Occasional paper no 7
THE CALM BEFORE
THE STORM (2)
The impact of HIV/AIDS on the South African
population, and constitutional and legal
issues surrounding the epidemic’s victims
Epicentre AIDS Management Services
July 2002
Commissioned by the Home Loan Guarantee Company
An URB AN INSTITUTE programme funded by US AID
Published in July 2002 by the
Housing Finance Resource Programme
The Isle of Houghton
Old Trafford 3, Level 3
11 Boundary Road, Houghton
Johannesburg, South Africa
P O Box 3350, Houghton
Johannesburg 2041
Tel +27 11 484-5278
Fax +27 11 484-1299
info@hfrp.org.za
www.hfrp.org.za
All rights reserved. This paper may not be reproduced, stored or transmitted without the
prior permission of the Housing Finance Resource Programme. Short extracts may be
quoted, provided the source is fully acknowledged.
Edited and produced by Riaan de Villiers
ISBN 0-9584476-7-5
This report was written by Karen Michael of Epicentre AIDS Management Services.
This publication was made possible through support provided by the Office of Housing and
Urban Environment, South Africa, US Agency for International Development, under the
terms of contract no LAG-I-00-99-00036-00, delivery order 800. The opinions expressed
herein do not necessarily reflect the views of the US Agency for International Development.
CONTENTS
Foreword 5
Research objectives 7
PART 1: EPIDEMIOLOGICAL ISSUES 9
Introduction 11
HIV/AIDS in Southern Africa 11
Completed and continuing research on HIV/AIDS in South Africa 14
Epidemiological surveillance 14
Demographic projections 17
Econometric projections 22
Weakness and strengths 22
Evaluation of the impact and projection models 23
Limitations of epi-data (antenatal clinic data) as an indicator of
general prevalence 24
The impact of HIV/AIDS on low income groups in South Africa 28
The progression and profile of HIV in South Africa 29
The natural history of HIV infection 29
The effects of HIV/AIDS on the capacity of various populations to
hold down jobs 33
The impact of the disease on the ability of people to repay loans 34
THE TREATMENT OF HIV/AIDS 38
Background on anti-retroviral therapy 38
Nucleoside analog reverse transcriptase inhibitors (‘nukes’) 39
How are antiviral drugs used? 41
Do antiviral drugs cure AIDS? 41
The cost-effectiveness of anti-retroviral treatment 42
Conclusions 46
PART 2: CONSTITUTIONAL AND LEGAL ISSUES 47
Research method 49
The legislative framework 49
The constitution 49
The Promotion of Equality and Prevention of Unfair Discrimination
Act (no 4 of 2000) 51
The Medical Schemes Act 54
The Life Offices Association Code of Good Practice 54
CONTENTS
Academic research 56
Case law 59
Conclusion 60
APPENDICES 61
Appendix 1: Modellling 63
Appendix 2: The Doyle and ASSA models 65
Appendix 3: Is HIV infection a disincentive to loan repayments? 69
Appendix 4: Persons interviewed 71
REFERENCES 72
4
FOREWORD
This publication is the second of two reflecting the results of a major research
project aimed at developing an understanding of the impact of HIV/AIDS on the
low-income housing finance sector. The project has been co-ordinated by the
Home Loan Guarantee Company (HLGC). The Housing Finance Resource Pro-
gramme has acted as a major funder of the research performed, and is pub-
lishing the edited reports as two volumes in its occasional paper series.
Two sets of consultants – Quindiem Consulting and Epicentre AIDS Manage-
ment Services – were contracted to perform different parts of the research.
Volume 1 contains the results of a survey – conducted by Quindiem Consult-
ing – aimed at establishing how lenders operating in different segments of the
low-income housing market are perceiving, and actually experiencing, the
manifestation of HIV/AIDS in their borrower populations.
Volume II contains the results of a comprehensive literature review – per-
formed by Epicentre AIDS Management Services – focusing on:
1. the epidemiological impact of HIV/AIDS on South Africa’s population by
identifying how it manifests (and will continue to manifest) across age,
gender, income groups, residential circumstances, and geography; and
2. the constitutional and legal implications arising from being an HIV/AIDS
patient/borrower.
Epidemiological impact
The Epicentre team approached this aspect of its task by:
1. identifying the work of health economists operating in research units and
consultancies across South Africa pertinent to this project;
2. describing the impact of HIV/AIDS on the South African population, with
particular emphasis on those earning less than R6 000 a month (strati-
fied as closely as possible into R1000–R2000, R2000–R3 500, and R3
500–R6000) income groups;
3. describing the stages of HIV/AIDS, ie mapping out morbidity through to
death, and its likely effect on the capacity of various population groups
(gender, income, age and so on) to hold down jobs;
4. projecting the future impact of the epidemic on the capacity of people to
repay loans, ie reflecting the effect of morbidity and death, as well as the
fact that families and communities must also bear the costs of the epi
5
FOREWORD
demic, eg the cost of anti-retrovirals, other increases in health care or op-
portunity costs and funeral costs; and
5. examining the issue of the potential for treatment to intervene in the epi-
demic, as well as the cost of this intervention (possibly indefinitely) and its
impact on the ability of the households to pay back loans.
Constitutional and legal issues
The researchers approached this aspects of their task by:
1. describing the rights as set out in the Constitution that apply to HIV/AIDS
victims;
2. interpreting the Equality Clause with respect to the specific rights to bor-
rowers;
3. describing the protocol on HIV/AIDS adopted by the Life Office’s Associa-
tion; and
4. describing all other legislation, e.g. insurance, pensions and so on that
may have implications for borrowers with HIV/AIDS.
It is hoped this volume – and the one preceding it – will help all the role play-
ers in the field of housing finance to improve their understanding of the issues
surrounding the tragic incidence of HIV/AIDS.
6
RESEARCH OBJECTIVES
This study forms part of a project aimed at assessing the impact of HIV/AIDS on
the low-income housing finance sector. It reviews the literature on the epide-
miological impact of HIV/AIDS on South Africa’s population, ad well as the con-
stitutional and legal implications arising from being an HIV/AIDS pa-
tient/borrower.
Method
The research has involved a comprehensive review of electronic databases; a
search of on-line databases and websites; a search of the titles and abstracts of
conference presentations; and a search of the bibliographies and lists of refer-
ences of articles collected. The literature review has been supplemented by
interviews or e-mail correspondence with key researchers.
‘I suppose in housing the issue hasn’t been out squarely on the table;
people aren’t dealing with it head-on … there are lots of loopholes and
problems we will be sitting on later on. It is partly because communities
have other problems … for a lot of communities we work with, aids has
not yet become a reality in daily life. And because people are dealing
with realities in a reactive way, it’s housing and job creation that they
put on the table.’
– Director of a development NGO, quoted in Lawson (1997: 34)
Standard Bank’s eviction of AIDS orphans ‘inhuman’,
says SACP
‘As the South African Communist Party (SACP) launches its Red Octo-
ber Campaign to make banks serve the people, Sowetan reports that
Standard Bank, one of the largest four banks in South Africa, is taking
action to evict orphans from their parent’s house in the Ekuhuleni town-
ship of Daveyton because they cannot pay and service the home loan
taken with the bank by their late parents. The parents of the four chil-
dren passed away last year due to HIV/AIDS-related illnesses. Given the
HIV/AIDS pandemic in our country and its particular impact on employed
workers, all financial institutions need to take measures to ensure that
credit, finance and credit insurance are available to all people living
with HIV/AIDS. Instead we have banks, insurance companies and other
financial institutions either omitting such cover or willy-nilly discriminat-
ing against people living with HIV/AIDS.’
-- http://www.woza.co.za/evictions8.htm
PART 1:
EPIDEMIOLOGICAL
ISSUES
INTRODUCTION
Housing the nation is one of the greatest challenges facing the Government
of National Unity. The extent of the challenge derives not only from the enor-
mous size of the housing backlog and the desperation and impatience of the
homeless, but stems also from the extremely complicated bureaucratic, ad-
ministrative, financial, and institutional framework inherited from the previous
government. – Department of housing (1995: 1)
South Africa faces a significant developmental challenge. Housing delivery is
a key element in the wider development framework. The 1995 white paper on
housing estimated the urban housing backlog at about 1,5 million units. The
consequences of this backlog are overcrowding, squatter settlements, land
invasions in urban areas, and poor access to services in rural areas. It adds to
the insecurities and frustrations of individuals and communities, and contrib-
utes to high levels of crime and other forms of instability. Due to the high rates
of population growth, and low rates of housing provision, the housing backlog
is estimated to increase by about 178 000 units a year (Department of hous-
ing 1995).
In addition, South Africa is currently experiencing one of the worst HIV/AIDS
epidemics in the world. General prevalence is estimated at 20 per cent, and
infections rates among the sentinel antenatal population groups continue to
rise year on year (UNAIDS 2001). Treatment options are limited due to the ex-
orbitant costs of anti-retroviral medication, as well as inadequate health de-
livery infrastructure. The prognosis is bleak, particularly for the poorest sec-
tors of the population.
South Africa’s HIV/AIDS epidemic has exacerbated its development challenges,
and presents a specific challenge to housing delivery. However, research thus
far has failed to illuminate and quantify the impact of the epidemic on housing
delivery. Furthermore, idt is not yet understood whether HIV infection adds to
the risks of lending in the low-income market.
This section of the report surveys completed and continuing research on the
epidemiological and demographic impact of HIV/AIDS on the South African
population. It also assesses the quality of the research and the data they util-
ise, and evaluates whether current data is adequate to quantify risk to lenders.
HIV/AIDS IN SOUTHERN AFRICA
HIV prevalence rates have risen to alarming levels in parts of southern Africa,
with the most recent antenatal clinic data revealing levels of more than 30 per
HOUSING FINANCE RESOURCE PROGRAMME
cent in several areas. In Swaziland, HIV prevalence among pregnant women
attending antenatal clinics in 2000 ranged from 32,2 per cent in urban areas
The high prevalence to 34,5 per cent in rural areas; in Botswana, the corresponding figures were
rates mean that even 43,9 per cent and 35,5 per cent. In the South African province of KwaZulu-
exceptional successes Natal, the figure stood at 36,2 per cent.
on the prevention front Adult prevalence is estimated at 10 per cent in 16 African countries; in sev-
will only gradually eral countries in southern Africa, at least 20 per cent are infected. Countries
reduce the human toll across the region are expanding and upgrading their responses; however, the
high prevalence rates mean that even exceptional successes on the prevention
front will only gradually reduce the human toll. It is estimated that 2,3 million
Africans died of AIDS in 2001.
UNAIDS has estimated that that one in nine South Africans (ie adults and chil-
dren) are infected, amounting to about 12 per cent of the population. How-
ever, it estimates that about 20 per cent of the adult population (people aged
15-49) are infected. Crude death rates in 2001 were also twice as high (14,7
per thousand population) than they would have been without AIDS (7,4 per
thousand population; UNAIDS 2001).
According to the US Census Bureau (2000), by the year 2010 Botswana,
South Africa, and Zimbabwe will experience population growths of –1,3 per
cent, -1,3 per cent, and -0,9 per cent respectively, instead of the 2,0, 1,0, and
1,9 per cent they would have without AIDS. This is the first time that negative
population growth has been projected for developing countries. This will be
due to high levels of HIV/AIDS coupled with relatively low fertility. In other
countries, populations will still grow despite high levels of mortality, due to
very high levels of fertility. The impact of the pandemic on child mortality is
highest in those countries that have significantly reduced child mortality due
to other causes, and where HIV prevalence is high. Many HIV-infected children
survive their first birthdays, only to die before age five. In Zimbabwe, 70 per
cent of all deaths among children younger than five are due to AIDS. In South
Africa, this percentage is 45.
12
THE CALM BEFORE THE STORM (2)
Figure 1: Predicted loss of life expectancy due to HIV/AIDS of children
born in 2000
Predicted loss in life expectancy
due to HIV/AIDS in children born in 2000
Predicted life expectancy Loss in life expectancy due to HIV/AIDS
Botswana
Zimbabwe
South Africa
Kenya
Zambia
Côte d'Ivoire
Rwanda
Mozambique
Haiti
Cambodia
0 10 20 30 40 50 60 70
Life expectancy at birth (years)
Source: U.S. Census Bureau, 2000
Since the epidemic began 20 years ago, more than 60 million people have
been infected with the virus. Sub-Saharan Africa remains the most severely
affected region. About 3,4 million new infections occurred in 2001, bringing
to 28,1 million the total number of people living with HIV/AIDS in this region.
HIV/AIDS is now the leading cause of death in sub-Saharan Africa. Worldwide,
it is the fourth biggest killer(UNAIDS 2001).
At the end of 2001 an estimated 40 million people globally were living with
HIV. Most of them do not know they carry the virus. Many millions more know
nothing about HIV, or too little to protect themselves against it. AIDS killed 2,3
million African people in 2001 alone. There were an estimated 3,4 million
new HIV infections in sub-Saharan Africa in the past year (UNAIDS 2001: 1).
Progress is being made on the treatment and care front. Botswana is begin-
ning to provide anti-retroviral drugs through its public health system, thanks
to a bigger health budget and drug price reductions negotiated with pharma-
ceutical companies (UNAIDS 2001: 16). South Africa has also taken the first
steps towards providing anti-retrovirals by offering Nevirapene to HIV-
positive pregnant women at state hospitals and clinics.
13
HOUSING FINANCE RESOURCE PROGRAMME
In the context of a public–private partnership between five research and de-
velopment pharmaceutical companies and five United Nations agencies, ac-
cess to anti-retroviral therapy in Africa is improving. At the end of 2001 more
than 10 African countries were providing anti-retroviral therapy to people
living with HIV/AIDS.
Serological COMPLETED AND CONTINUING RESEARCH ON HIV/AIDS
surveillance rests on IN SOUTH AFRICA
certain basic
The impact of HIV/AIDS is being researched by means of epidemiological sur-
requirements, such
veillances, demographic projections, and econometric projections.
as the absolute
protection of Epidemiological surveillance
confidentiality and
Background
privacy, and the
repeatability of the Since 1990, HIV prevalence data have been collected via an unlinked anony-
mous survey, conducted by the department of health, of women attending
sampling frame
state antenatal clinics (ANCs). This survey has provided the best measure of
changes in prevalence. The data are used to estimate the number of South
Africans infected with HIV.
HIV serosurveillance data are used to estimate HIV prevalence rates and the
geographic distribution of infection, monitor trends over time in specific
population groups, and identify subpopulations at increased risk of infection.
The seroprevalence survey is administered to 16 000 women at randomly
selected antenatal clinics. Blood samples are tested for both HIV and syphilis.
Data is disaggregated on the basis of age and geographical distribution.
Serological surveillance rests on certain basic requirements, such as the ab-
solute protection of confidentiality and privacy, and the repeatability of the
sampling frame. No survey system will produce a truly representative sample,
but should aim to broadly cover all sections of the population, including rural
and urban. The appropriate choice of populations will differ from country to
country, and should be guided by an assessment of scientific needs as well as
available resources and cultural and political factors. Serological surveillance
should be aimed at generating the regular analysis and dissemination of re-
sults, focusing on prevalence in young age groups as a surrogate measure of
HIV incidence, and producing data specific to each sex. Data are generally ana-
lysed by site, age, and – if applicable – sex, in an attempt to detect differentials.
Organisations such as UNAIDS and the World Health Organisation (WHO) con-
sistently praise South Africa for the quality of its surveillance data (Williams et
al 2000). However, this has a serological focus. While it is adequate for sero
14
THE CALM BEFORE THE STORM (2)
logical surveillance, it is questionable whether it can be used for reliable
demographic and econometric analysis.
35
30
25
1996
20 1997
1998
%
15 1999
2000
10
5
0
59 years), and spreads through the
the remainder. The 14–59 year age group is then further divided into four population at risk by
‘risk’ groups depending on the ease with which its members are expected to assumed infection of
contract and transmit the HIV.
non-infected individuals
Each year the new uninfected 14-year-olds are allocated to the four risk within and among
groups. Infection is introduced into the PRO risk group via 300 male and 450 groups
female infected ‘imports’ which are not added to the population but merely
used when calculating the ‘sexual activity weighted HIV prevalence’, and
hence the partners' force of transmission of HIV. The epidemic then spreads
through the population at risk by assumed infection of non-infected individu-
als within and among groups. The rate at which the infection spreads is con-
trolled by the following assumptions:
4. Those contained in the ‘contagions’ matrix, which gives the force of
transmission by an infected individual in a given risk group to members of
the other groups. This force of transmission is a function of the number of
sexual contacts a year, the number of new partners a year, and the ease of
transmission.
5. The sexual activity curve (to be found on the sex activity sheet), which is
simply an assumption of relative sexual activity according to age (sepa-
rately for males and females).
The following changes were made to the ASSA600 model.
A new starting population: The hypothetical population was replaced with
an estimate of the South African population in 1985 derived from the popula-
tion in 1970.
Fertility: The model was adjusted to allow for:
• The falling fertility of HIV-negative women over time, in line with past
trends
• the fact that HIV-positive women experience lower fertility than HIV-
negative women (except at younger ages), and that this effect increases
with age
Mortality: The base mortality table was replaced with one reflecting national
mortality circa 1985 (Dorrington 1998), and the model adapted to allow for
improving (falling) mortality over time. In addition, the mortality of HIV-
positive infants was changed from 30 per cent a year to that corresponding to
a survival curve with a median term to death of two years.
67
HOUSING FINANCE RESOURCE PROGRAMME
Migration: The model was changed to allow for net migration with specified
proportions in the risk groups (although, in the absence of any evidence, these
proportions were chosen to be the same as those of the whole).
Unfortunately, In this regard, the model reproduced fairly successfully both the pattern of
behavioural and reported AIDS cases in 1995 and the age distribution of ANC HIV prevalence for
social research is 1994–7. However, the model appears to be far less successful in tracking the
path of the epidemic in the PRO and STD risk groups, in particular with the
scant, and very
long-term prevalence being far higher than any of the surveys for other coun-
little national
tries seems to suggest. A possible explanation for this, apart from the suspect
behavioural
nature of much of the data, the very specific definition of the PRO risk group in
prevention data particular so as to comprise only 1 per cent of the population. In other words,
are available it is quite likely that the survey data represents a mixture of the risk groups as
defined in the model.
In the end, the model reproduces the estimates of the prevalence of pregnant
women fairly closely, and deviations are as likely to be due to errors and
shortcomings in the ANC surveillance estimates as to problems with the model.
As the epidemic progresses, and as behaviour change begins to be a more sig-
nificant epidemiological factor, there will be an even greater need to build
these changes into modelling efforts. Behavioural surveillance particularly
helps to explain trends within and among data sets, and data derived from
behavioural surveillance would be an important supplement to the existing
data derived from surveillance at antenatal clinics. Unfortunately, behav-
ioural and social research is scant, and very little national behavioural pre-
vention data are available. The need for such data is particularly acute in the
mature stages of the epidemic, when vectors of infection are more diffuse and
the boundaries between high and low transmission populations become less
distinct.
CONCLUSION
Given the questionable bases of these models in terms of the accuracy and re-
liability of data, their internal and external validity, and their sensitivity, the
results generated seem adequate for advocacy but inappropriate for research,
as the assumptions and the data they rely on are not empirical and not accu-
rate enough.
68
THE CALM BEFORE THE STORM (2)
APPENDIX 3: IS HIV INFECTION A DISINCENTIVE TO LOAN
REPAYMENTS?
In order to quantify the risk of HIV infection among low-income earners to
lenders, a basic question has to be asked: is HIV infection a disincentive to loan
repayment? This question cannot be answered by asking lenders or by mining
existing financial databases, which do not indicate HIV infection as a variable
for risk. This report has attempted to ascertain whether it can be answered by
using existing research and modelling practices. The answer appears to be
negative. Thus the question becomes whether existing models can be refined
to answer the research question.
ASSA is currently trying to plug existing income data into its model, without
much success. The reasons are familiar:
1. The models as they are currently calibrated cannot accommodate income
data.
2. There is a paucity of income data at a household level. There is no income
data for households affected by HIV/AIDS in South Africa
3. Income groups in South Africa are transitional and turbulent. There is a
great deal of mobility within and between income groups. No data exists
that captures the dynamic nature of income groups in South Africa, and
models which treat income as a fixed variable would invariably be inade-
quate.
4. Researchers and modellers have very little idea of the distribution of HIV
across ‘income groups’ in South Africa. Prevalence data are not corre-
lated with income, and any modelling of income as an independent vari-
able would necessarily be an educated guess (a macro simulation)
Ground zero is that there is a correlation between high rates of HIV prevalence
and poverty. Research from other countries has shown a high level of correla-
tion between poverty and HIV/AIDS. However, this research only illuminates as
much as it conceals. It is unknown for example, whether HIV infection consti-
tutes an added risk for loan default, To answer this question, we need to an-
swer a number of other questions:
1. What is the average payback period for a low-income housing loan, and is
this period shorter than the median time between infection and the onset
of severe HIV-related disease?
2. What is the profile of the progression of HIV disease among low-income
earners in South Africa?
69
HOUSING FINANCE RESOURCE PROGRAMME
3. What is the median time from infection to the onset of severe HIV-related
infection?
Such data would 4. Does the onset of AIDS-related complex (ARC) lead to loan default?
allow one to 5. What is the effect of various treatment regimes on disease progression and
accurately establish repayment?
whether HIV
6. How much risk variance is explained by HIV? There are other factors that
infection poses a contribute to the risk of loan default among low-income earners that have
significant risk of to be ‘weighted’ against HIV.
loan default among
The research void that exists cannot be spanned by creating a bricolage of
low-income earners results generated by existing models. Rather, in order to adequately answer
the research question, some fundamental groundwork needs to be done.
A significant step forward would be to collect primary detailed, time series
data, and construct a purpose-built model which could analyse changing
household structure, changing expenditure and consumption patterns, gen-
eral disease burden, employment issues, effects of treatment and behaviour
change interventions, social capital effects, and so on. Significant data sets
would include:
1. Prevalence and incidence – prevalence survey among a sample popula-
tion of low-income earners as defined by the HFRP’s definition of low-
income earners.
2. Establishing disease progression in sample population.
3. Establishing where significant increments of risk are located along this
progression.
4. Establishing variables that increase or decrease risk along this progres-
sion, such as behaviour and treatment interventions, or loss of employ-
ment.
5. Model should include appropriate disaggregators such as race, gender,
income, age, geographical distribution, household structure, etc.
Such data would allow one to accurately establish whether HIV infection poses
a significant risk of loan default among low-income earners, as well as the
significant increments of risk along the continuum of disease progression
among low-income earners. Advocacy work on the design of financial prod-
ucts appropriate to HIV-infected individuals in the low-income market would
then stand on a solid foundation.
70
THE CALM BEFORE THE STORM (2)
APPENDIX 4: PERSONS INTERVIEWED
Liesl Gerntlholtz, AIDS Law Project, University of the Witwatersrand.
011 717 8600
Cathy Albertyn, Centre for Applied Legal Studies, University of the Witwa-
tersrand. 011 403 2341
Robyn Solomon, Human Rights Commission. 011 484 8300
Dominic Liber, actuary. 011 489 5826
Prof Alan Rycroft , University of Natal, Durban. 031 260 2605
Richard Elliot, Canadian HIV/AIDS Legal Network.
Brendan Christian, Law Clinic, University of Natal, Durban. 031 260 9111
Anton Kok, Centre for Human Rights, University of Pretoria. 012 420 2878
71
HOUSING FINANCE RESOURCE PROGRAMME
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