Sexually Transmitted Diseases Hamper Development Efforts

July 1997 Improving the health conditions of individuals and families in the developing world has long been a priority for American humanitarian aid. As a result of 30 years of U.S. assistance, maternal and infant death rates have dropped in many regions, significantly more couples are using contraceptives to plan their families and more children are living past their fifth birthday. Nevertheless, despite the tremendous progress brought about by investments in maternity care, family planning, child immunization and better nutrition, one crucial element of maternal and child health has been sorely neglected: the prevention and treatment of sexually transmitted diseases (STDs). Historically, STDs have also been overlooked in the global fight against infectious diseases; as a result, they continue to drain the lives of young and old throughout the developing world. The vast majority of STDs are spread through sexual intercoursewhich is perhaps the most important reason for the lack of public discourse on their impactand women of childbearing age (15-44) are disproportionately affected. In addition, each year, millions of infants begin their lives disadvantaged by an STD they contracted from their mother; STD infections in newborns compromise their health, both immediately and in the coming years. STDs are a serious problem not only because they are widespread, but also because they may have delayed, long-term consequences, including poor maternal health, ectopic pregnancy, infant illness and death, cervical cancer, infertility and increased susceptibility to HIV. Millions of men and women suffering these and other effects of STDs are hindered in their ability to provide for their families and contribute to their society. For countries struggling to develop economically, the health and economic costs are immense. The toll of STDs also hampers U.S. international aid. American assistance aimed at improving educational, health and economic conditions overseas becomes less effective, and therefore more costly, when a substantial proportion of recipients are suffering from STDs. Thus, although this is not always well understood by policymakers and the public, the United States has a considerable stake in combating the burgeoning STD epidemic in developing countries. This Issues in Briefexamines the incidence and consequences of STDs in developing countries, and describes why a strengthened U.S. commitment to the prevention and treatment of these diseases is needed.

STDs Are Widespread

Worldwide, more than 400 million adults become infected with an STD every year. Four STDs that are spread primarily through heterosexual contact are completely curabletrichomoniasis, chlamydia, syphilis and

gonorrhea. These account for 333 million STD infections, or about 80% of the worldwide total (Chart A). Some 9% of all persons aged 15-44 in North America contract one of these STDs annually, but the rate rises to 25% in Sub-Saharan Africa. Tricho-moniasis alone has been detected in more than 40% of women attending prenatal clinics in Uganda and Botswana.
chart a

333 Million Infections

Each year, 11 of every 100 adults worldwide are newly infected with gonorrhea, chlamydia, syphilis or trichomoniasisall curable STDs.

Sources World Health Organization (WHO), An Overview of Selected Curable Sexually Transmitted Diseases , Geneva: WHO, Global Programme on AIDS, 1995.

Every day, about 16,000 people (or nearly six million people each year) become infected with HIV, a startling number, given the short period of time since the virus emerged. Some nations have been hit harder than others. Among developing nations, for example, the United Nations estimates that more than 20 million people in Sub-Saharan Africa are HIV-positive, and most are unaware of their infection. While fewer than 1% of India s adults have the virus, India has the largest number of HIV-infected people in the world: 3-5 million, 89% of whom are younger than 45. Globally, women and children represent a large proportion of those infected with HIV: In 1997, an estimated 36% of new HIV infections occurred among women; 10% were among children younger than 15. In Latin America, HIV infections among women and teenagers, who contract the disease primarily through heterosexual intercourse, have been increasing sharply. Throughout Africa, heterosexual intercourse was responsible for an estimated 85% of new HIV infections in 1997. Because STDs strike relatively young persons and treatment often is not sought or is inaccessible, delayed or inadequate, the impact of these infections on individuals health is high. The impact on society also is substantial, since STDs affect primarily men and women who are forming families and contributing to the work force. The World Bank and the World Health Organization have led efforts to develop measures to quantify the burden of disease. One of the best-known measures is the number of healthy years of life lost as a result of illness or premature death.

Each year, STDs, including HIV, account for 6% of healthy years of life lost among women aged 15-44 worldwide. The annual occurrence of four STDssyphilis, gonorrhea, chlamydia and HIValong with pelvic inflammatory disease (PID), a result of some STDs that often leads to sterility among women, accounts for the loss of more than 51 million years of healthy life among men, women and children worldwide (Chart B). Women lose a disproportionate share of healthy years of life to STDs, largely because of PID.
chart b

STDs' Toll

STDs account for the loss of millions of healthy years of life.

World Bank, World Development Report, 1993, New York: Oxford University Press, pp. 216

Symbiotic STDs
A mutually reinforcing link exists between HIV and other, more common STDs. One of the principal reasons HIV prevalence is so high in developing countries is that STD levels were high before the epidemic. The susceptibility of people to HIV infection is 2-9 times as high if they already have certain infections, particularly syphilis and chancroid. Similarly, HIV facilitates the transmission, hampers the diagnosis and accelerates the progression of other STDs. For example, human papilloma viruswhich is closely associated with cervical cancerprogresses at a much faster rate in HIV-infected women than in others. Early and effective treatment of STDs, especially those that result in genital ulcers, can reduce the incidence of HIV infection. In one Tanzanian community, a program that allowed for the diagnosis and treatment of STDs without using expensive laboratory tests reduced HIV incidence by about 40%.

Groups at Greatest Risk

Women.A variety of biological and social factors make women more susceptible to STDs than men. Women are physiologically more vulnerable than are men to contracting STDs when they have unprotected sex (i.e., without using a condom) with an infected partner. Additionally, STDs in women are more likely to be asymptomatic; if women are unaware of their infection, they will not seek timely care and hence may experience serious complications. Further, the use of traditional vaginal medications and douching may increase a womans risk of acquiring an STD. With the exception of HIV, STDs may have more lifethreatening consequences for women (PID, ectopic pregnancy and cervical cancer, for example) than for men. Married and monogamous women are often at higher risk of contracting STDs than might be expected, because of the high-risk behaviors that are relatively common among men in many countries: intercourse with multiple partners and with commercial sex workers. Moreover, in some countries, womens low social and educational status conspire to deny the majority of them the power and knowledge to protect themselves against STDs. In many cultures, few women are able to negotiate the conditions of their sexual lives or the effective use of protective measures with a partner. In fact, many women consider STD-related symptoms such as abdominal pain or vaginal discharge a normal condition, not realizing that their suffering is caused by a contagious disease and can be treated. Infants of Infected Mothers. Infants born to women with an active STD are highly likely to be infected before, during or after delivery. Globally, the probability that the mothers HIV infection will be transmitted to the infant at birth ranges from about 20% to 40%; this mode of transmission accounts for 5-10% of all HIV infections worldwide. The consequences of STD infection are serious for the newborn: stillbirth or prematurity, permanent damage to vital organs and possibly death. Should an infant manage to escape STD infection at birth, he or she is likely to feel the impact of the disease in other ways. By the end of 1997, more than eight million children had lost their mother or both parents as a result of AIDS before they had reached the age of 15. Further, untreated STDs can severely impair parents ability to work outside the home and provide for their family adequately, increasing the risks to their children's health and well-being. Teenagers. Sexually active teenagers, especially males, tend to engage in riskier behavior than adults: They have more partners, have more high-risk partners and often do not use condoms. Consequently, sexually active teenagers, along with adults younger than 25, generally have the highest STD rates of any age-group. Married adolescent women who themselves may be monogamous are at risk of acquiring STDs if their husbands have sexual encounters outside the marriage. Additionally, biological and social factors heighten the risk for young girls and teenage women. Young women contract STDs more easily than adults because they have fewer protective antibodies and the immaturity of their cervix facilitates the transmission of an infection. In some societies, sexual coercion has emerged as a

major risk factor for young girls; many are forced to have sex or are given gifts or money in exchange for sex, precisely because they are seen as being disease-free. Youth who are infected with an incurable STDgenital warts, herpes or HIVbear the debilitating effects of the disease for the rest of their lives. Many become infertile and are unable to have families of their own.

What Is Needed?
STD prevention efforts are critical and should be of highest priority for policymakers, a 1997 World Bank report declared. The sooner developing countries act to contain the spread of STDs, especially HIV, the more manageable and less severe the problem will be in future years. In particular, the Bank concluded, reaching groups most prone to spread STDs (such as sex workers, their customers and youth) with prevention programs will have the largest impact in reducing infection rates throughout a population. In a number of countries, national prevention campaigns, using a variety of messages targeted for specific audiences, have proven effective in helping people adopt healthier behaviors. Messages that should be promoted widely among the general public include the importance of reducing the number of sexual partners, the effectiveness of condoms in protecting against infection and the benefit of dual method use, or simultaneously using a condom to prevent STD transmission and another contraceptive method to prevent unintended pregnancy. How and in what clinical settings STD-related counseling and medical services might best be offered are less clear. These questions have long bedeviled health advocates and policymakers. In the United States, for a variety of reasons, largely separate networks of family planning clinics and STD clinics have evolved. Recently, this two-track system has come under criticism; opponents urge that whenever possible, STD prevention, screening and treatment services be fully integrated within family planning and primary care settings, which are considered conducive to providing counseling and services to help individuals meet their pregnancy and STD prevention needs. In developing countries, where the existing formal health system may provide inadequate or no STD services, there is an opportunity to think through these infrastructure issues from the beginning, with an eye toward developing a more integrated, comprehensive approach to STD care.

The Global Response

The extent of STDs and their impact on families and society first received formal recognition from the world community at the 1994 United Nations-sponsored International Conference on Population and Development, held in Cairo. At this historic gathering, policymakers pledged to focus on individuals reproductive and sexual health needs. Such a focus, they agreed, would enable women, men and young people to lead healthier and more productive lives, and would, in turn, promote sustainable development and lower population growth rates. The key question facing policymakers is howand, to some extent, whetherthey can fulfill their financial commitments to ensure that individuals most in need will have access to a full range of reproductive health care services. In addition to family planning, these include STD screening and treatment, maternity and postpartum care, safe abortion (where the procedure is legal) and routine gynecologic care. At the Cairo conference, both

donor and developing country governments pledged new funds to fight STDs, yet that promise has gone largely unrealized, in part because U.S. political and financial leadership in the reproductive health field has faltered in recent years.

The U.S. Challenge

Beginning in 1995, the long-simmering legislative feud over domestic abortion policies spilled over to the international arena, wreaking havoc with U.S. family planning and reproductive health care efforts overseas. Over the past three years, Congress has imposed deep funding cuts on the U.S. Agency for International Developments population assistance program, effectively scuttling its expansion into the provision of more comprehensive STD services. Continued funding at these depressed levels means that, in developing countries, far fewer resources will be available for STD care in family planning settings and that the burden of STDs will continue to fall on the primary caregivers and household managerswomen. Clearly, there is a compelling need for STD services. For decades, U.S. lawmakers have acknowledged the fundamental role of disease prevention and treatment in social and economic development, which remains a cornerstone of American foreign assistance. To the detriment of millions, however, the long-term impact of STDs has gone unnoticed. Fortunately, times are changing. The global consensus that emerged in Cairo recognizes the toll of STDs on individuals and society overall, but the funding to carry out this new public health mandate is crucial. The United States was instrumental in shaping this enlightened worldview and should endeavor to follow through on its political and financial commitments to STD prevention and treatment. The quality of life for individuals and families worldwide will be greatly enhanced.

Sources of Data
Eng TR and Butler WT, eds., The Hidden Epidemic: Confronting Sexually Transmitted Diseases , Washington DC: National Academy Press, 1997. Tsui AO, Wasserheit JN and Haaga JG, eds., Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions, Washington, DC: National Academy Press, 1997. United Nations Joint Programme on HIV/AIDS and World Health Organization, Report on the global HIV/AIDS epidemic, June 1998, "http://www.unaids.org/highband/document/epidemio/june98/global_report/index.html, accessed July 2, 1998. World Bank, Confronting AIDS: Public Priorities in a Global Epidemic , New York: Oxford University Press, 1997.

Credits
This Issues in Briefwas written by David J. Landry and Wendy Turnbull. It was prepared with the support of the Pew Charitable Trusts/Global Stewardship Initiative.

http://www.guttmacher.org/pubs/ib_std.ht ml
In the US, roughly 10 million new cases of STDs occur every year - and the proportions are similar for most western nations. The projected future costs of this are hard to estimate but the consensus for the US is about 10 billion dollars per year! This is just the direct cost.. It doesn't consider the damage done to peoples quality of life! Researchers are now seeing the emergence of a gonorrhea that's resistant to cephalosporin, the last known effective antibiotic! The almost inevitable spread of this strain will be catastrophic! Most of the population has little sympathy for victims of STDs. They judge them as "Sex in the City" types who deserve what they get.

http://vs2020.com/other-articles/healthcare/std-impact.html
Causes and Effects of Most Common STDs
SEXUALLY TRANSMITTED DISEASE MONTH April 13, 1998

There are more than 25 diseases that are transmitted sexually. Many have serious and costly consequences. Some of the most common and serious STDs include: Chlamydia * Used to Be Called: Non-gonoccocal urethritis. * Cause: Bacteria.
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* Number Affected: About 4 million new cases each year in the United States. * Infection Rate: Highest among 15- to 19-year-olds, followed by 20- to 24-year-olds. * At Risk: Everyone, but female teens are more likely to be infected because of immature cervix.

* Found in: Semen and vaginal secretions. * Affects: Genitals, rectum, eyes and eyelids. * Passed Through: Unprotected anal and vaginal sex. Oral sex can transmit it to the eyes, but not the throat. * Symptoms: For women, possible increased vaginal discharge; possible burning sensation with urination; lower abdominal pain; fever or bleeding between periods. For men, white, cloudy or watery discharge from the penis, burning sensation with urination. For both, rectal discharge or pain, inflammation of the eyes. Very often there are no symptoms at all. * Complications: For women, infection can spread from the cervix into the uterus, Fallopian tubes, ovaries and abdominal cavity, which can lead to infertility, ectopic pregnancy or chronic pelvic pain. For men, infection can spread to the testes, which can result in sterility. Gonorrhea * Also Called: The clap or the drip. * Cause: Bacteria. * Number Affected: At least 800,000 cases of gonorrhea occur each year. * Infection Rate: Highest among teens age 15 to 19, followed closely by 20- to 24-year-olds. Much higher rates among African Americans. * At Risk: Everyone, but female teens are more likely to be infected because of immature cervix. Women are more at risk than men. * Found in: Pus, semen, vaginal secretions. * Affects: Genitals, rectum, eyes, throat. * Passed Through: Unprotected anal and vaginal sex. Oral sex can lead to throat infection and eye infection. * Symptoms: For women, possible increased vaginal discharge; possible burning sensation with urination; lower abdominal pain; fever or bleeding between periods. For men, white, yellow or greenish discharge from the penis--usually thicker and in greater quantity than with chlamydia. For both, rectal discharge, pain or bleeding; redness and discharge from the eye; throat infection. Very often no symptoms at all. * Complications: Women can get pelvic inflammatory disease, which can lead to infertility, ectopic pregnancy or chronic pelvic pain. Infection can cause vulva to become swollen, red and painful. In men, it can result in sterility and occasionally swelling of the penis. If passed to infants, it may cause blindness. Syphilis * Also Called: Bad blood.

* Cause: Bacteria. * Number Affected: An estimated 101,000 people each year. * Infection Rates: Highest in 25- to 29-year-olds; 30- to 34-year-olds also have high rates. Higher rates among African Americans. * Risk: About a 30% chance of contraction after one sexual exposure to a lesion. * Found in: Blood, sores, mucous membranes. * Affects: Genital area, mouth, anus, other parts of the body.
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* Passed Through: Direct contact with sores, mucous membrane or broken skin, including anal, vaginal and oral sex. * Symptoms: Chancre sores or painless, rubbery sores with raised edges; rashes on the body or wartlike growths on genital area; round, gray patches in the mouth or throat; patchy hair loss; fever; fatigue; headache; sore throat. * Complications: Ulcers of the skin, bones and internal tissues; meningitis; seizures; paralysis; blindness; insanity; death. Genital Warts / Human Papillomavirus * Also Called: Venereal warts, condyloma or condylomata acuminata. * Cause: Virus. There are more than 80 known types of HPV, 25 of which affect the genital tract. * Number Affected: At least 24 million people in the United States. * Infection Rate: Peak age of onset is 16 to 25. * At Risk: Everyone. * Found in: Skin and mucous membranes. * Affects: Internal and external genital surfaces. * Passed Through: Skin or mucous contact. * Symptoms: Fleshy bumps in genital area that can be shaped like tiny cauliflowers or be flat and smooth. Sometimes warts are itchy or painful and may bleed if irritated or rubbed. Very often no symptoms at all.

* Complications: For women, HPV can lead to cervical cancer. For men, HPV is linked in rare instances with penile, urethral and anal cancers. Genital Herpes * Cause: Virus. * Number Affected: At least 30 million people in the United States. * Infection Rates: Highest among adults. Highest among African Americans. * Found in: Skin and mucous membranes, may travel into a nerve root. * Affects: Internal and external skin surfaces--vagina, anus, penis, cervix, mouth. * Passed through: Direct skin-to-skin, mucous-membrane-to-skin, mucous-membrane-to-mucousmembrane contact. * Symptoms: Painful blisters or sores around genitals, anus, thighs; urinating may be extremely painful; possible headache, muscle aches, fever, swollen glands. At least 50% of people infected have no symptoms. * Complications: No long-term damage, just inconvenience or pain of recurring outbreaks. Hepatitis B * Cause: Virus. * Number Affected: About 100,000 new cases a year in the U.S. * Infection Rates: Seventy percent of new cases occur among people 15 to 39 years old; of those, most are teenagers. * Found in: Blood, semen, vaginal fluid. * Passed Through: Unprotected anal and vaginal sex; shared needles, razors, toothbrushes. * Symptoms: Fever, headache, muscle aches; jaundice; dark urine; extreme fatigue; loss of appetite; abdominal pain. * Complications: Liver cancer, cirrhosis of the liver, liver failure. Source: L.A. County Sexually Transmitted Disease Program

http://articles.latimes.com/1998/apr/13/he alth/he-38749

hat do we mean by Sexually Transmitted Diseases (referred to throughout the rest of this paper as STDs)? They are diseases which require direct contact to spread from one person to another (because the organisms survive poorly outside the human body) and which over the years have been shown by medical research to be predominantly, if not exclusively, transmitted by sexual contact. (NB. Don't assume that all genital tract infections are sexually acquired.) Over 40 STD infections have been described. It is important to realise that the unborn child may become infected either in the womb or during birth and congenitally and perinatally acquired infections can be serious.

It is estimated that each year 13 million Americans will acquire a STD or, to use the opening words of a speaker at a New York conference entitled The Health Status of American Children and Youth held in 1992, "During this 10-min presentation, at least 50 adolescents across the United States will acquire one or more sexually transmitted diseases. Some of these diseases can fortunately be treated and cured; however, other diseases will remain with these young people for the rest of their lives, causing dramatic physical and psychological repercussions . The figures for Britain are incomplete because only STD clinics report their figures. Diagnoses made by doctors in other specialities are not recorded. Official returns from STD clinics for 1993 show 11,800 cases of gonorrhoea; 33,267 cases of chlamydia; 100,820 cases of non-specific genital infection and 25,500 cases of genital herpes . A recent large survey reported that overall 8.3% of men and 5.6% of women reported visiting a STD clinic . There was, not surprisingly, an association with age. The peak in men occurred in the age group 25-39 whilst in women it was age 16-24. There was also a large geographical variability with the highest incidence in the London area.
1 2 3 4

Whatever the source one clear fact that emerges is that the more sexual partners that you have the more likely you are to acquire a STD. The table below shows the results from the UK survey(4).

Percentage reporting to STD clinic by number of partners

Number of sexual partners

3-4

5-9

10+

- hetrosexual Men - homosexual

0.9

1.7

2.8

3.8

7.8

20.2

7.4

20.3

15.1

33.9

44.3

67.3

- hetrosexual Women - homosexual

0.5

1.3

2.4

6.1

12.2

26.7

5.3

27.9

16.9

32.7*

26.6*

0*

*only small numbers in these groups

It is equally important to recognise that not all infections cause symptoms, especially in women. Furthermore women are more susceptible to infection and are more likely to develop complications .
5

A useful way of considering STDs is by the time course of their effects and complications (see table below)

Major STD Microbial Agents and their Impact (Table taken from Ref 5)

Actute Disease

Pregnancy Associated Disease

Chronic Disease

Gonorrhea

Urethritis Cervicitis Salpingitis

Prematurity Septic abortion Ophthalmia of newborn Post partum endometritis

Infertility Ectopic pregnancy

Chlamydia

Urethritis Cervicitis Salpingitis

Ophthalmia Pneumonia in baby Post partum endometritis

Infertility Ectopic pregnancy

Syphilis

Primary and secondary syphilis

Spontaneous abortion Stillbirth Congentital syphilis

Neurosyphilis Cardiovascular syphilis

HIV

Glandular feverlike illness

Prematurity Stillbirth Perinatal HIV

AIDS

Human Papilloma Virus

Genital warts

Laryngeal papillomatosis in child

Genital cancer

Herpes simplex type 2

Genital ulcers

Neonatal herpes Prematurity

?Genital cancer?

Hepatitis B

Acute hepatitis

Perinatal HBV

Chronic hepatitis Cirrhosis Liver cancer Vascilitis

So let us look at some of these in more detail. Many, including adolescents, have heard of venereal disease but assume that they are all treatable with antibiotics. In many cases this is true, but what they forget, or are not told, is that many infections - especially the viruses - are not treatable. For instance an acute attack of genital herpes will subside, but then the virus can lay dormant only to reactivate later. [NB the herpes virus that causes cold sores (HSV type 1) is different from the virus that causes genital herpes (HSV type 2)]. They also forget that many infected individuals can be asymptomatic but the infection is causing permanent damage.

Psychological effects
The psychological impact has been poorly addressed. A study of adolescents found those who got infected were noted to have a lower self-esteem as well as suffering depression, guilt and shame . Another study found that 31 % of those attending a STD clinic were sufficiently anxious or depressed to warrant being classified as psychiatrically ill . A study from South Australia found a higher level of 'abnormal illness behaviour' in patients with a STD which increased with the number of previous infections. In a fourth study one third of patients scored positively on the 'general health and illness behaviour questionnaire.' The scores from STD clinic patients were higher than any other group of patients except psychiatric in-patients, indicating the high degree of psychological distress associated with a venereal infection .
6 7 8 9

Acute Disease
In general the acute symptoms of a STD affect the genital tract. Gonorrhoea and chlamydia can both cause a discharge, but it important to recognise that infections, particularly in women, can be asymptomatic. In fact 70% of chlamydial infections in women, and 25% in men are without acute symptoms . However, even if asymptomatic these organisms can spread higher up the genital tract to cause permanent damage. Gonorrhoea can be spread through the blood stream to infect joints and cause gonococcal arthritis.
10

Some individuals (related to their tissue type) are prone to a condition called 'Reiters syndrome' which consists of urethritis, arthritis and conjunctivitis. Many of these cases are related to STD (especially chlamydia) although it can also follow many non-sexual infections. There are many types of the human papilloma virus. Type 1 causes the common skin warts - this type has nothing to do with sexually transmitted infections. However, types 6 and 11 cause genital warts, while types 16 and 18 are associated with cervical cancer (see later) and are sexually transmitted. The warts can be obvious to the naked eye or they can be 'flat warts' that are visible only under the microscope.

Genital herpes in the woman can be asymptomatic, but the initial infections are usually associated with ulcerating and often painful blisters both on the cervix and external genitalia. Reactivation is common with genital herpes. Syphilis is rare in the UK, although the only official notifications are those that are diagnosed by STD clinics. In 1993 they reported 866 new attendances in the UK. However, there has been a dramatic rise in incidence in the USA (see later). The bacteria enter the body at the point of contact and rapidly spread throughout the body. After an incubation period of between 9 and 90 days a painless ulcer appears which spontaneously heals within 2-6 weeks (primary syphilis). There is a second period of about 6 weeks before the appearance of secondary syphilis, often seen as a skin rash. The disease can then remain latent for years before the appearance of tertiary syphilis that can affect the central nervous system, blood vessels etc. Syphilis is readily treated by penicillin. Hepatitis B is a form of hepatitis that is spread like HIV, ie via infected blood and sexual contact. About 1400 new cases are diagnosed each year in the UK. Do not confuse Hepatitis B with other viruses causing hepatitis that are acquired in other ways. Worldwide, transmission of the virus from the mother to the baby is the most important mode of spread. (see later) By the end of August 1994, there were 22091 known HIV infected patients in the UK. 9290 have developed full-blown AIDS, of which 6283 have already died. 13679 acquired their infection through homosexual contact; 3524 - heterosexual contact; 2588 - IV drug abuse; 1373 contaminated blood products; 927 - infected by unknown source . It has now been recognised that the presence of other STDs make it easier to pass HIV from one person to another, with the risk of transmission of HIV being reported as two to nine times higher .
11 12

Complications in pregnancy
So that I cannot be accused of being over-dramatic in the way I present the various problems associated with pregnancy, I would like to quote from the introduction of a medical article on the subject1. "The offspring of these women (ie with STDs) are also in jeopardy. Maternal STDs can result in conjunctivitis, pneumonia, laryngeal papillomas, liver disease, neurologic disease and even death for the exposed fetus. In communities endemic for STDs, more new-borns will die of congenitally acquired infections than die of all causes of infant mortality combined at average American Hospitals. It is clearly in the public interest to devise and implement strategies to protect mothers and children from the many risks associated with STDs'."

a. Gonorrhoea.
If gonorrhoea is acquired before the 12th week of pregnancy there is a risk of the infection spreading to the tubes to cause acute salpingitis. Reactivation of prior salpingitis can also occur and result in an ovarian/tubal abscess that may be more difficult to diagnose in pregnancy. Disseminated infection is also more common in pregnancy especially in the later stages . Intrauterine infection of the fetus does not occur. However in early pregnancy gonorrhoea is associated with spontaneous septic abortion and infection after surgical abortion. Later in pregnancy it is associated with premature rupture of the membranes and placental infection. The
13

most common complication is infection of the baby as it passes through the birth canal. This can result in genital infection of the baby but more commonly it presents as a conjunctival eye infection within 2-3 days. This is usually recognised and treated, but untreated this can cause perforation of the cornea with infection of the whole eye and disseminated infection of the baby.

b. Chiamydia
This is now the most common STD in western society, with surveys reporting between 2 and 27% of pregnant women having active infection and 20-40% of pregnant women have positive antibody tests1 (evidence of previous infection). If the woman has active infection then the baby has a 50% chance of picking up the infection during birth, with a 40% risk of developing conjunctivitis and 20% risk of developing pneumonitis. Although the lung infection is not life threatening, it can be protracted and is associated with a higher prevalence of childhood respiratory disease . Symptoms of both the eye and lung infections can be delayed for up to 6months after birth ! In one small prospective study of 268 pregnant women, the babies of 6 of the 18 infected mothers died (33% perinatal mortality) compared to only 1 of 250 non-infected women . In this same study 5 of the 18 (28%) infected mothers delivered prematurely compared with 6% of uninfected mothers. Prematurity and low birth weight is now well recognised in pregnant women with chlamydial infection.
14 15 16

c. Syphilis
Syphilis is rare in the UK and all antenatal clinics routinely test for syphilis. However, there has been a dramatic increase in incidence in syphilis in the USA, so we should not be complacent in this country. Primary and secondary syphilis in the mother often results in congenital syphilis of the fetus, which is associated with a 50% mortality. In the USA taken as a whole, there were 4.3 cases of congenital syphilis per 100,000 live births in 1982. In 1991 this has risen to 107 cases per 100,000 births. However there are pockets with a much higher incidence. Washington DC reported 2086.7 cases per 100,000 births (ie 2% of babies were born with congenital syphilis!!) and New York 1027.4 cases per 100,000 births .
17

d. HIV
In the UK there is no official register of HIV in pregnancy. However the Royal College of Obstetricians and Gynaecologists together with the Institute of Child Health, has set up a voluntary register. Between June 1989 and May 1994 a total of 695 pregnancies in HIV positive women were reported. By July 31st 1994 the register was aware of 750 children born to HIV positive mothers. 274 of these are known to be infected by HIV; 269 are unaffected; it is still too early to determine the HIV status of the remaining 207 babies . [NB It is invalid to calculate the transmission rate of HIV in pregnancy from these figures because in a proportion of the cases the HIV status of the mother only became apparent after the babies were diagnosed as suffering from AIDS.) Recent studies have shown that about 20% of babies born to HIV infected women will be infected. There are two patterns of disease progression in children infected during pregnancy. About 20% of infected children develop AIDS in the first year of life, with slower progression in the remaining children .
18 19

e. HPV (Human Papilloma Virus)

Pregnancy is associated with a more rapid growth of genital warts. Treatment of the warts is difficult in pregnancy because a commonly used treatments (podophyllin) is teratogenic (ie can cause fetal malformation). The baby can pick up the virus during delivery and although for most this does not appear to cause a problem, in a small number of cases the virus infects the lining of the larynx causing laryngeal papiliomatosis. This is a condition where large bulky warts grow in the larynx which obstruct the airway, necessitating repeated operations to remove the warts. NB Despite the high incidence of HPV infection, laryngeal papillomatosis is rare.

f. Genital Herpes (Herpes simplex virus)

Genital herpes infection in pregnancy, especially initial attacks, is associated with spontaneous abortion, preterm delivery and intrauterine and neonatal infection. Transmission of the virus to the fetus, via the placenta, is rare but when it does occur it is associated with brain damage and also infection of the retina of the eye. The most important complication is infection of the baby during delivery. If active herpes infection is present, then the obstetrician will deliver the baby by Caesarean, because of the devastating effect of neonatal herpes. 40% of babies born vaginally during active herpes infection will get infected. The infection becomes apparent between 1-3 weeks after birth with lethargy, irritability and poor feeding. Within 24hrs there is rapid progression with involvement of the liver, adrenal glands, lungs and brain. One third of the babies develop the typical painful blisters in the mouth or skin. Because of the brain infection the baby often suffers fits, coma, paralysis, meningitis and encephalitis. Up to 80% of infected babies will die or suffer serious brain damage.

g. Hepatitis B
Most adults who get infected with hepatitis B develop acute hepatitis; only 10% become chronic carriers. However, the baby who gets infected suffers no acute symptoms but almost invariably becomes a chronic carrier. Many years later in adulthood, that person can develop cirrhosis and liver cancer. Hepatitis B acquired at birth is the leading cause of liver cancer worldwide.

Chronic disease
Infertility, particularly tubal infertility (ie blocked tubes) and ectopic pregnancies are becoming more common. There are many causes for blocked tubes (eg severe appendicitis) but unequivocally STDs have been an important factor. Sometimes the women give a clear history of pelvic inflammatory disease, but more commonly they report no such symptoms, yet the doctors find scarred Fallopian tubes. In these cases doctors call this atypical (or covert) pelvic inflammatory disease, because the woman did not have the typical symptoms of the disease. There is an association between infertility and nearly all of the different STDs. However individuals may be infected by more than one infection and so it is not surprising that the strongest correlation comes when the data is analysed by the number of previous sexual partners. In one large study involving seven different institutions in Canada and the USA, doctors compared women with tubal infertility (ie blocked tubes) with fertile women delivering babies at

the same hospital. Among the questions asked were details about the numbers of sexual partners . This data is shown in Table 3.
20

Tubal infertility and Number of partners

1 or 2 partners

3+ partner

Fertile women

64.80%

35.20%

Infertile (Covert PID)

48.70%

51.30%

Infertile (Overt PID)

35.60%

64.40%

Table 3

Overt PID means that the women described typical symptoms of pelvic infection; Covert PID means the women did not describe any symptoms of pelvic infection, yet investigations showed evidence of such infection.

Tubal Infertility and Number of Partners

No partners

2-5

6+

Fertile Women

44.2%

36.7%

19.1%

Tubal Infertility

25.8%

42.4%

31.8%

Table 4

An almost identical set of figures is presented by another similar study (table 4)

21

A similar trend was found in a study of women with ectopic pregnancy .

22

It can be seen from these figures that those women with tubal infertility are more likely to admit to a greater numbers of sexual partners. For completeness here are the details of two studies looking at the association of chlamydial infection and tubal infertility. One study from Bristol found 73% of women with tubal infertility had antibodies to chlamydia (ie evidence of previous infection) compared with 34% of infertile women with normal tubes . A similar study from Finland found 46% of women with tubal infertility had chlamydial antibodies compared to 7% of infertile women with normal tubes .
23 24

One infertility clinic reported that 14% of its cases of infertility were due to tubal damage, most likely related to previously acquired STDs .
25

In summary, data from many studies show that the greater the number of sexual partners a woman has, the greater her chance of catching a venereal disease and, even if asymptomatic, the greater the risk of later infertility and ectopic pregnancy. Not surprisingly the UK survey found that the number of sexual partners was the dominant factor for the probability that a woman has had an abortion(4).

Relationship between number of partners and abortion

Number of partners

3-4

5-9

10+

Percent having abortions

6.0%

9.8%

16.5%

23.0%

34.4%

Abortion in last 5yrs

2.6%

8.7%

12.3%

15.7%

33.7%

Cervical cancer
Population studies of cervical cancer have clearly shown two important risk factors. Young age at first intercourse and the number of sexual partners. This is an associated with infection by the human papilloma virus (HPV), especially type 16. HPV 16 is not "the cause" of cervical cancer, since many women are infected by the virus but only a small number develop the disease, however it is an important factor. Cervical smears should pick up pre-cancerous changes and currently many laboratories are reporting up to 10% of the smears as abnormal. Many doctors believe that the screening programme has prevented a massive explosion of cervical cancer. The age of first intercourse is important because during adolescence the cervix is undergoing

important changes, and it appears that if the HPV virus infects immature cells, it is more likely to initiate the precancerous changes. Women should also be aware of their partner's sexual history. A study from India of women showing pre-cancerous changes on their cervix, but who had only a single lifetime sexual partner (their husband) showed that the sexual history of the man is crucial . Premarital relations by the husband increased the woman's risk by 190%; Extramarital relations by 270%; both pre and extramarital relations increased the risk of the woman developing precancerous changes in her cervix by 690%! The risk increased if the husband had 3 or more partners or had a documented STD. [NB The cause of any cancer is multifactorial and so there will be cases of cervical cancer in women who are virgins.]
26

The solution?
The appearance of AIDS, with its uniformly fatal outcome, has focused attention on the problem of STDs. It is obvious from the medical data that the only way to be sure of preventing AIDS and other STDs is by lifelong monogamous sexual relationships. (All blood products are now tested for HIV, so accidental non-sexual transmission will be very rare.) People who attempt to promote the idea of sexual abstinence are often branded as unrealistic, (or religious fundamentalists!) The establishment has come up with the concept of "Safer sex" (originally called safe sex). But surveys of the public have shown that only one aspect of this idea is known - "use a condom." In fact there are five a) Use a condom, b) Reduce the number of partners c) Know the sexual history of your partner d) Choose your partner carefully and avoid a high risk partner, ie intravenous drug abuser or man who has had homosexual partners. e) Avoid certain sexual practices eg. anal intercourse. But are these realistic aims? A survey of 9000 Swedish adolescents showed that 99% knew the claim that a condom was the best protection against STD , but despite this only 11% used a condom every time, 17% had caught an STD, and 9% had been or had made somebody pregnant. There is a plethora of studies to show that outside stable relationships condom use is inconsistent. A recent study on the transmission of HIV between heterosexual couples has revealed that the same is also true in cases where a high risk is known and there is a stable relationship. The multicentre study, involving 10 European AIDS units, looked at the transmission of HIV in couples in a stable heterosexual relationship where only one partner was HIV positive. All these couples were aware of the problems and were counselled about "safe sexual practices" every 6 months . Only 49% consistently used a condom (none got infected), with the remainder being equally divided between using condoms about half the time and very rarely/never (12.7% became infected). 17% of those not using condoms continued to have unprotected anal sex (27.8% of these women became infected).
27 28

But is the condom really effective as a protection against HIV and other STDs? Condoms are certainly promoted as such, and I am sure the above quoted study will be used as evidence to support it. But in that study only 124 couples used condoms consistently, the median follow-up period was only 2 years and the couples reported reduced sexual activity. However a review of the world medical literature shows that there is little solid evidence to support the claim that

condoms are effective . The "best" studies suggest a possible 40% reduction in the risk of contracting a STD, with one study showing no benefit at all! The author concludes his review by saying that when patients now ask whether condoms are effective he replies "I would say that they help to reduce the risk; that they do not prevent all STDs all of the time; and that other measures, such as limiting number of partners and getting screened for STDs, are at least as important(29)."
29

Is the money being spent on AIDS (and STD) prevention programs working? In 1990 the Centre for Diseases Control in USA spent $204 million on HIV prevention programs, of which half was for counselling and testing. One such centre in Miami carried out an audit of patients who had received an HIV test. All were counselled both before and after the HIV test and instructed on methods of "safer sex." They then looked at the number diagnosed with any STD in the 6 months before the test and compared it with the 6 months after the test. In those who tested HIV positive there was a 12% reduction in STDs in the 6 months after the test, but a 106% increase in those who tested HIV negative !
30

It appears that the so-called professional advice is not being reflected in practice, and those advocating abstinence can justifiably criticise those promoting "safe sex" education to the young. As a Swedish author wrote(27) - "Society today allows sex 'as long as you are in love' which is often interpreted as meaning 'as soon as you are in love': sexual intercourse today often marks the start of a relationship rather than, as some decades ago, the confirmation of an established relationship. These attitudes of adult society are reflected in the behaviour of young people. In general, adolescents are faithful to one partner at a time but their time perspectives are short and this, combined with coitus early in a relationship, results in each having high number of partners. This creates the conditions for the spread of STDs." Most of the STD prevention campaigns have been based on social psychology theories - with such grand sounding names as the 'health belief model'; 'theory of reasoned action'; 'protectionmotivation theory'. But people have now began to realise that these theories apply to 'adult' thinking and do not apply to adolescent psychology. Adolescents are in a transition between what is called "concrete operational reasoning' and the adult "formal operational thinking"(6) So it is not surprising that current secular education methods are failing to curb the increase in either STDs or teenage pregnancies. In addition there are some very important facts that many are ignoring. One of the effects of the hormones of the contraceptive pill is to enhance the acquisition of chlamydia infection and the presence of a STD enhances the transmission and progression of HIV infection . How many young girls taking the pill to avoid pregnancy know this?
31

Let us recognise that adolescents will not always follow advice given to them, but let us at least continue to give them the truth about the dangers of promiscuous sex, rather than lead them into a false sense of security. The educational experts argue that 'frightening' people by quoting the dangers of an action does not work; a more effective method is the promotion of a positive role model. Regardless of the methods people use, I hope this paper will allow informed discussion on this topic to take place.

http://lifeissues.net/writers/jar/jar_03sexu allytransmitted.html
In Southern Africa, as elsewhere in the continent, the AIDS epidemic is not just a health crisis. It is also "a major threat to development and to human society," as Executive Director Peter Piot of the Joint United Nations Programme on AIDS (UNAIDS) put it at a conference in Nairobi in April. While wreaking havoc on the present generation, the disease jeopardizes the future as well, undermining African economies and societies in ways that often are not immediately apparent. Taking a narrow economic approach, however, some have argued that AIDS is unlikely to inflict severe damage on national economies because those infected are, in their great majority, the poor and unskilled, who contribute little in pure economic terms. This view ignores not only the human dimension, but also the broader social and economic aspects of development. It likewise ignores the existing evidence of the many insidious ways in which AIDS already is harming key sectors in those countries most seriously affected by the epidemic. Harvard University economist Jeffrey Sachs ( see box below) pointed out at an international AIDS conference in South Africa last year that HIV/AIDS damages society just as it does the human body: it begins by killing those parts responsible for building society, the women and breadwinners who sustain and safeguard the community as a whole. Ultimately, AIDS undercuts economic growth and harms development, but its impact is felt first at the "cellular" level, among African households. Of all parts of Africa, the Southern African region has the highest infection rates (see map). In South Africa and Botswana, 15-year-olds currently have a one-in-two chance of dying of HIV/AIDS. The US Census Bureau last year forecast that Botswana, Zimbabwe and South Africa would experience negative population growth as a result of HIV. Slowly won development gains, such as life expectancy, education and literacy, are being eroded. In Botswana, it has been forecast that HIV will cut in half life expectancy at birth. South Africa, once seen as the economic powerhouse for the region, is thought to have the greatest number of infections in the world -- an estimated one in nine of the population has HIV. The spread of the virus is not expected to peak for another five years, when the estimated number of infected people may rise from 5.2 million to 8.2 million, or nearly 17 per cent of the total population. Such projections, of course, do not take into account new medical breakthroughs or changes in people's behaviours, which could impede the disease's progression. Families hit hard Among households, the direct costs of HIV/AIDS can be measured in the lost income of those who die or who lose their jobs because of their illness. Household savings fall, consumption on items other than health and funerals declines and expenditure patterns are distorted as families struggle to cope with the demands of the sick and dying.

Mr. Robert Greener of the Botswana Institute of Policy Analysis told Africa Recovery that while government revenue from its diamond industry has been relatively unaffected by the AIDS crisis, that of households has been hit hard. Overall poverty rates will not necessarily get worse, "but the rate of improvement will not be what it was. We found that HIV will have a major effect on how [people] can invest in their own future." He estimates that between 17 and 25 per cent of households will lose an income earner in the next 10 years, with total income falling by 15 per cent in the poorest homes. A government AIDS-impact study estimated that overall household per capita income will fall by 8 per cent, and as much as 13 per cent for the poorest quarter. Households which otherwise might have remained above the poverty line are pushed below it. This in turn can feed the epidemic. As the UN programme, UNAIDS, has pointed out, at least two of the behavioural responses to poverty can exacerbate the epidemic: migration in search of work and employment in the sex trade. When people are mired in poverty, "taking care to avoid HIV/AIDS may seem a less immediate concern for many people than simple survival." Combating poverty, in turn, can help make people less vulnerable to AIDS. A study in Bushbuckridge, South Africa, found that providing micro-loans to groups of women gave the women some financial autonomy, enabling them to better negotiate safer sex. On a wider scale and over time, the erosion of household incomes and opportunities can damage the fibre of entire communities and societies. Extended family networks, which can cope with the normal traumas of life in poor countries, often begin to fray when multiple orphans are dumped on them and when the breadwinners can no longer support themselves, let alone anyone else. The transfer of knowledge across generations is lost, and socialization is reduced. Health facilities under strain Not only do overall household incomes fall, but also what money remains tends to be diverted to meet the needs of the sick. Family expenditure on healthcare rises, eventually consuming savings and other resources in an attempt to keep death at bay, and to pay for funerals when the battle is lost. On a grander scale, countries' health systems themselves become overburdened. Already understaffed and underfunded, Africa's health infrastructure is struggling to cope with the enormous demands placed on it. Public health facilities in particular come under strain, as many private clinics and doctors choose not to offer treatment for HIV/AIDS. The lack of supplies can put healthcare workers at risk of becoming infected themselves. AIDS distorts health-spending priorities. According to UNAIDS, up to 80 per cent of hospital beds in Zambia and Zimbabwe (as well as Cte d'Ivoire) are occupied by HIV-positive patients. For governments, the epidemic poses a number of dilemmas: to spend limited resources on trying to prevent further infections, helping those already infected, or combating other serious health problems, such as tuberculosis, malaria and cholera. Empty schools

Many poor households affected by AIDS may not be able to afford to send their children to school. Even in countries where schooling is free, there are other costs such as uniforms and books. Specifically to address this problem, the World Food Programme has proposed that "takehome rations" should be added to school feeding projects to give families an incentive to send their children to school. Such a programme could particularly help female children, since cultural conditioning means that girls are more likely to be kept out of school to become caregivers. Where HIV infection rates are lower, school attendance, especially of girls, tends to be higher. Moreover, children may be the only able-bodied members of a household if the adults are sick -or dead -- and are likely to concentrate more on survival and raising their siblings than on education. Studies in Zimbabwe have found that of the AIDS orphans on commercial farms, not one was attending secondary school and almost half the primary school pupils had dropped out by the time their parents had died. According to estimates, more than 7 per cent of Zambia's 1.9 million households are now headed by children aged 14 or less. In some cases, students also may be subject to disproportionately high infection rates. At one South African university, it has been estimated that two-thirds of students will be HIV-positive by the time they graduate. As such students and pupils die, not only do Africa's economies lose potential skilled workers, but the governments' educational investment in them also is wasted. Similarly, families' expenditures on their schooling have been in vain, and they lose not just a loved one, but a possible source of future revenue. Infection rates among teachers also are high. According to South African economists Peter Badcock-Walters and Alan Whiteside, in 1998 the mortality rate among educators was 39 per 1,000, or 70 per cent higher than in the 15-49 year age segment of the population. In Zambia, during the first ten months of last year, 1,300 teachers died of AIDS -- two-thirds of the annual number of newly qualified teachers. Macroeconomic impact In many different ways, the devastation of AIDS among individuals and families ultimately affects a country's overall economic performance. The loss of experienced workers and skilled professionals saps production in key sectors. More insidiously, AIDS can erode the people's morale, weakening their confidence in the future, further harming productivity and undermining their willingness to save and invest. Foreign investors also are becoming increasingly concerned about the implications of the HIV/AIDS epidemic, at a time when Africa is seeking to attract more international investment. For foreign investors, notes Mr. Gordon Smith, chief economist of Deutsche Bank in South Africa, "uncertainty means sell rather than hold," much less invest more money. According to some estimates, annual per capita economic growth in Africa is 0.7 per cent less because of the cumulative impact of AIDS. Such estimates are seriously unreliable, however. There is a paucity of accurate data both on AIDS itself -- precisely who is infected, in which

economic sectors -- and on how the illness actually affects different economic activities. Nor can the impact of AIDS be easily separated from other factors. "AIDS is part of a whole. It will have a macroeconomic impact," admitted Mr. Whiteside, the South African economist. "But you cannot disimpact AIDS from labour legislation, for example." Nevertheless, numerous studies agree that AIDS can seriously slow down economic growth, to varying degrees. UNAIDS has estimated that when HIV prevalence rates rise to more than 20 per cent, gross domestic product (GDP) in those countries can be lowered by as much as 2 per cent a year. In South Africa, the investment bank ING Barings has projected that HIV/AIDS could drag down GDP by 0.3-0.4 per cent a year. Another study has indicated that by the end of the decade, AIDS could have knocked South Africa's GDP by 17 per cent, or $22 bn. The UN Development Programme (UNDP), in its Botswana Human Development reports, cites government studies that HIV/AIDS will result in GDP being between 24 per cent and 38 per cent lower by 2021. Mr. Greener says that 2 per cent of the workforce in that country is showing clinical signs of AIDS. He predicts that over 25 years, GDP could be 40 per cent lower than without HIV/AIDS. "There will be an increased cost of skills," he says. "There is a need to put in place practices to maintain productivity and prevent a skills-related bottleneck."
Southern Africa: labour force losses due to HIV/AIDS (%) by by 2020 2005 Botswana -17.2 -30.8 Lesotho -4.8 -10.6 Malawi -10.7 -16.0 Mozambiqu -9.0 -24.9 e Namibia -12.8 -35.1 South -10.8 -24.9 Africa Tanzania -9.1 -14.6 Zimbabwe -19.7 -29.4 Source: UN Africa Recovery from ILO and UN Population Division data.

Farm output erodes The agricultural sector is one of the hardest hit in sub-Saharan Africa, where it is often the largest contributor to the economy. As people sicken, the areas they cultivate may shrink, and yields decline as physical weakness reduces farmers' effectiveness. Food security is jeopardized,

as labour, time and money is diverted to deal with the illness. Agricultural households may revert to subsistence rather than cash crop farming, and the quality and quantity of food may decline. In Malawi, death rates among employees of the Ministry of Agriculture and Irrigation have doubled, almost all because of HIV/AIDS. In Namibia, studies indicate that agricultural extension workers spend a tenth of their time attending funerals. "The effect of AIDS on food production is both immediate and long-term," Dr. Piot of UNAIDS has pointed out. This has been confirmed concretely by a study from Zimbabwe, which looked at the impact of an adult death on the household's ability to produce different foods. It estimated reductions of 61 per cent for maize, 49 per cent for vegetables and 37 per cent for groundnuts (see graph). But AIDS also hits long-term agricultural capacity. Livestock is often sold to pay funeral expenses, and orphaned children often lack the skills to farm or look after livestock in their care. High infection among miners The mining industry is notorious for its high rates of HIV infection, particularly where there are single-sex hostels and attendant male-to-male sexuality and commercial sex. Migrant labour adds to the problem, with workers carrying infection to and from their employment on trips home, including in other countries. Areas of Lesotho are now being devastated by HIV as sick workers return from South African mines, a situation exacerbated by the economic reliance of the small country on their remittances. Although there have been anecdotal reports of infection rates as high as 60 per cent, some mining companies say this is exaggerated and claim rates among their employees are close to the national average. The mining companies in South Africa are regarded as being at the forefront of businesses taking action on HIV/AIDS. In Botswana, the highly mechanized diamond sector, which uses a smaller and more stable workforce, is likely to be relatively unaffected by HIV, unlike the gold mines in neighbouring South Africa. Few families realize direct earnings from diamonds and most of the revenue from the sector goes to the government. It therefore filters into the rest of the economy only through government expenditure. Thus, to an even greater extent than in many other countries, GDP, in per capita terms, does not reflect personal incomes. "Government is shielded, but people are not," observes Mr. Greener. "So that impact falls on the household." Companies bear the costs ... According to a Deutsche Bank study, while the HIV infection rate among unskilled and semiskilled workers in South Africa is expected to peak at just under 33 per cent by 2005, for highly skilled workers it is expected to be around 13 per cent. Nevertheless, such skills are scarce, and the impact of AIDS will be disproportionate. One study found that highly skilled workers are on average about three times as productive as unskilled workers, and productivity losses could account for about 54 per cent of total economic costs.

Employers will face other costs as well, for example through increased medical claims and insurance payouts. South Africa's Metropolitan Life insurance company has calculated that by the end of this decade payroll expenses could be 30 per cent higher as a result of HIV/AIDS related costs, including pension and sick leave payouts. Absenteeism rises as employees take time to nurse the sick or attend funerals. "There will be a decline in workers' morale as they become gripped with fear and uncertainty as they see people around them dying," said Ms. Tsetsele Fantan, head of the HIV/AIDS programme at the Botswana diamond company Debswana. "There will be accidents as they start to lose concentration. Management resources will be eaten away by problem solving." Skills shortages have been a perennial problem for businesses in Africa, a situation that HIV is making worse as more skilled workers die. Difficult or expensive to replace, the result can be a vicious circle as public and private infrastructure starts to decay. There have been reports of power failures in Zambia because there were not enough engineers to maintain the facilities. As HIV takes its toll, financial resources for training are being spread to cover more people, to ensure that enough will be available. Anecdotal reports suggest that some companies train several workers for every one they need -- they assume natural attrition in the form of HIV will remove the extra hires. ... and take AIDS prevention seriously Many large companies began planning responses to HIV/AIDS years ago, including researching the likely impact on their workforce. Although there are sometimes legal concerns about employee testing, companies often do surveillance studies using saliva samples as part of other health checks. The South African mining firm Anglogold, for example, conducts anonymous tests on its miners, with their consent, during their checkups for tuberculosis. According to a manager at South African Breweries, 40 per cent of the company's workforce in KwaZulu Natal is HIV positive. By planning ahead, the private sector has been able to shield itself to an extent. Some companies have sought to divest themselves of risk by outsourcing activities such as long distance transport, where workers tend to have high rates of HIV. One study by the Medical Research Council of South Africa found that approximately 90 per cent of truck drivers at one particular rest stop were HIV positive. Some companies have concluded that the costs of introducing prevention and treatment measures could be lower than not doing so. The Anglo-American Corporation is just one organization looking at providing anti-retroviral drugs to its infected workers, especially if drug prices continue to fall. In Botswana, Debswana has announced plans to provide anti-retroviral therapy to each HIV-positive employee and one dependent, a move that is also being considered by one of its parent companies, De Beers. Many firms have introduced AIDS awareness programmes, in conjunction with health checkups and free treatment of sexually transmitted diseases (STDs). Anglogold's research centre, Aurum,

calculated that the company was saving money by treating STDs, in that it contributed to lower infection rates. The South African power parastatal, Eskom, has been running HIV/AIDS programmes to educate staff and help those infected to remain healthy. The company, which employs approximately 32,000 people, claims to have infection rates "substantially less" than the national rate. Mr. Baningi Mkhize, the occupational medical services manager, says the company was inundated with employees wanting to take advantage of a voluntary counselling and testing programme. Staff who develop full-blown AIDS can join Aid for AIDS, a managed care programme that concentrates on the disease. Eskom itself earmarks R125 ($17) per employee for its HIV/AIDS programme, projecting to spend R150 per person the next financial year. In their efforts, employers are increasingly being helped -- and prodded -- by their trade unions. The Congress of South African Trade Unions, the largest union federation in the country, is planning to launch a campaign to get employers to pay for anti-retroviral drugs for infected