions and share their expe riences confidentially and in a way that can strengthen existing programs.

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100 In this area of occupationa l safety and health, which is still in its infancy, many businesses and workplaces suffer from lack of evaluation criteria a nd structures making it difficult to collect unified, easy to compare resp onses. In the literature, it seems as if companies are not admitting the weaknesses a nd failures of programs, or worse yet, not even aware of them. This thes is attests to the fact that many businesses are aware of and attempting to address the problems that aris e within their programs. Workplaces vary widely and must take the time necessary to asse ss situations that ar e specific to industry, education levels and backgrounds of work ers, locations, community and political influences, as well as religious, ideological, and economic factors. Local situations are important yet are shaped by larger politi cal and economic patterns, representing integrated contextual situations which anthr opology and social science in general is well suited to study. Formulas or guidelines for workplace pr ograms must be flexible and change as needs arise. Differences are apparent be tween the programs and various locales and industries of any given multinational company. Smaller companies in similar areas and situations may benefit immensely from the la rger private sector response and efforts should focus on adaptable, component based approaches that allow for variations between locations and according to availabl e resources. Programs should not remain constant because this implies a lack of co mmunication among parties involved regarding a disease that requires multi-sectoral and multi-stakeholder feedback.

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101 RESULTS Company Profiles To protect confidentiality companies are assigned letters in lieu of actual names and data has been de-identified to the fullest extent possible. He re I will describe company profiles such as relevant financial and production information, project descriptions, risk and prevalence data, and expected outcomes or monitoring results. Some information is based on global aspects of company performance but when possible I have included information specific to South Africas branch of the company. Much of the information in the followi ng sections is reported or published through projects and company specific websites. However, those sources are not cited here to protect the confidentia lity of the companies involved. I have done this for several of reasons. In my own qualitative resear ch interviewees mentioned statistics which closely mirror some published case studies. The interviews were carried out in the summer of 2003, so some information was updated as it became available on the World Wide Web. Also, already publis hed case studies of companys were presented in a more structured and standardized format which I ha ve subsequently adopted post-research. In addition all of the sources used in this next section which are not cited are present, either

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102 in direct form or through web links, in the reference list at the end of this thesis. Such protected sources are necessary to maintain anonymity for companies. Other information in the following sections come directly from the authors field notes and notes from interviews (Reed 2003) Company A is in the top five of the worlds largest automotive and transportation companies manufacturing in 37 countries and di stributing in more than 200 countries. It employed 370,000 people in 2001 and handled revenues of more than US $130 billion with a net income of more than US $580 million. Company A employs about 8,000 people in South Africa including contractor s. Estimated 2001 revenues were US$ 1.4 billion and net income was US$ 79 million for the South African branch. Company A established its workplace project in 2001 in partnership with a foreign government agency to address the syndemic based on incr easing financial burdens related to AIDS and as part of stakeholder pr inciples of Corporate Social Responsibility (CSR), with the objective to reduce further spread of HIV infection and STIs through treatment, care and support for PWHAs in their workforce a nd their families and communities. The company estimated a 2001 HIV prevalence of 9% among its employees and observed an increase in the proportion of employee deaths attributable to HIV/AIDS for more than 5 years. The average cost of an infect ion was US $31,000 in 2002 but goes up to US$ 126,000 for highly paid employees. The 2002 HIV/AIDS project budget was US$44 per employee per year. The company also spent more than US$100,000 for community HIV initiatives. On a global scale Company B employed 100,000 people in 2002, revenues were around US $44 billion and net income US $2.1 billion. An automobile and motorcycle

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103 manufacturer in South Africa, Company B employs about 5,000 people and exports 80% of its product. The companys HIV/AIDS budget for 2002 was US $54 per employee per year and workplace prevalence was estimated at 6%. Company B based its program on prevention and awareness training, peer educ ators, condom distribution, treatment for STIs, events, workshops, and theatre. Employees have access to VCT services as well as ARVs. The program has a multi-stakehol der HIV/AIDS committee and a full time nonmedical champion. Company C manufactures and mark ets food, hygiene products, and other consumable materials. It employed a bout 250,000 people in 2001 and generated US$ 46 billion in revenues and US$ 1.6 billion in net income. In South Africa Company C employs about 5,000 people and has more than 4 manufacturing sites. Condom distribution, peer education, and manageme nt training are all components of the 2002 HIV/AIDS program which had a budget of a bout US$ 78 per employee per year of which 60% is spent on awareness and education pr ograms and 40% spent on VCT services. This money is supplemented with about US$ 130,000 for community involvement. Company D is a major auto manufacture r and distributor with 300,000 employees in more than 100 countries. The South Africa branch employs about 3200 people with an average age of 41 and a male-fem ale ratio of ten to one. Prevalence in the workforce is about half of the national RSA average or ten to twelve percent and less than 20% of the workforce is white and even fewer are of Indi an heritage. Global revenues currently are in the US $80 billion range with net prof its at about US $4 billion per year. The company delivers trainings for all South Af rica employees and facilitates and hosts a variety of community events. One of the first auto companies and big businesses to

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104 develop an effective response, it was clear to relevant company committee members that the RSA government could not handle this fi ght alone. Widespread denial and stigma also prompted the company to action. Company E is an international commercial financial institution that focuses on emerging markets in Asia, India, the Middle East, Africa, and Latin America. Globally Company E employs 30,000 peopl e in 50 countries Response to the pandemic was initiated by country managing directors in Africa, where the company employs about 6,000 people. Expected impacts due to HIV/AIDS on the company included absenteeism, medical costs, and staff death and turnover, and human resource managers were requesting advice on how to deal with positive employees. The program is mostly awareness raising but medical benefits allo w employees access to treatment services. These companies, due to their self se lection and agreement to do the study, represent more successful programs than th e norm. Many businesses have no policy or program at all, and among those that do such comprehensive programs are rare. I would therefore caution the reader not to take these companies as a representative sample of South African business performance or ethi cs in relation to HIV/AIDS workplace programs. All of these companies are multimillion or multi-billion dollar transnational entities with massive funding and extremely large workforces capable of initiating HIV/AIDS programs. This is in contra st to many SMEs which do not possess the financial resources. For them, however, publ ic-private partnerships are even more important. Many of the multinationals sampled in this research agreed that they would work with SMEs on a consistent basis.

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105 Policy Development Company HIV/AIDS policies typica lly have five components: nondiscrimination, confidentiality and disclosure, employee benefits, ill health retirement, and contractor benefits. Many appear sim ilar and while each defines the above five components in different ways several commonalities exist. Non-discrimination components typically state that employees wi ll not be dismissed based on their HIV status and that hiring decisions and will not be based on an HIV test. Confidentiality and disclosure components typically state that employees are not required to disclose status and if status is disclosed it may only be done so with written consent from the management. Benefits components typically give employees access to health insurance plans and estimate expected health care premiums and payouts, allowing PWHAs access to ARVs in the process and often stating maximum benefits. Ill-health retirement components allow the employee and management to strike a balance between stay-athome and job-alternative options, usually encouraging employees to work as long as they can in conjunction with their wellness program. Many businesses have outside contractors who are not cons idered employees with the typical benefits. Policies typically outline benefits availa ble to contractors of ten stating that they are not required to adhere to the policy, do not have treatme nt benefits, but do have access to prevention

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106 programs. Most policies are approved by la bor, labor unions, and company management. Company As policy dates back to 1996 and possesses all of the components mentioned above. Other company policies are very similar but enacted much later. Company Bs policy dates back to December 2000 and includes all of the same components with added provisions for the im mediate dismissal of medical personnel should they breach confidentiality with pati ents. Company C launched a policy in May of 2002 and plans on continuing to develop si te-specific policies. Company D launched its program and policy in 1999 with the suppor t of management and labor unions. An HIV/AIDS steering committee was established as well. Company Ds policy stands out in that it imposes a zero tole rance rule on harassment and discrimination, and engages in active partnerships with others for the reduc tion of HIV/AIDS in South Africa. Company E developed a policy in 1999 to enhance hum an rights and equal opportunity protection in the workplace. The policy includes procedures for managing HIV+ employees that are flexible enough for adaptation by country-specific branches. All companies had developed an HIV/AIDS policy that is accessible to employees in a variety of ways including posting in public places, inclusion in newsletters, and in one case interactive computer stations av ailable to employees. Keeping the policy available and accessible is necessary for boldening individuals to learn their status and to be cognizant of their rights, but policy development is not alwa ys the necessary first step toward an effective strategy against the disease. A policy may come later after motivation is assessed and support initiated. Ne wsletters or other ways to view the policy in private are necessary in the face of stig ma. Finally, an HIV/AIDS policy must be a living one that is subject to change and revision as companies and workers see fit, barring

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107 any backward steps which may negatively im pact universal human rights for those living with and affected by the disease.

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108 Prevention, Education, and Awareness Many companies conduct economic impact, KAP, and/or prevalence surveys. Company A used a stratified random sampling technique to determin e prevalence rates in their workforce. With a response rate of 79% and more than 1,300 people surveyed average prevalence stood at about 9% in 2001. A multilingual KAP survey conducted that same year revealed that many employees believe traditional African medicine can cure the disease, that sex with a virgin will cure AIDS, and about half have never used a condom. In addition many employees do not disc uss HIV due to fears of rejection. The percentage of worker deaths attributable to HIV/AIDS has increased from 15% to 40% in recent years. Training, condom promotion and distribution, peer e ducators, and community activities are all components of Company A s program. Employees belong to a health plan which funds treatment for them and dependants including ARVs, general health promotion, nutritional counseling, STI treatment, and TB treatment. The company also has touch screen computer kiosks availabl e in workplaces for employees to gather information. One informant stated that many people access the kiosks primarily for entertainment because the most highly visited pages involve condom demonstrations rather than STD or opportunistic infection information searches. Many are scared to

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109 access the policy in public on the kiosks. A more confidential manner for information access is given through a national employee help line for employees with questions. All new employees receive training in basi c HIV/AIDS knowledge and the company program guidelines. Condoms are distribut ed in 200 different dispensers placed throughout the workplace at a rate of a bout 1.2 condoms per employee per month. Treatment of STIs is available at company c linics or through extern al providers and the KAP survey suggested that most employees pr efer to seek treatment externally. One company clinic recorded 76 STI cases per 1,000 employees. Company B did not conduct a prevalence study or an economic assessment but did conduct a KAP study on which to base inte rventions. Company B claims CSR as its reason for initiating an HIV/AIDS program Awareness raising is accomplished through events, workshops, and theatre performance planned on a regular basis. The company also trains targeted groups of employees, in particular shop stewards and supervisors, and all new employees are educated on the policy and program. Company B provides free gove rnment condoms via dispense rs in the workplace. Distribution rose from about 4 condoms per employee per month in 2002 up to about 9 condoms per employee per month in 2003. Female condoms are available at the clinic which also treats STIs. Most employees s eek STI treatment through external providers who are compensated through an insurance sche me. Such infections have decreased by 50% since program implementation. Company C did not conduct a prevalence survey or an economic assessment but has begun tracking HIV/AIDS related retirement, disability, deaths, and turnover. A KAP study was done exposing the fact that many employees had false knowledge about

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110 the disease. Upper management attended trai nings in 2001 which have rolled out to other units through time and also been added to initial trainings upon hire. Company Cs condom distribution corresponds to about 0.4 per employee per month. Company D conducted KAP surveys and di scovered that myths about disease transmission and treatment were co mmon among employees HIV/AIDS program coordinators were appointed as well as peer educators and company specific educational materials developed. All employees were trai ned about HIV/AIDS via a half day session during which the entire production line was shut down solely for this purpose, and presentations were made by the CEO, PWHAs, and professional drama groups. Condoms are distributed in areas such as re strooms and at entrances and exits so that workers can grab some on their way home from work. Distribution increased in 1999 from 700 per month to 17,000 per month (or 63 condoms per employee per year). Company E, in 1999, assessed its po licies and prevalence of HIV/AIDS in 45 branches and developed a thre e-pronged strategy that incl udes education, monitoring, and management. In 2000 Company E initiated an awareness campaign to educate staff, change risky behavior, and reduce the impact of the disease thr ough peer education and the distribution and posting of company specific handbooks and information. This information was created with the help of NGOs and other companies and was made available to other financial companies a nd organizations after production. A second awareness campaign for 2002 focused more on living with the disease by providing positive images of PWHAs, giving information on treatment and nutrition, dispelling myths about the disease, and gi ving guidance for caretakers.

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111 Workplace interventions among companies surveyed indicate moves toward holistic, flexible, and long-term approaches for combating HIV/AIDS. Prevention efforts include condom distribution, often in the form of dispensers placed in high-traffic areas, and all informants reported increases in the number of condoms given. Three of the companies began offering this service before condoms were available for free from government clinics. The most drastic increa se reported was up from 700 per month to a stable 17,000 (a 24 fold increase) following the initiation of prev ention and education trainings and workshops. However, in ge neral people do not like to be seen taking condoms, and pervasive stigma still exists re garding the motivations and moral character of individuals, especially women, who use and carry condoms on a regular basis. The prevailing notion is that such people are cheating on their partners, already carry the virus, or regularly sleep with people that are positive. High traffic areas, however, may also be private to some extent (restrooms fo r example). One site found that people prefer not to take condoms from the dispensers at all but to remove them from storage rooms where the items are kept in large boxes befo re being transferred to the dispensers. Another issue in South Africa is the no tion that free or government condoms are of lesser quality than those purchased in s hops. One woman told me that she conducted tests between store-bought condoms and those av ailable for free, and found that over half of the free condoms contained holes which wa ter passed through freely. I was told by a government employee in Botswana that this could not be because in fact the only difference between free and bought condoms is the packaging, which prevents individuals from taking them and reselling them on the street.

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112 Education and prevention programs seem to have, generally speaking, taken a back seat in South Africa, especially co mpared to testing and anti-retroviral (ARV) programs. This is due in part to intense prevention education efforts in the past. Many informants claim that much of the public is aware of HIV transmission routes and has been bombarded for years now with pam phlets and media campaigns, which explain myth-busting facts about the virus. Nevertheless, some still do not believe the virus exists. Evidence points to the need to con tinue with education and continue to expose and refute myths. Traditional healers in some areas continue to claim that they can cure the virus, and some confusion exists in Gauteng province concerning a traditional widows disease known as Makoma, which finds its way into a womans body after a husbands death and poses a threat to any man choosing to sleep with her until six to twelve months have elapsed following the de ath. Individuals ques tioned about this had conflicting ideas as to whether or not Makoma is in fact the same as HIV/AIDS. This is where traditional healers, in partnership with biomedical experts, are able to clarify misconceptions among the general public. All of the companies visited use so me type of employee handbook on HIV. Monthly company magazines or newsletters address HIV regul arly, often touching on the importance of voluntary counseling and testing as well as education. One company is in the process of developing a resource cen ter devoted to comprehensive disease management including a TV/VCR for employees to watch videos on subjects of interest. In clinics or other appropriate areas, however, each company provided employees access to free pamphlets and information regarding th e disease. Tool kits have been and are being developed. The package for Company E includes screen savers for computers,

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113 posters, and games for peer educators to use in education and awareness initiatives. Currently a tool kit for the automotive industr y is being developed in South Africa with the help of Companies A, B, and D. Informants stressed the importance of using PWHA speakers for education, however, this has become big business in S outh Africa and some of those capitalizing may not be appropriate according to the backgr ounds and education levels of employees. Such speakers should, if possible, come fr om the surrounding communities and look and feel healthy to stress that a nyone can get the disease and th at one cannot tell anothers status by appearance alone. Religious leader s and speakers are being utilized as well to show that this subject is worthy of discussi on even among the holy. Such an approach is useful for including HIV awareness among a set of life skills in a framework that is acceptable to South Africans. An effective education method is to gi ve workers the opportunity to understand issues surrounding HIV in the real world. Some companies allow employees to use company time for volunteer efforts in surround ing communities. One company organizes weekly visits to a hospital giving workers th e chance to spend time with AIDS patients. Awareness, sympathy, and compassion may devel op as a result and workers may be more motivated to protect themselves from risk, seek answers to their questions, as well as stem their prejudices against those who have contracted the virus. All-hands meetings have been used in order to underscore the seriousness of the disease and to allow for thorough targeting of all worker levels. Company D shut down operations for an entire afternoon in order to gather employees and discuss the impacts of HIV on their workplace as well as the local policy and workers rights in terms of

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114 discrimination. Skits and plays were used to get the message across that the company supports those living with the disease and will not fire employees or disclose individuals status.

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115 Peer Education Peer educators are used at each of th e companies surveyed and are the most powerful component of each of the programs. They help people see things in a different manner and are seen as planting sources of knowledge in workplaces and communities. Peer educators are almost always voluntee rs, although according to one coordinator they are nominated or hand selected in countries or parts of the world where HIV/AIDS infection rates are not as heavy. Peer educat ors should be representative of the company according to gender, age, worker tier, and in come level. It is common to find very religious peer educators in South Africa. Company A has a 1:46 peer educator rati o and they are selected based on peer nominations. About 75% of th e educators actively participate in ac tivities including training during team meetings, informal sessions, promotion of campaigns, and community outreach. Company B has a 1:52 peer educator ratio and they are selected based on sensitivity, empathy, communication sk ills, and popularity. They organize and conduct meetings and trainings and prepare m onthly reports on education and condoms. Company C, in 2002, had 25 peer educators (a 1:36 ratio) who have been externally trained through a certified cour se and who attend regular workshops to update their capacity. Company C stated that about 15 peer educators are regularly active. Company

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116 Ds peer educators, at a ratio of 1:41, are designated to enco urage others to learn their HIV status focusing on the treatment program a nd the fact that a positive diagnosis is not a death sentence. They are also important in convincing others that learning of a negative diagnosis is very powerful information and e fforts can be taken to remain negative. Company Es peer educators participate regul arly in training work shops and facilitate games and activities at corporate events to raise awareness of the disease. Companies should focus on the quality of p eer educators rather than quantity and it is helpful to establish a good core team before attempting to train too many. This facilitates use of a train the trainer model and takes some burden off of coordinators themselves and may also limit the need for externally hired trainers. It is helpful to supply appropriate clothing for peer educators to help iden tify them to others. Peer educators answer questions that others may have in the workplace, however, people do not approach them often in public because stigmatizing assumptions may be made. One company whose employees have access to ema il noted that this is a good way for people to approach their peer ed ucators confidentially. There is some distinction between peer educators and peer c ounselors, the latter being further capacitated to disc uss issues of living with HIV and disclosure for affected or infected individuals. Using comprehe nsive training not only in education and awareness but also in care and support is the recommended path for businesses. Among those diagnosed with HIV/AIDS in the work force many consider suicide a viable option and do not know how to handle their lives af ter a positive diagnosis. Understanding that PWHAs can live healthy and productive lives fo r many years after cont racting the virus is

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117 an important message for peer educators to impart to their co-workers, who often have children and families to support. Businesses try to have peer educators m eet and debrief as much as possible. Some meet weekly, others monthly, and still others find it difficult to take all peer educators off of the production line simulta neously and cannot manage to find common times on everyones schedule to allow for full m eetings. It was noted that motivation for doing the job of peer educator tends to decrease with time. As none of the companies included in this data provide monetary incen tives for being a peer educator the primary motivation for doing so must come from pe rsonal passion, and it was mentioned that most peer educators try a number of times be fore they give up. This job is very difficult in the face of stigma and it may take some searching to discover rewards, which may be entirely personal and em otional, for a job well done. Some support is given to peer educators through acknowledgement and recognition. One spoke of himself as a f reedom fighter capable of motivating and speaking for the people of his company. However, such pride and resounding commitment are rare. Some companies offer ince ntives such as contests restricted to peer educators to go, for example, to an HIV c onference on behalf of the company. Others offer trainings for the peer educators in exot ic or exciting places they might otherwise never be able to visit. All of the comp anies, however, give their peer educators certificates of accomplishment and recogni ze them as vital components of their HIV/AIDS programs. There can be a give me effect with p eer educators, particularly when efforts focus more on quantity rather than quality. Some may join the ranks just to see what they

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118 can get out of it for themselves. There shoul d be more emphasis on life skills education among peer educators so that they are not si mply point persons for HIV but also life in general, and consequently less stigmatized. They also should be given more training on opportunistic infections and the side effects of AIDS medi cation. One peer educator spoke to me of the need to do more educati on in peoples homes, wh ere there is a higher level of comfort for both parties as well as privacy, and where higher quality relationships can be established. While the need for more disclosure a nd greater involvement of PWHAs in the workplace is necessary, peer e ducators who may be living with the disease should not be singled out and should be given a choice whethe r or not to disclose. The atmosphere in most workplaces is not at the level where even peer educators feel comfortable to disclose status in spite of the fact that ma ny of them may be motivated primarily by their own positive diagnosis. The need for labor and trade unions to more actively support peer educators was raised and some dissatisfacti on exists regarding trade union backing for HIV/AIDS. All of the companies visited indicated a lack of white peer educators among their core teams. This was attributed to status consciousne ss and the notion that HIV is a black or gay disease. One coordinator told me, however that infection rate s among whites in one company had tripled in the past year and that the answer to this information had predominately been denial from the white community. Peer educators do as much or more work in their own communities and on their own time as they do in the workplace on compan y time. Such efforts are a result of personal connections and working within ones group of family and friends. Work with

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119 churches is common as well as with youth groups. Company D encourages them to adopt a tavern and use time spent socializi ng and drinking with fr iends at the local Shabeen or bar to correct misconceptions and answer questions about the disease. People are relaxed and willing to talk in taverns and much conversation centers on sexual matters in general. Company E noted that peer educators have b een instrumental in helping to translate educational material s and employee handbooks into local languages.

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120 Care, Support, and Treatment Many of the coordinators with whom I s poke noted that medical schemes must be made more flexible in order to allow PWHAs to adjust work schedules and take time off work for unpredictable illnesses. Employees who test positive should be placed on wellness programs that include intense m onitoring of CD4 counts and opportunistic illnesses or infections. Those that require ART often must leave work but should not be fired outright. PWHAs are protected by th e policy, and South African law, in that situation. The focus should remain on returni ng to work in the future which may mean those with physically demanding jobs must decrease time spent on them and increase time doing something less physically intense. Individual case monitoring and personal attention are necessary to ensure that such an approach is viable. Businesses tend to offer the option of on or off site clinic/health care, but on site care is not always comprehensive and often does not include VCT or HIV/AIDS care. On site care, when it does include HIV/AIDS care and treatment, allows for more direct monitoring and for the building of rappor t and trust between medical staff and employees. Employees seek care for a variety of ailments and occupational injuries or illnesses at such clinics, which may allow fo r anonymity within the workforce but not in the medical setting itself. Confidentialit y is guaranteed in an ideal situation.

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121 An informant in Company B noted that ha ving the clinic in a high traffic area, such as next to the cantina or caf, contribu ted considerably to the success of the clinic. Workers can easily access their medications a nd do so under the guise of routine visits. Seeing the clinic daily helps remind indi viduals to keep appointments and seek information. The return rate for HIV tests was highest among all the companies surveyed at this particular c linic. Some have commented that testing on site is not good because my face will give me away, however if pr oper counseling is done this is less of a problem. Efforts should focus on identifying these gaps in the companys own clinics and initiating training to create a knowledgeable staff. On site clinics facilitate direct observation of employees on the part of medical staff. One coordinator and her staff conduct regular walkabouts on the factory fl oor which is particularly effective for identifying TB patients. Presence on the f actory floor shows that the company cares and is actively involved in the medical situations of workers. Off-site care in regard to HIV is a re sult of the relationship between businesses, employees, and their medical schemes (i.e. insu rance coverage). This can help ensure nearly complete anonymity, but according to informants in Companys B and D health care providers in South Africa often l ack knowledge in the area of HIV/AIDS, particularly counseling and me dication related issues. Case managers are assigned to positive patients and there may be more serious quality assurance issues associated with this, whereas on-site care allows a company to concentrate efforts on its own clinic staff in terms of training and capacitating them to d eal with HIV. Problems with care are more difficult to identify when an employees stat us is unknown to any medical professionals within the company system of care. Off site care may ensure anonym ity but this is the

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122 easy way out for companies who should be trying to facilitate an environment where trust and support for PWHAs is forthcoming, encour aging people to disclose and accept their virus as simply a disease and not an indication of their personal or moral values or status in society. Clinical services must be focused on personal well being in general and comprehensive disease treatment. STDs, TB, and other opportunistic infections must be dealt with quickly and properly. When possible the best approach is one that facilitates trust and builds solid relationships between employees and health service providers. Employees are more likely to trust the medical st aff, and are therefore more likely to seek treatment, when nurses and doctors are familiar with that employees particular personal and work life. In one company on site care, and the trustful relati onships that result, account for a nearly 70% VCT rate and a 99% TB medication comp letion rate. Followup and monitoring of HIV positive employees is essential to maintain productivity, much more so than a simple ARV medication sche dule, as well as to ensure that proper nutrition suggestions are being followed. Ex ternal case managers take on this burden when off site care is utilized and company health care staff, who are in a much better position to see and visit with workers on a more regular basis, are left in the dark. In South Africa the African potato or Modicare (an immune system booster) as well as E-pop (soybean fortifie d corn maize meal) are examples of potential quick fix nutrition options. However, more focus should be placed on the development of vegetable gardens and maintaining a balanced diet for HIV positive employees and their families. Making seeds available as well as providing courses in nutrition and simple gardening techniques may go a long way in helping PWHAs maintain their immune

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123 systems. Company D participates in an ini tiative with such compone nts. The vegetable garden is grown next to the co mmunity outreach center. Employees should also be counseled on pr oper birthing procedures in relation to HIV/AIDS. Nevirapine, the standard PMTCT medication, is available in government clinics and should be accessed whenever possible. However, in the country there is little follow up and monitoring after this treatment is delivered. While it is widely recognized that an infant may contract the virus th rough mothers breast milk, according to an informant in Company D, little is done to make sure that milk powder and safe water are available for the child during his or her nur sing years. Work w ith traditional birth attendants is needed to in crease and safeguard sound res ponses to this problem. While post exposure prophylaxis (PEP) does not seem to be an issue for a majority of companies, which are often based in urban areas and capable of securing such medication should the need suddenly arise, on-s ite needle sticks occur as well as bloody accidents that may jeopardize observance of universal precautions in the workplace. While HIV is rarely contracted in the workplace problems can occur which necessitate a rapid response, and providing PEP for businesse s that are too far from urban centers or state-of the-art hospit al facilities for quick delivery of such drugs should be considered.

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124 Voluntary Counseling and Testing Company As VCT project was launched in 2001 and is available to employees and dependants for free through company c linics and external providers who are reimbursed. Since 2001, Company A has provided VCT services for 1,750 employees, which is about 39% of the workforce. The company attributes this success to clear communication about employee benefits and the promise of treatment, but also offered cash prizes in the form of a raffle. Company B began VCT in 2002 and provides the service free for employees at on-site clinics, while dependents are compensate d through insurance. It is estimated that 77% of employees have been tested. The company has provided counseling to 88% of employees and has an 85% consent rate after counseling and tracks VCT rates by department. Employees in Company C also have access to VCT services if they are on a medical plan through on-site and external providers. Those without insurance may access the service on a fee basis. About 65% of Company Cs employees are on a medical plan, and about 16% of its employ ees have accessed VCT as of 2003. This number most likely increased when the comp any carried out a VCT campaign that same year.

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125 Company D provided VCT for a designated period of time following the factory shut down training session. On-site health clinics provide th e service on a more consistent basis which incl udes a pre-test one-on-one private counseling session, the signing of an informed consent form, an ELISA blood sample test, followed by another counseling session. Anyone found to be pos itive is enrolled in the Aid for AIDS treatment program free of charge. This non-profit organization collects left over medication from developed countries and re-d istributes it to needy people in Latin America, the Caribbean, and Africa. The Af rican AIDS Program is currently providing antiretroviral therapy to 83 clients in Bu rundi, Ethiopia, Mali, Uganda, Kenya, South Africa and Zimbabwe (AFA 2005). Company E, whose employees represent a different tier and skill level higher than other companies presented here, does not provide VCT services but encourages employees to get tested through their preferre d provider. The setting for this workplace is an office building rather than a factory, th erefore, no medical facilities exist on site. Located in a premier Johannesburg office park, most employees working here are able to access VCT during non-work hours. VCT has the potential to br ing new life to a companys prevention programs, but rates remain surprisingly low for most comp anies in spite of comprehensive medical schemes that make ARVs affordable and with in grasp of not only an employee but also families of employees. It seems that education and awareness initiatives are not as successful as they need to be, otherwis e workers would not question the companys motivation for wanting employees to be test ed and know their status. Many people do not understand why companies would want empl oyees to be tested, indicating a general

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126 lack of trust. Hesitancy exists regarding testing positive and then becoming reliant on the company and medical scheme for the remainder of ones life. Peopl e are scared to know their status in general because they dont want to know they will die. Some coordinators have toyed with the notion of providing incen tives for employees to be tested but, according to informants, this should not be necessary and individual motivation is preferable. It is helpful to provide VCT centers in every department, particularly in large companies, to facilitate quick access. Howe ver this may be unsustainable, as the rooms cannot be staffed for very long without high funding costs. Such an approach may be appropriate following a mass media campaign within the company where all employees are sensitized and VCT centers made widely av ailable for a short and specified amount of time. However, VCT should continue beyond this even if only in one place, such as a room or office, or at or near the company clinic. Combining sensitization and VCT is an viable idea, since many informants noted th e increased interest in VCT following large campaigns and particularly leading up to World AIDS Day in December. One suggestion is to require compulsory attendance at sensit ization meetings and th en using an opt-out form of VCT as a general company policy so th at all employees will be tested unless they make a conscious decision otherwise. One problem in South Africa is that comp anies are not required to offer benefits to seasonal or temporary employees. This decision is up to the company and some division may occur in upper management over whet her or not this is co st-feasible. Also, employees on medical schemes must pay extra for dependents and coverage of the family is not consistent and often limits the number of children allowed to participate.

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127 The use of rapid versus ELISA tests within companies, as well as in general, is an issue of debate. Among the sample in this research Company C solely suggests using rapid tests and claim that many choose not to return for their ELISA results. When they do there is denial on the part of an individual as to whether or not he or she received the correct results. The idea that some mix up may have occurred is common. However, it should be noted that one may go on to verify with a rapid test after this occurs. An ATTIC employee told me that this happens often, and that she has never seen a case where an ELISA and a rapid test produced disc ordant results. Some confusion exists and more myths developed about rapid tests because they are saliva based and so many prevention programs stress that saliva is not a transmission route. One informant stated that people dont take rapid tests seriously, and that re tention rates for posttest counseling with rapid tests are much lower th an with ELISAs. An informant in Company D mentioned that suicides due to results w ould increase drastically if the company used rapid tests and that he would not want to be responsible fo r those tragedies. Some people commit to behavior change while waiting for, and consequently thinking about, results from ELISA tests. An informant in Company E stated that one must have their head space correct before h earing results. Company B puts more than one indicator on ELISA results including firs t and last name and company number to limit denial on the part of workers. The sa me company has a 98% return rate for ELISA testing at its on-site clinic.

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128 Anti-Retroviral Therapy (ART) Company A allows employees and dependant s to confidentially join a treatment program called Aids for AIDS (AFA). Si nce 1999 this program has enrolled 150 members on Company As insurance scheme of whom 130 are curre ntly participants representing about 26% of the estimated HI V+ employees in the company. Many are on ARVs. Many participants ( 62%) are already experiencing si gns and symptoms of AIDS by the time they join the plan. Company Bs ARV program is also provided through AFA. Company Bs wellness program provides antibiotics for OIs, as well as counseling and nutritional supplements for PWHAs. Of employees who have learned their status through VCT 90% participate in the wellness program and 40% ar e enrolled in the treatment program AFA. Dependents may also join the treatment plan. Company C employees living with HIV ha ve regular check-ups at an on-site clinic and are offered antibiotic treatment for OIs. Counseling is provided as well as nutritional supplements and advice. If an employee has insura nce then more specifically appropriate benefits may be conferred depe nding on the plan chosen. A financial cap exists on ARVs for employees in this situation ranging from US $1,500 to $4,000. Company D enrolls HIV positive employees in Aid for AIDS free of charge.

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129 Support for treatment with ARVs is also pr ovided to a community outreach and income generation project for PWHAs from the surr ounding township. Company Es employees are supported by their insurance schemes for any life threatening illness. Program coordinators agree that ART shoul d be the last line of defense against the virus and that wellness and diseas e management are much more important. According to informants in Companys B and D this is particularly true in the South African context where medical providers have limited knowledge of the side effects of ARVs and often switch patients medications upon request and for the wrong reasons. Resistance is occurring as a re sult and patients need to understand that the drugs will not make them feel 100% better. Side effects differ based on the indi vidual but can involve nausea, bone marrow pain, gastrointestinal discomfort, and a host of other problems. ART requires adherence to diets and re gular eating schedules and many South Africans do not have choices in food vari ety and often experi ence a lack of food altogether. Nausea may encourage someone to skip breakfast and subsequently skip medications. Disease management should be the priority and this requires close monitoring of HIV positive individuals. Th e lack of VCT participation among South Africans means that HIV is often not discove red until it reaches late stages, at which point drugs are not helpful and are so t oxic as to cause potentially even worse complications. Many companies do offer ART through medical schemes and often the cap on spending is higher for people needing these dr ugs. Still, VCT rates are low and people are not learning their status. Apparently th e ARV incentive is not enough to motivate

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130 people to make significant changes in behavior or get tested. Some informants went as far as saying that a majority of their workers are s cared of ART. Employees in situations where trust is not high should have several de livery options made available to them. One company noted that employees may receive thei r medications on site, at another clinic, or through the mail.

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131 Community Involvement For Company A, cost benefit analysis was important to help determine whether or not to implement an HBC component to its pr ogram. It was decided that the companys best interests would not be served by providing continuous supportive provisions. Company B provides traini ngs for external medical provider s in HIV clinical issues for both biomedical professionals and traditional healers. B also works with religious groups to capacitate members on stigma reduction and will in the future establish a community center with VCT, programs for youth, and income generation projects. Employees in Company C are encouraged to participate in HIV/AIDS outreach providing support to the community. Many have been allowed to adjust their shift schedules in order to visit an AIDS hospi ce or orphanage. Also the company sponsors support for several orphan homes in surroundi ng communities in partnership with other companies and organizations. Company D has increased levels of HIV/AIDS awareness and knowledge amongst the families of employees by focusing on the youth and sports. Interventions have also been undertaken to raise awarene ss in the automobile industry in the country through partnerships and providi ng assistance to suppliers an d dealers as well as trade unions. Also, an income generation projec t was launched that provides treatment and

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132 support for PWHAs in the surr ounding community whether or not they are otherwise affiliated with the company. Evidence points to the need to address the entire package of issu es associated with HIV/AIDS. People in South Af rica are scared of being test ed not only because they are afraid of dying but also because they lose st atus and respect within their communities. The portrait of an AIDS patient thus far in southern Africa supports the view that these people are at the end of their lives, sick a nd vulnerable, lacking in morals and being punished by a greater power. ART is misunderstood because it does not cure and many people in Africa believe that western medica tion is a one-time quick fix, one step above the traditional cures which are cheaper yet less effective. AIDS is so stigmatized that products bearing the HIV/AIDS red ribbon anywhere on the box will most likely be left on the shelf by consumers. Company C had to pull items off the shelf because they had printed red ribbons on them and consequently were not selling. Much of what workplaces are fighting agains t is encapsulated in such stereotypes. HIV is often perceived as a disease of the o ther and many do not f eel vulnerable. Ways to get around this involve addressing why pe ople place themselves at risk to begin with, and mitigating the circumstances that allow for vulnerability. As such some companies have begun classes and trainings addressing the wider scope of problems associated with HIV. Offering information to employees and their families about how to increase income within the household, for example, helps further economic independence and limits the attraction of commercial sex work. How to c ope in an increasingly industrialized world should be a topic of special c onsideration, helping South Afri can society adapt traditional realities and values to what may appear to be new situations and perspectives.

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133 Discussion over sexual issues, for exampl e, may no longer remain taboo. Conflict resolution in marriage is an increasingly neces sary skill in order to limit infidelity and to maintain love and devotion between husbands and wives. Empowerment broadens the options available to workers and their families and helps offer people choices so that they do not place themselves at risk, giving them the pride and negotiation skills necessary to increase self-efficacy regarding condom use. Particular attention should be paid to the vulnerability of women in South Africa. An informant in Company B completed a study showing that on average 3 out of 10 women in the country are victims of sexual violence. There is a prevailing attitude among women that it will happen to them at some time or another. In many cases dowry is still paid to the family of a woman, supporting the woman as property and domestic servant value so common in the traditional pa st. Women in the country are not likely to report sexual violence to th e police in spite of the fact that two-thirds of such perpetrators are known personally to women. Young girls, left home with uncles and relatives who are often unemployed and drinking, are mole sted due to unsupervised situations. According to Company Bs program coordinato r women are taught to garner the favor of men and are led to believe that most men w ill run away from intimacy should the subject of condoms be broached. There is an acceptance of violence agai nst women that goes as far as to incapacitate health workers themselves. One informant in Company B discussed the fact that nurses working there are often so emoti onally scarred by sexual violence in their own lives that to properly counsel another woma n on how to deal with it is a difficult, intimidating, and frightening situation.

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134 Capacitating health service providers in th is area is necessary. Talking with men and exposing their prejudices and prevailing b lame the victim mentalities are necessary as well. Married adult women need to hone skills related to rai sing a non-rapist male child as well as a proud and strong female child, capable of defending her rights and values. One trainer uses newspaper articl es from around South Africa during workshops to facilitate discussion and sh e noted that such articles are available and printed every single day. Companies have begun to use fema le rape survivors as public speakers to raise awareness on some of these issues. Financial independence and self-defense classes for women were recommended as one path of action. Community involvement activities tend to focus on the communities where a majority of the companys wo rkers and their fam ilies reside. None of the companies visited by the author utilized significant numbe rs of migrants within their labor force and it should be noted that this set of workers br ings other community i nvolvement issues to the forefront. Namely, the lack of stabil ity and residential re sponsibility for these workers coupled with disposable income and no immediate family obligations results in more drug use, drinking, and visi ting commercial sex workers. Still, many stable communities are places of little hope focused on day-to-day survival. As such, what communities want from companies may not always be possible. One community was interested in a company providing home based care for patients but the company couldnt manage because of program costs. Nevertheless positive feedback and successful programs are more possible if the community is involved in planning from the start when and if companies choose to become involved.

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135 Companies are unable to provide treatment to all family members, primary health related or otherwise, at on-site facilities b ecause of security and the sheer numbers of people that would come seeking care. Howe ver, in most cases family members are encouraged to become involved in counseling should a worker or spouse be diagnosed as positive. This stems from the fact that stigma is pervasive enough that workers feel uncomfortable, in general, discussing HIV/AI DS at home because it suggests to family members that he or she may have the virus. Family members are also, in many cases, encouraged to participate in classes or trainings on HIV/AIDS. One company in particular focuses on children and attempts to impart upstanding values and morals to the children of workers, as this is the next generation of worker and will help build a stronger South Africa for the future. Companies A, B, and C are working with doctors and nurses at health clinics in surrounding communities to help fill the know ledge and training gap for government employees in HIV/AIDS. HIV is a fairly new disease and many professionals received little to no information during their school te nure on the disease and its complications. Such efforts to work with service providers are legitimized in most cases by the awarding of points, which are necessary for professionals to maintain their licenses to practice within the country. Many companies are also working with traditional healers to train and support them in HIV/AIDS knowledge. S outh Africans often seek treatment from traditional healers and businesses recognize that this can directly benefit or harm their workforce. Other community involvement effo rts include developing multi-purpose community care centers, where information is available not just on HIV but on life skills

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136 and job or education opportunities. Wo rk with community organizations and nongovernmental organizations (NGOs) is going on as well with some businesses offering small grants for projects that benefit su rrounding communities. Businesses have also become involved in sports activities and in setting up areas for sports games and entertainment. One company regularly grates the soccer field and keeps netball courts in proper shape. Another has its own soccer l eague and does HIV education and awareness during matches, at which family and community members are present. Such gatherings can provide excellent forums fo r public health education. Companies B and D are helping to provi de income generation opportunities for PWHAs from the community who are not necess arily related to employees. Such effort helps people regain or hold onto their dign ity and according to an informant in Company D gives them a reason to wake up in the morning, as well as provides money for food and other necessities. In Company D this has been coupled with financial support for travel to hospitals, which can be quite far, for purposes of monitoring disease progression and CD4 cell counts. Web sites are being de veloped to market PWA crafts as well. Company C sponsored the construction of homes for orphaned ch ildren in surrounding communities and went into partnerships with other companies for the window glass and paint. An NGO provides the staff and house parents for the children. Such houses will not include advertisements for the company a nd are intended to be a natural part of the community in an attempt to limit the potential for discrimination against its occupants.

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137 DISCUSSION Implementation and Success Company As partnership with a governmental agency provided that business with project management, technical expert ise, and financial support. Trade union partners contributed to the design and helped provide the input necessary to stimulate workforce participation. Implementation of assessments concurrently with the project allowed objectives to be more rapidly met than if project implementation occurred after assessments. Peer education allowed for greater access to workers. Company A is required to conduct regular monitoring and eval uation of the project s interventions twice per year specifically as it relates to outcomes and activity goals. The companys HIV/AIDS committee meets ev ery two months to discu ss the project and includes members from management, human resources, me dical, labor, and non-unionized staff. Company Bs rapid VCT uptake was facili tated by a culture of trust between labor and management. The company recommends KAP surveys as a means to develop company specific programs. Company B re gularly evaluates program performance by tracking VCT uptake, wellness program enrollm ent, peer educator responses, condom distribution, and STI cases. Their HIV/AIDS committee is staffed by multi-stakeholders and monitors the budget as well as evalua tes program components. Company C has

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138 developed assessment tools to measure progr am performance, which is reviewed on a quarterly basis by the companys board. Th e company recently conducted an economic impact assessment as well. Company D has seen its situation impr ove in numerous ways: HIV/AIDS knowledge has increased to the point that ev ery worker has been exposed to education and training, people speak more openly about the disease and are seeking advice more often, condom distribution has increased ten times, community organizations are seeking technical assistance, and benefits have been restructured to better protect PWHAs in the workforce. The HIV/AIDS steering committee meets monthly to monitor and evaluate the program. In Company E, the advice of HIV/AIDS organizations at the early stage was helpful, such as presentations about the progr am to convince senior management to act. Country-specific offices were essential in the development of the awareness program, and sharing of information was and is critical to widespread relief from the disease and is not an issue to be used for business competition. In South Africa, much like the rest of the world, society does not support HIV status disclosure. People do not want to be identified as positive. Several informants stated that many people are sick of hearing about HIV/AIDS and th at people dont think of this disease constantly in their daily lives in spite of the high infection rates in the country. Employees of multinational companie s are privileged to receive knowledge and information about the disease that is reliable and consistent, but many still follow outside information and there are notable negative in fluences and people w ithin companies that prohibit establishment of trus t and acceptance of anti-discrimination policies. Some

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139 employees believe that their companies are ly ing and that by disclosing their status they will be fired or laid off. In terms of cost-efficiency anything addre ssing health in the workplace should be considered and costs must be measured over the long term. This includes educating and working with children of employees to secure their place in the future. Many companies have spent funds over initial budget estimates to continue to fight the disease and this is not due to ARV costs but to cost-subsi dies related to medical schemes. Corporate Social Responsibility (CSR ) was the most frequently mentioned motivator for companies in their fight agai nst HIV and this is related to having a good name in the community, noting that the wor kplace cannot escape the influences of the communities in which businesses are situated and from which workers come. The traditional indicators such as lost productivit y, absenteeism, and staff turnover are no longer huge concerns and many businesse s have implemented programs without conducting economic impact assessments. Em phasis is placed on doing the right thing for employees, bearing in mind that HIV/AIDS is causing severe trauma for employees, if not directly then indirectly through fam ily members or friends infected with the disease. Many must spend significant amounts of time away from work caring for or contributing to care for others. Some busin esses, however, focus more on waiting for those infected to die and make way for new wo rkforces. Others stil l are afraid of being attacked by the negative media press, whic h unfortunately tends to focus less on what companies are doing well and more on what they are not doing.

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140 Implementation and success of programs is facilitated by a number of factors including high levels of trust between employ ees and medical staff. HIV is a personal disease and should be addressed on a persona l level. One on one discussion, counseling, and treatment should be a focus as much as possible. Relationships are important for developing trust and consequently maintaining effective monitoring of positive individuals as well as safe pr actices for uninfected people. It helps whenever possible to help people realize that the company cares a bout its employees and this is furthered by including family members as much as possi ble. While mining companies often utilize free clinics many of the companies surveyed here rely on medical schemes that offer more comprehensive and exhaustive services helping to solve problems associated with opportunistic infections as we ll as the usual range of occ upational health concerns. Effort must be put into understanding the demographics and needs of employees. For example, one company surveyed employees and found that sexual partners were very limited contradictory to previous assumpti ons. Based on this evidence the company knew not to focus their prevention efforts on monogamy lest they risk providing irrelevant education. Howeve r, shifts in partners tend to occur every few years, suggesting that education should be focused on knowing partners previous histories and potential past risk behaviors as well as HIV status. Understanding and communicating with workers, who will be the beneficiaries of programs, helps ensure that local branches of multinational companies are capable of designing their own relevant interventions based on local need. Identification of proper communication channels from the very beginning is necessary to help programs unfold successfu lly. Designing interventions from the top

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141 down will almost inevitably lead to program failure. In South Africa, trade unions are especially helpful here as they give workers voices and negotiating power with companies and businesses. This helps to ensure a multi-sectoral response as trade union contacts are manifold and multi-tiered. However, trade unions themselves need continual motivation to help maintain involvement. Government involvement is necessary as well and if businesses can align goals with government programs some help and support from this sector will be more likely. The Automotive Industrial Development Center (AIDC), which is a government agency, helps fund projects and is currently developi ng a tool kit within that industry. Should governments or trade unions seem uncoopera tive one informant suggested taking the approach down one level to work with regi onal or local representatives. Trade union representatives are chosen for each company and they can broach subjects with larger committees or task forces within their own organization. Governmental contacts can be developed nationally, regiona lly, or by city. Apart from KAP surveys, which may be regarded as interventions in and of themselves due to increasing awareness and causing people to question their own knowledge, large-scale campaigns within comp anies can help to sensitize and prepare workers and staff for more intensive future interventions. This can include posters and public gatherings as well as distribution of employee handboo ks or other literature. Collaboration with radio, TV, or other medi a to promote AIDS education and awareness is helpful as well and can include billboards or other public advertis ements. All of the companies sampled had developed posters a nd internal documents for education and

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142 awareness, however, none had partnered in collaboration with media or advertising companies. KAP surveys and prevalence assessments should be done well or not at all. Several informants mentioned that quality a ssurance with surveys is difficult to guarantee and resulting data is difficult to compare and often not fully reliable. Program coordinators varied drastically on whethe r or not KAP and prevalence surveys are necessary at all. Some relied on prevalen ce assessments from their own VCT programs, others did blind assessments with blood supp lies, and others used rates from surrounding clinics and antenatal samples in communitie s. One informant found prevalence rates necessary to measure impact, but the majority felt that this was a waste of time and money. Some companies are able to hide behind such data and use it as an excuse not to implement programs at all. A business may justify inaction as a result, when knowledge of HIV transmission routes is not necessa rily indicative of em ployee risk and/or vulnerability to the disease. The involvement of top level staff fo r support and initial design of HIV/AIDS programs is necessary. An understanding of work er perspectives facili tates receptivity of programs, but they will not take off wit hout support from upper management. Many companies note a serious lack of involvement from upper level management and white employees. While there is no problem getting whites and supervisors to attend trainings having them talk about HIV openly and admit it as a problem within their communities is a different matter. Businesses recognize this as a problem and one common response has been to get the Chief Executive Officer (CEO) and other higher-ups tested in the same facilities available to workers and publicize th is clinic visit in an attempt to lead by

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143 example. An overarching concern is that peer educators need more support from their direct supervisors in order to become more effective. According to one informant the white co mmunity in South Africa is isolated and many are too busy to bother with testing a nd attending trainings or workshops. Within all of the companies visited white peer educ ators are rare and often nonexistent, other than program coordinators themselves. Whites in South Africa, in gene ral, feel that this disease is a black disease. One woman remarked to me that apartheid is in their genes and with its end in 1994 and a long history of institutionalized discrimination it will take South Africa time to heal from these wounds. White trade unions are not very active in general and should be more i nvolved with encouraging memb ers to participate in the struggle against HIV and AIDS in the country.

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144 Ways Forward-Lessons Learned from Stigma Stigma comes from both how one per ceives oneself as well as how others perceive them. To combat this requires a ddressing individuals own personal concerns with HIV as well as societys perceptions and assumptions. Stigma remains the main factor as to why workplace programs are not going smoothly. The workplace cannot escape community and societal influences. Issues and concerns within the community are the same in the workplace and it is impossi ble to divide the two. Currently in South Africa there is little incentive for people to present themselves as HIV positive. According to several informants from Co mpanys A and D, ARVs are not enough and most people would rather die than risk losi ng status in the community. Thus, companies must attempt to bolden and empower people to resist the outside nega tive perceptions of HIV/AIDS and to realize that this virus doe s not mean that a positive individual is a bad person. Informants overall felt that stigma is be ginning to decrease but the process is very slow. An informant in Company B brought up th e fact that 15 or so years ago TB was equally stigmatized in society but is no longer consid ered the fault of the victim. Stigma surrounding HIV effectively displaced stigma around TB. HIV may go through a similar process, hopefully not through displacement by a greater health threat, but as myths are

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145 destroyed and as the process of time allows for acceptance of the f act that everyone is vulnerable to this disease regardless of th eir sex lives, religio n, and status in the community.

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146 Involving people with AIDS and other unique initiatives In terms of advising the implementation process of workplace programs in other companies, and learning lessons from their own programs, coordinators overwhelmingly shared the desire to see more disclosure among their staff. People are beginning to do so but this is a recent trend. VCT rates are not yet as high as most coordinators and as one informant from Company D put it to know ones status is one thing, to disclose is a different kettle of fish. The workplace should be a warm environment that is conducive to disclosure and free of stigma. Once ag ain, the connection betw een community values and workplace settings is undeniable. Greater involvement of people with AI DS (GIPA) is one way to potentially increase disclosure within workplaces. This model places PWHAs in workplaces with a variety of duties ranging from th e typical jobs or duties of th at workplace or industry to acting as peer educators and HIV/AIDS coordinators for companies (UNAIDS 2002). The idea behind such an initiative is to show the workforce that people can live with the disease and maintain productive and satisfying li ves. They act as emblems of consistent activity surrounding HIV/AIDS in the workplac e and are typically on-site and actively paid members of the company. There are dr awbacks, however, and presenting oneself as an HIV positive role model can be challenging and isolating for many individuals.

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147 Other suggestions given by informants for new and unique initiatives include increasing one-on-one or small group educati on, placing more of a focus on children, and following cohorts throughout their lives to en sure that education and information is appropriate and useful depending on life stages. All of this would help show that the company cares about employees and is will ing to offer the personal and consistent attention necessary to increase and maintain trust. These initiatives also reveal a desire to tailor interventions to partic ular age groups and to keep e ducation appropriate throughout a lifetime. Several coordinators found that programs, literature, and counseling need to offer more in terms of issues surrounding death and dying, the writing of wills, and what happens to ones family when an HIV positive breadwinner comes to the end of his or her life. An informant in Company E (a financial services company) noted that many employees who have died from AIDS in the pa st failed to utilize company benefits at the end of their lives and conse quently wives and children were left without the money and services that would have otherwise been available.

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148 CONCLUSION This research is not intended to generalize to a majority of businesses or locations around the world but to offer a brief snapshot of what is working for some businesses in South Africa. It offers suggestions for the direction of workplace programs in the future by pointing out some issues and concerns of individuals currently involved. While this thesis offers few solid conclusions the data co llected point to the need for more directed and focused research in this subject area as well as more comparative case studies within workplaces. The need for consistent a nd reliable monitoring and evaluation of HIV/AIDS workplace programs would help ensu re that future efforts are appropriate, realistic, result in fewer infections and better trea tment, and are cost effective as well. Some of the most important issues rais ed by this study include how to keep peer educators motivated and supported within wo rkplaces, the importance of stigma and why it cannot be ignored, the undeniable relations hips between workplaces and communities, the use of rapid versus ELISA testing, and th e need for more disclosure and involvement of PWHAs in the workplace. It is clear from the ILO estimates wit hout treatment, by the year 2015 we will have lost 74 million workers globally since the start of the pandemic (see appendix I-D). That is 46 million more than we lost up to this year, but, it assumes that PWHAs in the

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149 workforce have no access to treatment. While workers in the US have had access to ARVs since the drugs debut (Newberger-L owenstein 2001) workers in Africa not covered under medical schemes await a govern ment rollout (IRIN PlusNews 2005b). It is true that more people have access to ARVs in the US but an issue not commonly discussed is the social classe s of those with access. A hi gher tier worker in South Africa has more opportunity for HIV/ AIDS education and treatment than a lower tier worker in the US. I have already mentioned that the US and the RSA have HIV/AIDS rates which are thirteen times higher in blacks than whites (Basyurt 2005; KFF 2005a). Both countries also are the only two industrialized nations not to record mortality rates by socioeconomic status (Farmer 2003; Navarro 1990). There are more parallels between the two countries than commonly assumed. The le gacy of apartheid is akin to the legacy of slavery in the US and both societies contin ue to struggle with r acial integration and tolerance. States in the US and provinces in South Africa have local laws subsumed under wider government legislation. Ther e are concentrated areas of immense overdevelopment (Miami or Cape Town for instance) surrounded by vast expanses of undeveloped rural areas (the Ev erglades in southern Florid a and the Western Cape). Inequalities extend past so cial class to include the urban/rural divide (FAO 2005; Stephens 1996). Arguments against the use of ARVs in Africa assume the worst in terms of infrastructure and drug delivery on the continent and subsequent multi-drug resistance. If we assume that half of the 46 million worker s expected to die without treatment will never have a medical plan or support for treatment, massive efforts to expand treatment to workforces could still add years to the working lives of 23 million people.

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150 Shareholders must hold businesses accountable and boards should act to provide treatment to workers regardless of social cl ass or skin color. Governments, schools, NGOs, and organizations should more activel y seek partnerships with philanthropic multinational corporations regardless of workplace HIV prevalence or lack of obvious economic impacts. Involving people living with AIDS more in the workplace is a necessary step toward reducing stigma and proving to employees that the reality of this disease is much more than a stereotype. However, open disc losure is not to be taken lightly. One presentation by a former GIPA participant in a recent research symposium highlights the fact that claiming the illness openly to peers ma y lead to isolation and dissatisfaction at the job. If done well, however, it is this re searchers assessment that GIPA-type models will greatly help facilitate the more open di sclosure within workforces that program coordinators in large South African companie s would like to see happen. This is one way in which businesses can obtain the critical ma ss necessary to combat discrimination and stigma within their own labor force, hopefully setting a standard that the rest of society can follow as well. Workplaces differ widely ba sed on a variety of factor s and all have their own cultures and contexts, which must be consider ed in the design and implementation of any health related program. The involvement of all levels of affected parties is necessary for success. This means using not only a bottomup approach which takes into account the perspectives of workers on all levels but also requires ceiling work among the top decision makers within workplaces. Implem enting programs to combat HIV and AIDS in the workplace takes time and effort and no cookie-cutter formula exists that can be

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151 applied universally. Component based approaches are more easily adaptable. The differences in approaches toward peer e ducation and VCT efforts between workplace settings show us that even these common responses, ofte n the staples of commendable workplace interventions in Africa, require mo re thought and effort than what might be assumed in order to apply them effectively. Companies, NGOs, governments, and donors must consider the diversity in the workforce, as well as local res ources and constraints, which can affect the program on the gr ound. Again, local context is the key. Ethnography and participant-observation are exam ples of research methods that can be utilized effectively. This authors suggesti on is for researchers to conduct long term ethnography by participating in worker traini ngs, assisting with projects, and possibly even living and working in townships to ge t a community perspective as well. This would facilitate intervention development or modification to include concerns or issues of which decision makers may not be aware. Some of the biggest challenges for workplace HIV/AIDS programs lie in maintaining the momentum of concern among employees and the motivation for investment by decision makers. In the wake of the tsunami in Southeast Asia, HIV/AIDS activists watched as billions of dollars were donated to the cause dur ing a short period of time. It appears that respons es to immediate devastating crises strike more sympathy in the hearts of donors than the slow, hidde n, and complex killer known as HIV/AIDS (IRIN News 2005a). In this authors opinion the biggest obvious difference, however, is the stigma attached to HIV versus conceptions of the tsunami as a na tural disaster. A reevaluation of risk groups, due to the diverse ways in which people construct their social identity, is necessary.

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152 In light of the resources in the private s ector and the lack of funds for health care in developing countries multinational busin esses and corporations will be called upon more and more often to partne r with the public sector to support health prevention efforts and disease surveillance. While social res ponsibility is not a new consideration on the part of corporations the far-reaching impact of HIV has raised red flags in the developing world. The response has been impressive from some and depressing from others, but one of the biggest obstacles has been overcome. Businesses are beginning to wake up and take action, others are noting how this can benefit society, and the potential for collaboration has emerged.

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167 Teunis, Niels 2001 Same-Sex Sexuality in Africa: A Case Study from Senegal. AIDS and Behavior 5(2):173-182. Tracey, Roxane 2000 Dispelling myths about AIDS in Africa. es/2000/07/13/53.asp Turshen, Meredeth 1984 The political ecology of disease in Tanzania. New Brunswick, N.J.: Rutgers University Press. 1997 U.S. Aid to AIDS in Africa. In AIDS in Africa and the Caribbean. Pp. 181-188. Boulder, CO: Westview Press. UNAIDS 1998 Putting HIV/AIDS on the Business Agenda. ocInfo.aspx?LANG=en&href=http%3a% 2f%2fgva-docowl%2fWEBcontent%2fDocuments%2fpub%2fPublications%2fIRCpub01%2fJC105-Workplace-PoV_en%26%2346%3bpdf 2000 The Business Response to HIV/ AIDS: Impact and lessons learned. ocInfo.aspx?LANG=en&href=http%3a% 2f%2fgva-docowl%2fWEBcontent%2fDocuments%2fpub%2fPublications%2fIRCpub05%2fJC445-BusinessResp_en%26%2346%3bpdf 2004 AIDS Epidemic Report 2004. US Congress, (107th) 2002 Sarbanes Oaxley Act HR 3763 http://www.nfcgindia .org/sarbanes2002.htm Vass, Jocelyn 2004 Policy Versus Reality: A Prelim inary Assessment of the SA Code of Good Practice on HIV/AIDS and Key Aspects of Employment. WITS HIV in the Workplace Research Symposiu m Conference Proceedings upload/Jocelyn%20Vass.doc Vaughn, Susan 2001 Career Challenge; Companies' Work Not Over in HIV and AIDS Education; Many with disease still expe rience job discrimination and irrational responses from worried co-workers. In Los Angeles Times. Pp. 1. Versteeg, Marije 2004 A License to Choose? HIV/AIDS Workplace Responses from South African Profit-Making Companies in C ontext. WITS HIV in the Workplace Research Symposium Conference Proceedings upload/Marije%20Versteeg.doc

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168 Williams, K. R., et al. 1991 Improving community support for HIV and AIDS prevention through national partnerships. Public health reports 106(6):672-7. Wilson, M. G., C. Jorgensen, and G. Cole 1996 The health effects of worksite HI V/AIDS interventions: a review of the research literature. American journal of health promotion : AJHP 11(2):150-7. World Bank, and AIDS Campaign Team for Africa 2000 Exploring the Implica tions of the HIV/AIDS Epidemic for Educational Planning in Selected African Count ries: The Demographic Question. 004def60/9631986c0c414a8085256a33004f1e23/$FILE/Final%20version%20%20AIDS%20and%20Education%20Assessment%20%20with%20source%20lines.doc

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170 Appendix I Appendix I-A: PWHAs in the labor force Country 2003 Prevalence Rate PWHAs (15-64 years) in the labor force in 2003 Total Population 2005 (X 1000) Life Expectancy at Birth 20002005 Dependency Ratio (dependents per 100 nondependent persons) South Africa 21.5% 3,698,827 45,323 48 57 United States 0.6% 928,800 300,038 77 50 Total ( all countries ) 1.5 26,084,517 3,866,468 n/a 55 Source: ILO, 2004

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171 Appendix I, continued Appendix I-B: GDPs and losses due to AIDS Country GDP (US$ millions) 2002 GDP per capita (US$) 2002 annual GDP loss attributable to HIV/AIDS 19922002 (US$ millions) annual GDP per capita loss attributable to HIV/AIDS 1992-2002 (US$) South Africa 392,380 8,923 7,230 115 United States 9,221,212 31,660 x x Total ( all countries ) 20,150,840 5,641 25,092 5 Source: ILO, 2004; x=no impact

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172 Appendix I, continued Appendix I-C: PWHAs unable to work because of HIV/AIDS Country Number of PWHAs unable to work-1995 Number of PWHAs unable to work-2005 Number of PWHAs unable to work-2015 South Africa 8,090 298,280 481,740 United States 58,610 14,880 20,740 Total ( all countries ) 546,380 2,352,650 4,195,530 Source: ILO, 2004

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173 Appendix I, continued Appendix I-D: Cumulative mortality lo sses in workforces due to HIV/AIDS Country Cumulative mortality losses to workforce1995 Cumulative mortality losses to workforce2000 Cumulative mortality losses to workforce2005 Cumulative mortality losses to workforce2010 Cumulative mortality losses to workforce2015 South Africa 64,900 499,900 2,070,000 4,423,300 6,634,500 United States 506,000 922,000 1,316,200 1,714,800 2,143,900 Total ( all countries ) 4,458,900 12,779,600 27,654,100 48,174,900 74,210,400 Source: ILO, 2004

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174 Appendix I, continued Appendix I-E: Orphans and annual working age deaths due to HIV/AIDS Country Number of Orphans 0-17 due to HIV/AIDS2003 total annual HIV/AIDS deaths in working ages (15-64)-1995 total annual HIV/AIDS deaths in working ages (15-64)-2005 total annual HIV/AIDS deaths in working ages (1564)-2015 South Africa 1,100,000 10,880 401,330 648,160 United States x 78,860 20,020 27,920 Total ( all countries ) 14,668,800 733,966 3,165,470 5,623,750 Source: ILO, 2004

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175 Appendix I, continued Appendix I-F: Economic and Social Burden increases due to HIV/AIDS Country Economic Burden increase-2005 Social Burden increase-2005 Economic Burden increase-2015 Social Burden increase-2015 South Africa 3.50% 7.20% 12.50% 18.30% United States 0.20% 0.60% 0.70% 0.80% Total ( all countries ) 0.40% 0.30% 0.90% 1% Source: ILO, 2004

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176 Appendix I, continued Appendix I-G: Current impact of HIV/AIDS on businesses Country Expect serious impact Expect some impact Expect no impact No response South Africa 41% 88% 8% 4% United States 6% 39% 61% 0% Total (all countries) 12% 30% 67% 3% Source: GHI, 2005a

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177 Appendix I, continued Appendix I-H: Future Impact of HIV/AIDS on businesses Country Expect serious impact Expect some impact Expect no impact No response South Africa 51% 84% 12% 4% United States 6% 38% 61% 1% Total (all countries) 14% 37% 58% 4% Source: GHI, 2005a

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Appendix I, continued Appendix I-I: Businesses with and without HIV/AIDS policies 178 Source: GHI, 2005 Country No policy Informal policy Written HIV specific policy No response South Africa 7% 14% 77% 3% United States 45% 24% 15% 15% Total (all countries) 71% 12% 7% 11%

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179 Appendix I, continued Appendix I-J: Urban households with piped water, LDCs by region, 1990s Country, year of survey Percent with piped water Sub-Saharan Africa Namibia, 1992 82 Senegal, 1997 64 Kenya, 1998 58 Cte d'Ivoire, 1998-99 51 Zambia, 1995-96 47 Eritrea, 1995 41 Ghana, 1998 41 Tanzania, 1996 32 Niger, 1998 27 Burkina Faso, 1993 26 Rwanda, 1992 26 Mozambique, 1997 23 Cameroon, 1998 20 Benin, 1996 19 Madagascar, 1997 18 Nigeria, 1990 17 Uganda, 1995 13 Malawi, 1996 12 Togo, 1998 12 Guinea, 1999 10 Central African Republic, 1994-95 5 Near East/North Africa Jordan, 1997 97 Egypt, 1995 92 Morocco, 1995 86 Yemen, 1997 66 Asia Kazakstan, 1995 91 Kyrgz Republic, 1997 87 Uzbekistan, 1996 87 Pakistan, 1990-91 48 Philippines, 1998 47 Nepal, 1996 46

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180 Appendix I, continued Appendix I-J: Urban households with piped water, LDCs by region, 1990s continued Bangladesh, 1996-97 32 Indonesia, 1997 29 Latin America/Caribbean Brazil, 1996 81 Paraguay, 1998 75 Peru, 1996 72 Nicaragua, 1998 70 Dominican Republic, 1996 50 Bolivia, 1998 47 Haiti, 1998 29 Source: Brocherhoff, 2000

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181 APPENDIX II Appendix A: Abbreviations used in this document ACHAP African Comprehensive HIV/AIDS Partnership ADA The Americans with Disabilities Act AIDC Automotive Industrial Development Center AIDS Acquired Immune Deficiency Syndrome AFA Aid for AIDS ALP AIDS Law Project ALRP AIDS Law Referral Panel ART Anti-Retroviral Therapy ARV Anti-Retroviral Drug ASPH Association of Schools of Public Health ATTIC AIDS Training, Treatment, and Information Center BET Black Entertainment Television BRTA Business Responds to AIDS Program CDC Centers for Disease Control and Prevention CEO Chief Executive Officer COBRA Consolidated Omni bus Budget Reconciliation Act

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182 APPENDIX II, Continued CSR Corporate Social Responsibility DHAP Division of HIV/AIDS Prevention EAP Employee Assistance Plan EEA Employment Equity Act EEOC Equal Employment Opportunity Commission ELISA Enzyme-Linked Immunosorbent Assay FAO Food and Agriculture Organization of the United Nations FHI Family Health International FIBA Fdration Internationale de Basketball GAP Global AIDS Program GBC Global Business Coalition on HIV/AIDS GDP Gross Domestic Product GHI Global Health Initiative GRI Global Repo rting Initiative HBC Home Based Care HIPAA Health Insurance Port ability and Accountability Act

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183 APPENDIX II, Continued HIV Human Immunodeficiency Virus HRSA Health Resour ces Services Administration IDU Injecting Drug User ILO International Labor Organization IMF International Monetary Fund IRB Institutional Review Board KABP Knowledges, Attitudes, Behaviors, and Practices KAP Knowledges, Attitudes, and Practices KFF Kaiser Family Foundation LDC Less Developed Country LRTA Labor Responds to AIDS Program PEP Post Exposure Prophylaxis PSA Public Service Announcement PWHA Person with HIV/AIDS M&E Monitoring and Evaluation MDC More Developed Country MSM Men who have Sex with Men MTV Music Televisions

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184 APPENDIX II, Continued NBA National Basketball Association NGO Non-Governmental Organization NLRA National Labor Relations Act OI Opportunistic Infection PAR Participatory Action Research PEPFAR the Presidents Emergency Plan for AIDS Relief PMTCT Prevention of Mother to Child Transmission RSA Republic of South Africa SADC Southern African Development Community SAPs Structural Adjustment Programs SMEs Small and Medium Sized Enterprises STD Sexually Transmitted Disease STI Sexually Transmitted Infection TAC Treatment Action Campaign TB Tuberculosis UN United Nations UNAIDS The Joint United Nations Program on HIV/AIDS

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185 APPENDIX II, Continued UNDP United Nations Development Program UNEP United Nations Environment Program UNGASS United Nations General Assembly Special Session UNICEF United Nations Childrens Fund US United States of America USAID US Agency for International Development USF University of South Florida VCT Voluntary Counseling and Testing Programs WEF World Economic Forum WHO World Health Organization

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ABSTRACT: This thesis focuses on the private sector response to the human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) in the Republic of South Africa (RSA) and the United States (US) in multinational businesses and corporations. From an epidemiological perspective HIV/AIDS and its co infections cause acute and chronic illness in the workforce leading to programs and interventions of various complexity and effectiveness. Workforce HIV/AIDS epidemiology in South Africa and the US is reviewed and discussed. From a critical medical anthropology perspective multinational corporations are political and economic entities with immense resources and power over people, communities, and governments globally. Corporate culture becomes important in the design of prevention and treatment strategies.
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