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In order to better inform the decisions that must be taken today on AIDS, it is necessary to look fearlessly into the future, however difficult that may be. Therefore the UNAIDS Secretariat, the UN Development Programme, the World Bank (two of the eight Cosponsor agencies of the UNAIDS Programme), the African Development Bank and the Economic Commission for Africa have jointly initiated this project. It draws on the extensive expertise in scenario building of the Global Business Environment team at Shell International, and has received funding support from a number of governments, foundations and businesses.
A scenario is a story that describes a possible future. It identifies some significant events, the main actors and their motivations, and it conveys how the world functions. Building and using scenarios can help people explore what the future might look like and the likely challenges of living in it.
Ressources:
UNAIDS (2005): AIDS in Africa. Three Scenarios to 2025 (Executive Summary)
UNAIDS (2005): AIDS in Africa: Three Scenarios to 2025 (Full Report)
The Scenarios:
Tough Choices scenario
What is the gist?
‘Tough choices’ tells a story in which African leaders choose to take tough measures that reduce the spread of HIV in the long term, even if it means difficulties in the short term. This scenario shows that, even with fluctuating aid, economic uncertainty, and governance challenges, collectively, Africa can lay the foundation for future growth and development, and reduce the incidence of HIV.
In ‘Tough choices’, the AIDS epidemic is seen as part of the crisis of underdevelopment and actions are taken by each nation—in the context of limited domestic resources and stagnant overseas development assistance flows—to tackle underdevelopment and to find development models that suit their particular needs and environment. The spread of HIV means that difficult choices come into even clearer focus. However, solutions are devised not as a response to AIDS, but with the goal of securing sustained, more autonomous development. Governments insist that HIV and AIDS are tackled as part of an overall, coherent strategy for national medium-term and long-term development. They impose discipline on themselves, each other, and their external partners (if they refuse to take this on themselves) and demand that action match rhetoric.
While the main HIV and AIDS programme effort in ‘Tough choices’ focuses on prevention, there is scaling up of antiretroviral therapy: from less than 5% treated at the start of the scenario to just over one third of those who need it by 2025. The trajectory of antiretroviral therapy roll-out is steadily upwards, reflecting the continued investment in health systems and training, as well as drugs manufacturing capacity within Africa.
What are the key messages?
- Tough Choices scenario shows that, when our options are limited, our decisions become even more critical and require leadership of the highest caliber.
- Tough choices shows that, despite the enormous odds, there is much that countries in Africa can do with their own strength - and particularly with their collective strength -to grow their economies, to prioritize developmental objectives, to lay the foundation for future growth and development, and to reduce the incidence and prevalence of HIV.
- This scenario reminds us that AIDS is a lightning rod for the governance challenges and the resources dilemmas that confront Africa.
- Tough Choices scenarios is about what Africa might do in its own collective strength to end the cycle of underdevelopment and AIDS, even if there is no major sustained international interest in Africa’s overall development. The scenario shows how, with scarce resources, governments and their civil society are forced to confront tough choices in improving Africa’s future. If you can’t do everything, what are the best choices to make to try and end the HIV epidemic, and Africa’s underdevelopment.
- We need do what is feasible, and do it well. If it is impossible to implement a comprehensive response, it becomes very important to tailor prevention and care strategies to the local dynamics and impacts of the epidemic.
What are some of the ‘tough choices’?
The first ‘tough choice’ is the decision to take ‘tough choices’. Leaders decide to set priorities for their countries—rather than avoiding or displacing them with externally imposed or suggested priorities. Not everything can be done at once, so choices must be made between competing priorities. It may require sacrificing some immediate economic comforts for a longer-term sustainable national development.
Those choices include weighing:
- The interests of the state as a whole versus those of individual communities, and individual rights versus the collective good. Inevitably, this includes managing dissent.
- Immediate economic growth versus longer-term investment in human capital.
- Choosing how to target resources - should the priority be to rapidly develop the skills and capacity of a minority essential for building and maintaining the functions of the state, or should most resources be spent on services for all and alleviating general poverty. - Navigating between helpful and risk-enhancing cultural traditions.
- Balancing nation-building with strong regional and pan-African alliances;
- ‘Protecting women’ versus increasing women’s freedom.
- Determining the focus of HIV and AIDS programming: ‘targeting’ versus generalized prevention; treatment for key cadres only or treatment for all.
- The needs of rural areas (including agricultural reform) versus the benefits of urbanization and industrial development.
What is the outcome?
Economic growth outstrips population growth in some regions, and donor aid is accompanied by significant levels of foreign direct investment from other African countries. There continues to be a high number of deaths in the ‘Tough choices’ scenario - though the rate begins to fall by 2015, reflecting the fact that prevention measures take time to work through the system.
Initiatives in support of children orphaned by AIDS are increased rapidly in the years to 2010 and then keep pace with population growth. Nonetheless, the number of children orphaned by AIDS almost doubles over the course of the scenario.
Overall, however, the foundations are laid for a future that is no longer blighted by AIDS. Population growth means that, even with considerable efforts in prevention, the number of people living with HIV and AIDS will continue to grow, but by 2025 numbers will fall to levels similar to what they are today and continue to fall as long-term investments in social, economic, and human capital over the two decades begin to pay off.
Traps and Legacies scenario
What is the gist?
‘Traps and legacies’ is a story of good intentions thwarted by an underlying development malaise, which remains unchanged in the quest for swift dividends. African countries integrate deeper into the global system but on very unequal terms and find themselves even more dependent than before. Foreign aid and investment declines, and economic growth slows.
The AIDS epidemic does catalyze people and institutions into responding, but they cannot make sufficient headway in the face of depleted capacity and the spillover impacts from high-prevalence to low-prevalence countries. HIV and AIDS receives very strong emphasis in the near future—but the responses are fractured and short-term. There is a proliferation of poorly coordinated local responses—which in turn wastes resources, skills, energies and institutional capacity.
AIDS is treated in isolation from its social and economic context. There is a focus on women, but little is done to change their status in society. As a result, their burden grows. Because of the emphasis on antiretroviral therapy, the overall response focuses on a medical approach: the urgent need to respond to AIDS is translated into a medical emergency. AIDS captures much of the additional money that goes to Africa between 2004 and 2010, and diverts money and capacities from other areas.
Despite the good intentions of leaders and substantial aid from international donors, a series of traps prevent all but a few nations or privileged segments of societies from escaping poverty, depredation and continued high HIV prevalence. Africa as a whole fails to escape from its more negative legacies and constraints, and AIDS deepens the traps of poverty, underdevelopment, and marginalization in a globalized world.
What are the main messages?
- sketches the dismal outcome if we divorce AIDS from its root social, economic and political causes, and address it primarily as an issue of individual behavior change, and if we allow Africa’s marginalization and underdevelopment to continue.
- suggests that there could be another 90 million new infections in Africa over the next 20 years. This is despite keeping the level of HIV services at the same level as they are at today.
- hows how cycles of depletion, from one generation to another; get successively more difficult to escape from. It shows that putting lots of money into AIDS programmes could act as a substitute for
tackling more extensive and fundamental problems.
What is the outcome ?
‘Traps and legacies’ describes how AIDS does catalyse people and institutions into a response, but they cannot make sufficient headway with depleted capacities and infrastructure. The additional burden of responding to the AIDS epidemic detracts from other development efforts—continuing underdevelopment in turn undermines the ability of many countries to get ahead of the epidemic. The scenario shows growing disunity and disintegration, diminishing capacity, ongoing ethnic and religious tensions, and wasted resources, with (initially) abundant funding supporting a growing so-called AIDS industry alongside a discourse of blame and punishment around the epidemic.
In this scenario, across the continent by 2025, HIV prevalence remains similar to today, at around 5% of the adult population, with some countries above, or below this level. The high prevalence rate translates into continuing reduced life expectancy across many countries, and an increase in the number of people living with HIV and AIDS of more than 50%. Prevention efforts are not effectively scaled up—although the level of services achieved in 2004 is maintained and expanded, it only grows at the same rate as the population.
Efforts to roll out antiretroviral therapy continue, but are impeded by a combination of underdeveloped and overwhelmed systems, and overall cost. By 2015 a little over 20% of people who need antiretroviral therapy have access to it and this figure stubbornly refuses to budge for the rest of the scenario. Care and treatment for a minority still costs an average of US$ 1.3 billion per year over the 23 years of the scenario. By 2025 this scenario is still costing US$ 4 billion per year in HIV- and AIDS-specific programme costs—just to keep service provision at the level that it is today. Because there is a failure to get ahead of the epidemic in terms of prevention, the costs continue to rise,
and this rise continues into the foreseeable future. Eventually, the antiretroviral therapy roll-out fails.
‘Traps and legacies’ offers a disturbing window on the future death toll across the continent, with the cumulative number of people dying from AIDS increasing more than fourfold, and the number of children orphaned by the epidemic continuing to rise beyond 2025.
There are some winners: enclave economies, based on Africa’s mineral wealth, and an élite who continue to live an international lifestyle. However, for most countries, demographic, social and economic effects will gradually erode capacity in high HIV prevalence countries, with profoundly negative effects for the worst-affected countries and their neighbours.
Times of Transition scenario
What is the gist ?
‘Times of transition’ is a story about the transitions and transformations that must take place in the way in which the world and Africa tackle health, development, trade, security, and international relations.
The scenario describes a mobilization of national and international civil society, which begins with treatment activists working towards the safe delivery of antiretroviral therapy, and leads to a gradual broadening of civil society concerns, skills, and engagements.
The story suggests that, if these transitions could be made in a generation, they could dramatically reduce the number of people infected with HIV. They could fundamentally alter the future course of Africa, and the world, in the twenty-first century.
There is profound recognition of the extent of interdependence in a globalized world, and this helps trigger huge paradigm shifts occurs in Africa and at the global level. The prospect of another century of conflict and impoverishment drives changes in attitudes, values, and behaviour—spearheaded by civil society as much as by state leadership.
Civil society is a central force behind many of the transitions that take place, and operates within sometimes contested, but always robust relationships with government. AIDS engenders an exceptional response, but it is not treated in isolation from its wider social and economic context. Understood to be a symptom of wider dysfunction and injustice, AIDS serves as a spur for activism in Africa and globally.
The ways in which Africa is perceived and understood change. Attitudes to Africa are transformed in an increasingly interconnected world and, within Africa, Afro-pessimism is replaced with new understandings of solidarity and citizenship. Interdependency is achieved. A series of transitions occur in the ways Africa and the world approach health, development, trade, security and international relations.
Internationally, a new global covenant, involving security and human rights agendas brought together in coherent international frameworks that encompass economics, trade, social justice, and political equality. These changing international norms are shaped by, and are more responsive to, African needs and perspectives. Within Africa, this scenario requires pan-African solidarity and high levels of regional cooperation.
Significant increases in aid and the facilitation of trade occur. There is sustained social and infrastructural investment. Fundamental changes are made in the ways donors provide aid and governments deal with it—so that it promotes sovereignty, but does not undermine national autonomy, is not inflationary, and does not promote dependency.
A strong focus on achieving more equitable gender relations proves to have massive transformative power, and catalyzes social, economic, and political reforms.
What are the main messages?
- Comprehensive and sustained AIDS response can only be achieved alongside wider developmental transformation.
- We can halt the AIDS epidemic in Africa—if we translate today’s rhetoric about international development and human rights into reality in Africa and beyond.
- Both national and international civil society will have to assume major roles in these efforts. This will require major transitions in the ways in the world, and Africa, tackle health, development, trade, security, international relations etc. Such transitions fundamentally alter the trajectory of Africa – and the world – in the 21st century.
- Just as the causes of the AIDS epidemic are complex, so are the responses. No single policy route will change the outcome of an epidemic that is so intertwined with the wider crisis of underdevelopment.
- The epidemics in Africa can be brought under control. Collectively, we have the resources and ability to prevent more than 40 million new HIV infections in Africa over the next 20 years—equal to almost the entire population of South Africa.
- Times of Transitions scenario uses HIV as a catalyst, but it is not only about HIV. Rather, it explicitly puts HIV and AIDS in a broader development context. A truly comprehensive response can only be rolled out in a genuinely developmental context.
What is the outcome?
There is a dramatic reduction in the number of people infected with HIV and a fundamentally altered future course for Africa—and the world—in the twenty-first century.
Changes in the delivery of aid, in the rules around trade, in addressing human security, and in national and international governance gradually lead to a more stable world, with benefits for the global North and South.
Aid flows to Africa double, are sustained for a generation, and help finance investments in health systems, agriculture, education, electrification, water, roads, social development, and institutional and governance capabilities.
Both the prevention and treatment components of the AIDS response are effective enough to reverse the epidemic’s growth, so that by 2015 the number of adults in need of antiretroviral therapy, for example, starts declining.
Provision of antiretroviral therapy expands dramatically. By 2012, almost half the people who need treatment are receiving it. By the end of the scenario, coverage has increased to 70%—reflecting the fact that expanding care beyond the capacity of existing health systems will be a time-consuming and painstaking process.
Although antiretroviral therapy extends the lives of many millions of people, total cumulative deaths on the continent continue to rise, leading to a steady increase in the number of children orphaned by AIDS, although the longer life-spans of parents has made a significant difference in the socialization of many children.
The number of people living with HIV and AIDS almost halves between 2003 and 2025, despite the fact that the population grows by 50%. The gender bias in infection and prevalence patterns begins to even out, though women are still slightly more adversely affected at the end of the scenario.
How much does it cost to achieve the outcomes?
Achieving this scenario requires cumulative investments of nearly US$ 200 billion, in the context of greater overall investments in health, education, infrastructure, and social development. HIV- and AIDS-specific funding is increased at an average year-on-year rate of more than 9% and spending is most rapid in the early phases, with external donors covering approximately half of the overall costs. Spending reaches US$ 10 billion per year by 2014 and remains at this level until near the end of the scenario when it begins to tail off, reflecting the fact that earlier investments are paying off.
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Fact: "Sub-Saharan Africa remains the most seriously affected region, with AIDS remaining the leading cause of death there." UNAIDS (december 2007): AIDS epidemic update.
Diskussion: Many debatable explanations and theories exist. A controversial debate is about the existence or non-existence of an african sexual behaviour linked to culture, tradition and/or religion.
Caldwell et al. believes that there is a specific african sexual system which is responsible for the HIV/AIDS epidemic:
Caldwell et al. (1989): The Social Context of AIDS in sub-Saharan Africa. Population and Development Review, Vol. 15, No 2, pp. 185-234
“This essay will argue that there is a distinct and internally coherent African system embracing sexuality, marriage, and much else, and that it is no more right or wrong, progressive or unprogressive than the western system, or, to employ Jack Goody’s (1976) term, as we will, Eurasian society.” (p. 187)
"The touchstone of the contrast between Eurasia and Africa is not male but female sexuality. A pragmatic attitude exists in Africa towards the latter, with fair degree of permissiveness toward premarital relations that are not too blatantly public, and a degree of acceptance that surreptitious extramarital relations are not the high point of sin and usually should not be severely punished.” p. 197
“Societies that do not regard most sexual relations as sinful or as central to morality and religion, and, at the most, have fairly easily evaded prohibitions even on female premarital or extramarital sex, are dominant in sub-Saharan African.” p. 222
LeBlanc et al. believes that this is nonsense:
Le Blanc, Meintel, and Pichė (1991). “The African Sexual System: Comment on Caldwell et. al.” In Population and Development Review, vol. 17, no. 3, September. pp 497-505.
“They imply that sexual promiscuity, particularly among woman, is the norm in Africa, and that the lack of ‘control’ of woman’s sexuality is the key to the AIDS epidemic in that region. It is our view that, in fact, the sexual behaviour of woman is subject to great deal of social regulation and that norms are highly variable from one African society to another. That sexuality is regulated by different moral considerations in Africa than in Europe is evident, but it is regulated and ordered socially.” p. 501
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