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DOCUMENT 5: INCLUDING HIV/AIDS IN CONSULTANTS' TERMS OF REFERENCE

Guidelines for Consultants

The Commission of the European Communities is concerned about the potential impact of the HIV/AIDS epidemic on the developing world. It was one of the first donors to recognise the potential impact of the epidemic and to see it as a development issue. The CEC has developed an AIDS Policy (Communication from the Commission to the Council and the European Parliament, AIDS Policy of the Community and the Member States in the Developing World, COM (93) 479, final Brussels, 7 January 1994.). The four strategic priorities identified are to:

The policy recognises the link between the epidemic and development, and that this is a circular process, with development affecting the epidemic and the epidemic affecting development. It is therefore appropriate that consultants should consider HIV/AIDS, where relevant, and these guidelines are designed to show where and how this should be done.

1. What is HIV/AIDS, and Why Does It Need Special Attention?

It is important to begin by explaining why this disease is given special consideration. It has been argued that other diseases such as malaria kill more people, and that, anyway HIV is a health problem. Unfortunately this is not the case. HIV/AIDS is unique because of:

1.1 The Location of the Epidemic.By this is meant the age groups affected. There are two groups who bear the brunt of the disease: the first are infants, who make up about 10% of cases. They are infected in the womb; during birth; or through breast-feeding. Most die before their fifth birthdays. The second group are young adults (25 to 45), who account for virtually all the other cases. Women are likely to be infected and fall ill at a slightly younger age. AIDS is unique, as most other diseases predominantly affect the young or the elderly.

1.2 The Prognosis.The prognosis for people infected with HIV is bleak. Infected adults can expect to have a number of healthy years (during which they will not know they are infected unless they have been tested). They will then experience periods of sickness increasing in severity, duration and frequency until they die. With most other diseases there is, at least, the possibility that the individual will recover.

1.3 The Magnitude. HIV is also different in scale. Data from some African urban locations show that up to 30 percent of the female childbearing adult population is infected. It is possible that, with time, similar levels of infection may be seen in rural Africa and parts of Asia. The result will be a significant increase in mortality rates and an erosion of development indicators such as infant mortality and life expectancy. The epidemic is of a different order of magnitude in the developed world, where it is either under control and declining, or spreading only very slowly. This is hardly surprising as HIV, like most infectious diseases, spreads most rapidly in situations of poverty and deprivation.

1.4 The Transmission Mechanisms. The most common mechanism of transmission is sexual (70-80 % of global infections, and most of these are heterosexual). Mother to child infections account for 10 % of infections, and the balance are through blood and blood products (including intravenous drug abuse).

1.5 The Incubation Period. Although the disease is fatal it is characterised by a long latent period in adults. This may average about 10 years but can vary greatly. African experience suggests that in poorer populations the period is shorter (6-8 years). During this time the individual is infected and infective, but can work and function in society. Early and appropriate treatment of symptoms can extend the period of healthy life.

1.6 The Novelty. Perhaps the most important point about this disease is that it is new. The first cases of the disease were identified in the USA in 1981, but it was not until 1984 that the causal virus was identified. HIV first spread in Africa in the 1980s, and today it continues to spread there and in many parts of Asia. In no developing nation has the HIV epidemic peaked, and the long incubation period means that the number of AIDS cases, with the associated morbidity and mortality, will continue to grow even after the levels of infection have reached a plateau. This further means that we have no examples to show us what the possible effect of the epidemic might be, as nowhere has it run its course.

2. Why Consider HIV/AIDS in Planning?

The reasons why the issue of HIV/AIDS should be considered in planning of development assistance are:
(i)The viability of projects may be jeopardised by the disease and the morbidity and mortality arising from it. For example a school expansion programme would need to consider the change in the number of school-going children (both because of increased infant mortality and decreased fertility rates); the increase in mortality among education staff; and the special needs of growing numbers of orphans and children from affected households.
(ii)Projects may, unwittingly, facilitate the spread of HIV or create conditions in which it is spread. This has been documented as having occurred in a number of road construction programmes in Africa. Where road are being constructed in remote areas the contractors will frequently establish camps to house their staff (who are usually male and unaccompanied). These workers will have disposable incomes which will allow them to procure alcohol and women. Thus they may be a factor in spreading STIs and HIV.
(iii)Awareness of the potential impact can be a powerful advocacy tool in motivating policy- makers and politicians to develop and support prevention activities; and
(iv)Planning can mitigate the impact of the disease.

3. The Role of the Consultants

Consultants typically have the following roles:

The methodology for preparing projects in the EC is set out in the Project Cycle Management Manual: Integrated Approach and Logical Framework (Commission of the European Communities, Directorate General for Development, Evaluation Unit, Brussels, No. 1 February 1993). In terms of these procedures, consultants can most often expect to be involved in the identification and formulation phases of the project cycle. The logical framework formulation provides for a problem analysis at the beginning of the process; consideration of assumptions, factors that are important for the success of the project, but lie outside its scope; and a sustainability check. HIV/AIDS should be considered here in most instances.

4. Putting HIV/AIDS into Consultancy Reports

HIV/AIDS will not be an issue for all consultancies or projects. This section outlines the techniques for assessing if it is, and what can be done about it. A decision tree is shown on Figure 1 and can be cross-referenced to this section.

4.1 Is HIV/AIDS a National or Regional Issue?

If reported HIV prevalence is very low nationally (<3%), or low in at-risk groups (<5% in truckers, commercial sex workers and military), and there has been no significant increase over the past few years, then HIV/AIDS is not an issue, unless the project involves large-scale international movement of people or relates directly to high-risk groups. The consultant should begin by establishing the HIV/AIDS situation in the project area to ascertain if it is an issue of concern. Sources of data include:

If more than 3% of a low-risk population (women attending ante-natal clinics for example) are HIV-positive, or the numbers are doubling every two years or less, then the country can be considered to have a problem with HIV. Two tools that can be used and are available as part of this toolkit are "Document 2: Assessing the National Importance of the HIV Epidemic", and, where available, the associated country profiles.

If the country does not have a serious problem there is no need to proceed further, unless the consultant or client feels that there is the potential for a problem and the data do not properly reflect this.

4.2 Is HIV/AIDS an Issue for the Sector?

HIV/AIDS is clearly not going to be an issue or need consideration in all sectors of support. For example a livestock improvement project is unlikely to be affected by HIV/AIDS, but a rural development project may need to consider it as an issue.

The consultant should establish if HIV/AIDS is an issue for the sector. This can be done by consulting "Document 3. A Sectoral Checklist" in this Toolkit (and, where relevant, the associated sectoral tools on Education, Infrastructure and Rural Development). Where HIV/AIDS is an issue for the sector it should be included in the sector plans and in the project associated with the sector.

4.3 Is HIV/AIDS an Issue Relevant to this Project?

This can be assessed by asking the following questions:
A. Is the HIV/AIDS Issue Relevant to the Project?
Does the project rely on a long-term input of skilled human capital?
Is the project operating in an area where labour is a constraint (Note: It is possible that labour is a constraint only at certain times of the year)?
Is the project dependent on overseas foreign direct investment (private capital)?
Is the project in social sectors affected by HIV/AIDS?
B. Will the project affect the HIV/AIDS epidemic?
Will there be increased mobility of the general population?
Will sub-groups be increasingly mobile during or as a result of the project (for example construction workers or truckers)?
Will some groups be disadvantaged by the project?

4.4 How Vulnerable is the Project?

A. Project Vulnerability to HIV/AIDS.
Skilled Labour.
Does the Project rely on skilled labour?
- If yes, is there a shortage of skilled labour?
- If yes, can more be trained and employed?
- If no, look at ways of changing this.

Unskilled labour.
Does the project rely on unskilled labour?
- If yes, are there constraints on labour availability?
Note this may only occur at peak agricultural times.
- If yes, can more be recruited or mechanisation be adopted?
Project Costs (Employee benefits).
Will the project have employee benefits, for example pensions, insurance, housing and health care?
- If yes, will HIV/AIDS increase these costs?
- If yes, can they be controlled or reduced?
- If no, can HIV spread be controlled or HIV+ people excluded from benefits or employment?
Project Markets.
Will the project's products be vulnerable to the HIV infection through death or loss of disposable incomes among consumers?
If yes, can alternative markets or products be developed?
Project Funding.
Is the project dependent on private sector funding that may be vulnerable to the perception of an area having a high HIV incidence?
If yes, can this be altered or the importance of private funding be reduced?
B. Project Effect on HIV/AIDS.
Mobility (Specific groups)
Will the project result in increased mobility of specific groups such as construction workers; tourists; traders; or transport workers?
If yes,
(i) can (should) this be reduced or can they be encouraged to spend less time away from home?
(ii) can they be targeted with specific prevention messages, condom promotion and STI treatment?
Mobility (General population)
Will the project result in increased mobility of the general population, e.g. for trade or pleasure? If yes,
(i) can (should) this be reduced?
(ii) can they be targeted with specific messages?
Poverty and Disadvantaged Groups
Will the project result in specific groups being disadvantaged, for example being relocated by a dam or having income-earning opportunities taken away?
If yes, can this be prevented or alternative sources of income be found?
Health I
Will the project affect the health status of the population?
If yes, will this be beneficial and can emphasis be placed on safe blood and STI treatment?
Health II
Will the project affect the access to health care in the population?
If it reduces it, can this be addressed?
If it increases it, should this alter the way and what health care is provided?
Education
Will the project affect access to any type of education?
If yes, should this change to provide emphasis on HIV/AIDS?

4.5 Implementation

Once the project is being implemented, and if it has been identified as a project where HIV/AIDS is an issue, then the following checklist should be applied where appropriate.

Should the implementing agency be made aware of the HIV/AIDS issue?

Is there provision for targeted education?

Is there provision for condom distribution?

Have attempts be made to reduce high risk mobility?

Is health care and particularly treatment of STIs being addressed?

4.6 Evaluation

Once a project has been completed the effect it had on HIV transmission might be assessed. To do this the following checklist can be applied.

Was there a change in sero-prevalence (or number of cases of sexually transmitted infections) in the project area? Can any of the change be attributed to the project?

Were any vulnerable groups specifically targeted and empowered?

Was there any education linked to the project and did it include an HIV/AIDS component?

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