AmfAR's Treatment Insider Newsletter
January 2003

Many view business, and specifically large multinational industries, as a critical ally in the fight against AIDS. But the private sector has been slow to respond to the devastation AIDS is wreaking on developing nations' human and economic health. As the losses become impossible to ignore, corporations in poor countries are beginning to revitalize their efforts to prevent AIDS and make treatments more accessible.

Over 28 million people in sub-Saharan Africa have HIV, and up to 30% of adults are affected in the hardest-hit countries. Per capita growth in the region has dropped 1.2% annually and it's estimated that five countries - Botswana, Mozambique, Namibia, South Africa and Zimbabwe - will lose up to a third of their workforce by 2020. By then, according to the International Labor Organization, the population of the 29 hardest-hit African nations will be 9% smaller due to AIDS, and their workforces will be 12% smaller.

AIDS is now the paramount threat to every economic sector in Africa, targeting skilled workers in blue- and white-collar jobs, including miners, teachers, farmers and health and security workers. The most affected industries are mining and extraction, followed by agriculture, construction, tourism, transport and security. In the public sector, HIV rates in the military and police are also very high, with 50% of soldiers infected in the hardest-hit countries.

Take the case of Botswana, where nearly 40% of adults are HIV-positive and life expectancy has dropped to 37 years. A 2001 survey by the Debswana Diamond Company in Botswana found that 60% of employee deaths were due to AIDS. Almost 30% of workers who agreed to testing were HIV-positive. Rural residents who do agricultural work are also affected. Around the world, 7 million farmworkers have died of AIDS since 1985, and another 16 million will die unless they access treatment.

The Cost of Neglect
This dire picture represents only the tip of the iceberg, since no one knows the real scope of AIDS in most poor countries. HIV testing is limited in many countries and given the prevailing stigma of AIDS, many workers have avoided getting tested for fear of discrimination and job loss. Until recently, only 1% of South African firms had assessed the impact of AIDS on their companies, according to Andrew Sykes, chief executive of consulting firm NMG-Levy. In Nigeria, a recent survey from the Joint United Nations Programme on HIV/AIDS (UNAIDS) showed similar foot-dragging: AIDS was not cited as a management concern in 230 Nigerian manufacturing firms, although the epidemic is raging there.

"The truth is that businesses have not done 10% of what they could be doing," said Richard Holbrooke, head of the Global Business Coalition and former US ambassador to the United Nations. The GBC is a nonprofit group that is pushing companies to confront the epidemic. "Frankly, most of them have had their heads in the sand. Now we see that it's starting to change because it's been proven to be more cost-effective to put good AIDS programs in place."

In 2000, Debswana tallied the cost of AIDS care to be 10.7% of its payroll. A South African agency estimated in 1997 the average annual AIDS-related cost per patient to be 45,000 Rand ($9,500 at the time), but that shot up to 70,000 Rand ($15,500) in unmanaged patients. These costs take many forms, including employee absenteeism, sick days, hospital costs, days lost attending funerals of loved ones or caring for a relative, all of which results in lower productivity and the bottom line for all businesses, diminished profits. A recent study commissioned by the South African subsidiary of British Petroleum, for example, found that workers with AIDS had taken on average 27.5 more sick days than expected. Each death from AIDS equaled four days of a manager's time and resulted in 20 employees losing five days of productive time. For each worker that died, the cost of recruiting a new worker was 15% of an annual salary. Many of the dead are managers - in Zambia, for instance, over two-thirds of deaths among managers are due to AIDS. That has made it harder for companies to replace their ailing workforce.

By the early 1990s, life insurance payouts had increased sevenfold in Zimbabwe, where 60% of death claims from employees were from AIDS. There, one million people died of AIDS from 1984 to 1990.

Such figures do not factor in the impact of sickness or death on the workers' families and dependents since many workers are the primary breadwinners for extended families. Nor do they reflect the negative impact of AIDS on local buying power or the consumer market for company products.

The Cost of Intervention
"The message is beginning to get through," stated Holbrooke. "It's not just treatment, it's a comprehensive package that includes prevention and education. You end up doing the right thing morally because you take care of your workers and you also save your company money. There is that initial investment that can be costly, but in the end, it pays off."

The automotive giant DaimlerChrysler estimated that averting one new HIV infection among its employees saves the equivalent of three to four annual salaries. AngloGold, the South African gold producer, found that providing HIV drugs to its workers with AIDS would add $4 to $6 - up to 2% - to the cost of producing an ounce of gold. But if no action was taken, that cost could rise to $9 per ounce.

"It's hard to put a dollar amount on it, and it depends what element of the [AIDS workplace] program you're dealing with," said GBC staff member and South African physician Neeraj Mistry. "Companies have expressed it as a dollar amount per employee per year for all HIV-related activities. But they've also looked at the cost of not doing anything. A lot of models have shown a distinct benefit to actually providing care."

Key reasons for the shift to action are the falling prices of antiretroviral drugs and the arrival of cheaper generic HIV drugs, which result from a global pricing battle between drug companies and AIDS activists. "A lot of the pharmaceutical companies are willing to give businesses with workplace HIV programs the preferential prices and low cost prices, as well as to NGOs providing treatment for companies," reported Dr. Mistry.

Mobilizing Leadership
Holbrooke is well known in global and diplomatic circles. He is credited with almost single-handedly getting the Security Council in January 2000 to declare AIDS a national security issue, a landmark resolution.

Back in 1997, Holbrooke's friend UN Secretary General Kofi Annan, asked him to help mobilize the private sector's response to AIDS in Africa. Annan steered him to the nascent GBC, then essentially a paper organization that hosted meetings between drug companies like Merck, GlaxoSmithKline and Pfizer and several corporations active in AIDS, including Levi Strauss, MTV, Viacom, MAC Cosmetics and The Body Shop. The latter companies had pioneered corporate AIDS awareness campaigns and programs, for both their workplaces and the general public.

The GBC's ambitions have grown markedly since then. It wants to act as a central AIDS coordinating group for businesses worldwide. GBC will advise companies on formulating workplace policies and action plans, helping them seek out local AIDS resources and potential allies. Holbrooke tapped Ben Plumley to become executive director of the GBC after the 2000 UN Special Summit on AIDS. Plumley , who is on loan from UNAIDS, oversees a small staff of six in New York.

There are now 105 corporate members of the GBC. They represent a diverse group including many of Africa's biggest employers: Coca-Cola and Heineken, Exxon Mobil and British Petroleum (BP), DaimlerChrysler AG, Standard Chartered Bank, and South Africa's national electricity utility, Eskom. Appropriately, the mining and extraction companies are heavily represented, including South Africa's AngloGold, De Beers, and Debswana. The GBC also has forged ties with the Asian Business Coalition on HIV/AIDS and the Thai Business Coalition on HIV/AIDS. In India, Tata Iron and Steel, Bajaj Auto and RRR Industries are active members, while Nike is leading the push among textile companies in Thailand. There are also such communication giants as Viacom, MTV and AOL Time Warner, and most of the large brand-name pharmaceutical companies.

"Our strategy was to first look at the really big employers: mining, oil, extraction industries," explained Plumley. "Our second priority has been textile industries with large numbers of workers. Essentially you have champions of industry in every sector and you work with them - it's peer to peer advocacy." Looking ahead, he added, " I think the oil industry is now poised for a significant response. There is direct leadership by BP. They are addressing it head on, with prevention, testing and treatment, but also by looking at trucker routes and informal settlements and trying to learn some of the lessons of the mining industry."

Treatment Models
Given the magnitude of the epidemic, there is no historic precedent for what's being asked of businesses in confronting AIDS. In many ways, the challenges to the private sector are similar to those for the public sector: African countries are hobbled by weak economies and health infrastructures, low literacy rates (especially in rural areas), a lack of AIDS education and a high death toll among professionals.

Many companies have limited experience in directly providing medical services for their employees. Those with their own medical programs still need to establish or upgrade drug procurement and monitoring systems as well as train doctors, nurses and technicians in HIV care and diagnosis. Most companies have forged new private-public partnerships with community-based and government agencies to help them. But in high-impact areas, such organizations need help to develop the technical and human capacity to deliver HIV services, including testing, counseling, nutritional and home-care programs.

On the plus side, businesses have unique resources to offer the public sector and affected communities. Large beverage companies like Coca-Cola or Heineken have transport and communications systems, trucks and drivers, warehouses and even clinics. Their trucks can serve as mobile billboards for HIV education, their supply systems and warehouses can procure, store and deliver medicines to area health centers, and their bottlers can provide clean water to communities.

One of the most useful steps the GBC took recently was to set up a website listing the workplace AIDS programs of its members. "We want to see companies implementing comprehensive programs, from awareness to treatment," said Plumley. "There's no road map but there are some good models out there for others to look at. A fundamental role of the GBC is to stop companies from working in silence. Unfortunately, they're not always good at documenting things in a way that would be appropriate to the WHO or broad health community." Plumley cited Levi Strauss and Unilever for their model nondiscriminatory policies and programs.

As an advocacy group, the GBC promotes job policies that protect the rights of HIV-positive workers, urging companies not to prescreen workers for HIV and backing confidential testing. Its five-step "action plan" calls for each company to begin by doing a risk assessment of HIV's impact on its workforce, one that will identify potential hurdles to action. The second step calls for developing nondiscriminatory HIV policies that ensure employee confidentiality. After that comes teaching staff about HIV/AIDS and setting up prevention programs, including condom distribution. Voluntary counseling and testing on or off-site are next, followed by care, support and treatment for affected employees.

The thorniest questions come after that: what to do about workers who fall ill and are no longer employed? How much responsibility do companies share in caring for family members of an employee who dies?

New Corporate Programs
With many programs just commencing, no one has an overall number of total workers receiving HIV treatment in Africa or Asia. But several companies have garnered praise for model treatment programs that rely on new private-public multisector partnerships. In 2001, DaimlerChrysler paired up with the German Technical Cooperation Agency (GTZ) to offer comprehensive HIV care to some 23,000 workers and their families at three sites in South Africa. GTZ provides the technical program expertise, while Medscheme, a South African insurer, provides medical services through its "AID for AIDS" (AFA) program. Today, over 36 medical insurance providers are part of the AFA program, and other companies like Debswana and Rand Water have signed on with Medscheme. As of early 2003, over two-thirds of AFA's 12,000 patients were taking HIV medications. The average patient's age was 34 years old and 62% were women; over a third began the program with CD4 T-cell counts below 200. The results are quite promising, showing clinical benefits to patients, good adherence to therapy and a significant, sustained reduction in hospitalization costs. This is especially impressive since a majority of hospitalized patients had full-blown AIDS. Medscheme has determined that costs can be further reduced if people access the AFA services earlier.

Heineken has adopted another model, creating its own local infrastructure for treatment with help from outside experts. It teamed up with the Dutch nonprofit group PharmAccess, headed by AIDS expert Joep Lange (University of Amsterdam) to set up a drug procurement, delivery and monitoring system for medical treatment. The company flew doctors and nurses from its clinics in Africa and Asia to the Netherlands for HIV training. HIV patients are now treated on-site, and the firm has implemented a practice of "Directly Observed Therapy" or DOT, borrowed from tuberculosis therapy, to bolster adherence to treatment schedules.

Heineken is the largest employer in Rwanda. There, it has partnered with the Pangaea Global AIDS Foundation, an offshoot of the San Francisco AIDS Foundation. Since the Rwandan Heineken subsidiary also bottles Coca-Cola, a plan is brewing to establish a joint treatment project with the soft drink company, starting with two clinics in Kigali. Coca-Cola began rolling out treatment for its employees last year. For many years, it has partnered with Population Services International (PSI) to implement its AIDS prevention programs in southern Africa.

"We're in a discussion about how the partnership could work," said Eric Goosby, CEO of Pangaea. "It's about using and not recreating or duplicating any systems of care, but maximizing the systems that are there already and expanding their purview to include Coca-Cola employees and distributors."

The other critical partner is the government. In Rwanda, the government is backing a national scale-up of treatment and recently teamed up with another new player, the William J. Clinton Foundation, to get it moving.

Slow on the Uptake
Not all has been smooth on the road to treatment. Behind the scenes, the cost-benefit debates have often been fractious, and the low ground has been taken in moral debates. Plumley admits that some workplace prevention plans he's seen are sorely lacking. Coca-Cola drew the ire of activists around the world when it rolled out a phased treatment plan that offered HIV drugs to 1,600 corporate employees in Africa but not 58,000 workers at 40 independent Coca-Cola bottling plants across Africa. The US-based activist group Health GAP launched a media campaign calling for a boycott and staged a colorful protest at the International AIDS Conference in Barcelona last July.

Stung, Coca-Cola revised its plan. Last September, it announced a cost-sharing scheme with bottlers to subsidize 90% of treatment costs for the bottling plant employees and their families. PharmAccess was contracted to roll out the treatment program, and a US nonprofit organization, Family Health International, agreed to provide prevention services. GlaxoSmithKline is also contributing to the effort.

Months later, Health GAP spokesperson Sharonann Lynch complained that Coca-Cola was moving too slowly. "Nothing's really happened since the announcement," she charged. "No workers have gotten treatment." On March 31, Coca-Cola released a statement saying that its HIV treatment program had enrolled all 40 bottlers. But the company did not provide any hard numbers for workers who have actually started therapy. Although PharmAccess chair Joep Lange said that he is pleased with Coca-Cola's progress, Lynch promised that Health GAP will increase the pressure "to make sure Coke delivers on its promise to workers."

A different problem surfaced for Anglo American, owner of De Beers: national politics. South Africa's government is led by President Thabo Mbeki, an AIDS denialist who opposes treatment for HIV. Under pressure, DeBeers initially put an HIV treatment feasibility project on hold, angering workers, unions and activists. Last fall, DeBeers finally rolled out an AIDS care plan that provides 90% coverage of HIV drugs for its 90,000 workers.

In another step forward, South African giant Gold Fields Limited (GFI) announced on April 3 that it will extend its existing Wellness Management Programme to include HIV treatment for all employees with AIDS. This will be rolled out through pilot projects at all its sites. Gold Fields previously provided workers with voluntary counseling and testing services for HIV, drugs on a limited basis to prevent mother to child transmission (MTCT) of HIV, and as post-exposure prophylaxis to rape victims and employees with occupational exposure to HIV.

New Challenges
With so many players, funds and programs materializing, how many workers will access treatment? Only a fraction, based on initial results. It's proving difficult to change human behavior overnight. In Botswana, a national treatment program is underway with support from the Bill & Melinda Gates Foundation and participation by Debswana. But few workers are taking advantage of the new accessibility. The same thing is occurring at other pilot company programs, said Dr. Goosby.

"The concern at the moment is that employees are not taking advantage of the services," admitted Plumley, who recently visited Botswana. "Take-up of these services is very, very slow. Time and again, it's, 'If I come forward, I'll be sacked.'" Stigma is also the reason why many employees said they would prefer to see their own physicians and be referred to off-site clinics.

Hard-hit Ghana offers another example. Management at the Accra Brewery just decided to prescreen all job candidates for HIV and test all employees. The company said it will not discriminate against HIV-positive workers and will maintain confidentiality of test results. But it will not employ anyone who tests positive.

"I have been humbled by the degree to which people are afraid to reveal themselves even to people who love them," said Dr. Goosby. "You have a situation where people are getting physically attacked and beaten by people they have known their whole lives. It's a level of disincentive to revealing your status that is much higher than in other places. I honestly believe the stigma will only be addressed after a critical percentage of people known to the community are demonstrating the benefits of antiretroviral care - that's when it will diminish."

"The most important thing is for companies to make it absolutely clear that people who come forward for testing and accessing services for HIV aren't going to be discriminated against," said Plumley. Toward that end, the GBC is hosting a meeting of business experts this year, and hopes to produce a consensus "code of conduct" for industries. It's also recruiting in Asia, and looking next at Eastern Europe. For their part, Health GAP activists are eyeing the oil and textile industries. "I don't think we can underestimate the contribution that the private sector has to offer," summed up Plumley. "This is the first occasion where we're making some kind of change. Our job is to keep building that momentum and take it up to the next level."