Issues Paper No. 1

The HIV Epidemic and Development: The Unfolding of the Epidemic
by Elizabeth Reid 

TABLE OF CONTENTS

THE DEVELOPMENT IMPLICATIONS OF THE HIV EPIDEMIC
THE EPICENTRE: THE SPREAD OF THE VIRUS
THE WAVES OF CONSEQUENCES
THE CHALLENGES OF THE HIV EPIDEMIC
ACKNOWLEDGEMENTS
BIOGRAPHICAL NOTE

THE DEVELOPMENT IMPLICATIONS OF THE HIV EPIDEMIC

The HIV epidemic will pose an unprecedented challenge to communities, nations and to the international community: a challenge to human survival, human rights and human development. It is difficult to visualize the devastating effect of the HIV epidemic within our lifetimes and beyond.

The consequences of the spread of the virus will be inexorable and awesome. The challenge facing national and international communities is to act speedily and effectively to limit the further spread of the epidemic and to minimize its impact.

The impact of the HIV epidemic in developing countries must be understood in the context of the critical social and economic problems already experienced by these countries: poverty, famine and food shortage, inadequate sanitation and health care, the subordination of women and adjustment policies that allocate insufficient resources to the social sectors.

These factors create a particular vulnerability to the devastating consequences of the epidemic. Economic need and dependency lead to activities that magnify the risk of HIV transmission and mean that many people, particularly women, are powerless to protect themselves against infection. Inequitable power structures, a lack of legal protection and inadequate standards of health and nutrition all further exacerbate the spread of the virus, accelerate progression from HIV infection to AIDS, and aggravate the plight of those affected by the epidemic.

The setting of the HIV epidemic in developing countries creates a downward spiral whereby existing social, economic and human deprivation produces a particularly fertile environment for the spread of HIV and, in turn, the HIV epidemic compounds and intensifies the deprivation already experienced by people in those countries. Not only must the epidemic itself be directly addressed in programmes of assistance but its consequences will impact upon all existing development initiatives which themselves will need to be reformulated in order to encompass these new situations.

The important lessons learned from the first ten years of responding to the epidemic are that behaviour change to stop the transmission of HIV can and does occur but that it needs the support of community and an enabling and supportive legal environment. Behaviour change is a process which must essentially involve changes in community and sexual norms and values, the availability of voluntary and confidential counseling and testing services and the creation of an environment which creates the possibility of open and honest discussion of sexuality and dying.

We have also learned that for sustainable behaviour change to occur, there has to be a belief in the future, or at least a reason for hope. This, we have found, comes about when communities and individuals become involved in the care of those living with HIV. We know this care leads to compassion and caring, rich and valuable human attributes which are at the centre not only of the response to the epidemic but of human development itself. The coping strategies of communities must be central to national responses.

For there to be a future in the face of this terrifying epidemic, the infrastructure required by communities must continue to function. As we respond to the immediate needs of behaviour change and the care and support of those infected and affected, the need to maintain the physical, social and economic infrastructure of communities and nations must not be overlooked. The impact of the epidemic begins to affect this infrastructure when increasing numbers of people sicken and die.

The challenges posed by the epidemic to human well-being and development are so immense that collaborative and complementary action is essential for our assistance to be timely and effective. Our efforts must also be sustainable. Effective responses to the epidemic will be needed for many years to come and we must recognize this in the care with which we develop and coordinate our efforts.

Coordination occurs when there is mutual respect, a common vision, the exchange of experience and a shared sense that the policies and programmes established are effective and sustainable.

THE EPICENTRE: THE SPREAD OF THE VIRUS

The analysis presented here places people and their communities at the centre of the exploration of the repercussions of the spread of the virus. At the epicentre (Figure 1) of the inexorable chain of consequences is the transmission of the virus from person to person, from adult to child. We are still struggling to understand the factors which determine to where and how fast the virus spreads and who gets infected. An improved understanding of these factors will enable us to better understand how the virus moves from place to place, person to person, day to day so that we can more effectively limit its spread and anticipate its repercussions.

Inequalities of Wealth, Power and Autonomy

The first factor is inequalities of wealth, power and autonomy. The greater the disparity, the more stratified a society, the faster and further the virus spreads. Both the rich and the poor are likely to have higher infection rates.

The rich, like the powerful, are more mobile, less constrained by community norms and can afford the lifestyles they choose, which often place them at risk of infection. The poor and the powerless alike are less able to make choices about their life circumstances, more often forced into work away from home and family, or commercial sex work. Their health and nutritional levels are low and they cannot afford to use health services.

Attitudes to Women

These inequalities and stratifications are linked to the second determining factor, namely that of attitudes towards women which are demeaning or which deny women value and dignity. The indicators of these attitudes will include levels of domestic violence, physical and sexual abuse, abortion laws and practices, and whether women are listened to when they speak. For example, one study of couples who describe themselves as true equals shows that, whereas 97 per cent of conversations initiated by the husband succeeded, only 30 per cent of those begun by the women were continued.

Cultural prescriptions, myths and jokes all embody these attitudes to women, along with the popular and serious literature of communities and nations. Where women are denied dignity and respect, the virus spreads.

The type of attitudes that lead to the spread of the virus may co-exist with a quite high status for women in terms of access to education, training and employment.

Community Norms and Values

The third determining factor is community norms and values. Communities where the social construction of gender leads to quite different paradigms of masculinity and femininity have higher infection levels. Similarly, communities and families which tolerate or encourage male sexual behaviour patterns that separate sexual satisfaction from responsibility to others and which value passivity and self-effacement in women will be disproportionately highly infected.

Pathology and Immaturity of the Genital Area

The fourth determining factor of the speed and extent of spread is the pathology and immaturity of the genital area. When unprotected, penetrative intercourse takes place, the virus is much more likely to be transmitted if there are lesions, secretions, inflammation or scarification of the genital area. The existence of these conditions is related to hygiene practices, nutritional status, access to sensitive health services, cultural practices and reproductive practices. In women, transmission may also occur more easily at different stages in the hormonal cycle or if the genital area has not reached maturity, which does not usually occur until young women are in their twenties.

This factor is clearly implicated in the high infection rates in young women and probably in infection rates in uncircumcised men, and contributes significantly to the different rates of infections between developed and developing countries.

Mobility

The fifth determining factor is mobility. The patterns of spread of the virus follow the movement patterns of people: the criss-crossing of armies across countries, the transport routes, the commercially vigorous trading centres, job markets, seasonal flows for agriculture or for ceremony.

Mobile groups of people - senior civil servants, parliamentarians, teachers, students, migrant workers, pilots, truck drivers, the military and so on - have higher infection rates than others.

People Telling Their Stories

The final factor which determines the speed and extent of the spread of the virus and who gets infected is whether conditions exist for people to tell their stories, stories of being infected and stories of changing their behaviour to prevent themselves from becoming infected.

For this to happen, there must be a strong legal and ethical framework which will lessen the almost inevitable discrimination and stigma surrounding HIV infection. There must be community and family support systems. There must be supportive government policies relating to continuation in employment, in school, etc. Finally, there must be the courageous people to tell their stories, for the cost to the individuals and their families of speaking out is usually very high.

If we bear in mind these determining characteristics, we can now put some faces to the estimated 12 million adults already infected in the world today. We now know that soon there will be as many, or more, women infected as men. Many, perhaps most, will be couples, husbands and wives. Many, of not most, will be poor. Although there will be a not insignificant number of the infected among the rich and powerful, many will be in situations that take them away from their families and communities and most will come from communities which accept and even value the behaviour which puts men, women and their families at risk of sexual transmission. We can now begin to see our own faces amongst those 12 million.

THE WAVES OF CONSEQUENCES

The consequences of this spread radiate out over time and will continue to spread. Over time, various types of repercussions are becoming apparent. Their extent and nature are determined by many factors but there is a small number of dominant ones. The first wave of consequences follows directly from the spread of the virus: Those who are infected will, in time, start falling ill and dying.

The second wave of consequences arises from two dominant characteristics of the epidemic:

• those who are infected are overwhelmingly at a stage in their lives when they have the maximum number of dependents: children, parents, others living with them, others that they are supporting; and
• the virus is clustered in households and so their dependents will be left with few or no means of support.

The third wave of consequences arises from those other dominant characteristics of the epidemic:

• those who are infected are at their most economically productive and active period in their lives;

• the virus is clustered occupationally and geographically; and
• the rigidity of the gender division of labour, skills and responsibilities.

The extent and nature of the fourth wave of consequences is determined by two dominant characteristics:

• the response of communities and nations to those infected, those caring for them and those who survive after their deaths, in particular by whether or not they remain an integral part of their communities, supported and cared for by them; and
• the clustering in certain occupations and geographically.

The personal, psychological, social and economic consequences of the spread of the virus will unfold for decades after the virus has taken hold in a community and will continue to unfold for as long as the virus continues to spread.

Let us look at the overlapping waves of consequences more closely.

The first wave of impact to emerge is centered on the infected person and her or his family, partners and carers. It includes the trauma of diagnosis, community reactions (acceptance or stigma and discrimination), economic and emotional impact on their households, reaction of health care workers, illness and death. As indicated in Figure 2, those primarily affected are individuals and families, and the ways in which they are affected and the resources that they and others can bring to bear on their problems determine the policy and programme requirements.

In developing countries, most women and men are faced with the probability of their being infected when a baby or young child is clinically diagnosed with HIV. The lack of confidentiality, which is too frequent in these settings, often leads to the mother being singled out for blame. Fear and denial on the part of the father can lead to the woman's rejection and repudiation. The family may be torn apart and the women and her children left destitute and homeless. Strict confidentiality and the disclosure of the child's HIV status with counseling to both parents, not just the mother, can often protect the women and enable the family to continue as a basic nurturing and socializing unit for the children.

The immediate concern of infected women, and often men, is the future well-being of their children. Who will look after them after their deaths? Where the receiving family cannot be the extended family, many women would like to participate in the choice of an alternative form of care and help prepare their children for the future. Already at this stage, long before the children are left without parents, attention needs to be given to identifying or establishing forms of care for these children.

The second area of immediate concern is that the parents continue to be able to provide for and nurture their children for as long as possible. In one Kigali community, the women identified one nutritious meal a day and the treatment of any opportunistic infection, oral thrush, for example, which might impair their ability to look after their children.

As more and more children and adults fall ill, the demand for the treatment of opportunistic infection and for anti-virals will increase as will the demand on hospital beds. Whilst neglect of these demands may cause political unrest, addressing these demands may not be possible because of a lack of a basic health infrastructure and because of resource constraints. There is thus the need to achieve an informed and widespread consensus in the community, as well as in the health sector and among bureaucrats and politicians, on a treatment strategy.

The formal health care system will have to rationalise its role as it ceases to be able to provide institution-based care for all those with HIV-related illnesses. New modes of care management and collaborative and complimentary home and institutional-based care regimes will need to be designed. The increasing burden of care will be to a great extent borne by family and friends, but probably disproportionately by women and girls.

In this latter case, women's other roles and responsibilities, including child rearing and their productive roles, will be seriously affected if the burden of care is added to women's illness and death. Young girls may be withdrawn from schools to help care for the sick and for siblings and to keep the family together as long as possible.

As the burden of illness increases, household incomes and provisioning will be directly affected. Those unable to pay rent or repay mortgages may lose their homes. School fees and food requirements may become unaffordable. Furthermore, the use of household savings and assets in the futile search for a cure can seriously impoverish the family. There will need to be programmes of assistance to meet the basic needs for food, shelter, counseling and school fees in affected households.

The effectiveness of programmes for affected individuals, families and communities will ultimately depend on the legal, ethical and human rights milieu pre-existing or established to respond to the epidemic. Respect for the rights and dignity of those affected, guarantees of confidentiality, anti-discrimination provisions and a policy context of support and commitment that all affected people remain an integral part of their communities are sine qua non conditions for an effective response. Furthermore, without this legal framework, the affected will not speak out and tell their stories so that others may learn and change their behaviour. Such stories are amongst the most effective motivaters for behaviour change.

Often it is not until large numbers of the population are infected and many have progressed to AIDS or associated diseases such as tuberculosis that there is the possibility of a national consensus on the urgency of the matter. It is usually only at this stage that the voices of public health officials, health workers and the infected and their families finally begin to be heard.

As more adults die, the second wave of impact begins to emerge: increasing numbers of children and the elderly left without support and of single-headed households (Figure 1). For every adult dead, there could be on average two to three dependents. Thus the amplitude of this phase could be two to three times greater than the mortality rates in the previous phase. Poverty will also be spreading: households disintegrating; children scattered.

The most striking feature of this wave is the psychological impact on individuals and communities of so many lives lost, so many parents, siblings, friends, children, colleagues, neighbours dead. In young children this often induces an almost catatonic state, a withdrawal from the world of pain and despair. One story from the Kagera region in Tanzania is of a young girl sitting day after day at the edge of the yard, rocking on her heels and staring into space. Both her parents are dead, brothers and sisters, aunts and uncles. There is little food but she is not hungry. She rocks, grieving.

The grandmother takes time away from her overwhelming burden of care of all her other grandchildren to come and sit quietly beside the young girl. She knows she must gently draw her back into the land of the living or she will slowly die. The little girl has no will to eat, to go to school, to help out in the house. Unless programmes find a means of reaching out to such children, and similarly affected communities, other assistance programmes will be less than effective.

Grandmothers and grandfathers are bearing a crippling burden of care although, as the epidemic deepens, they too are increasingly numbered among the infected. The extent of homeless, destitute and traumatised children and elderly will be largely determined by the extent of caring environments that can be found or created for them.

Extended family and neighbourhood forms of care will soon become overwhelmed unless they, themselves, are supported. A recent study in Kigali, where the impact of the epidemic in creating dependent survivors has already become visible, shows that already one in every two households is caring for one or more children other than their own.

There are various different ways to provide assistance to the survivors and their communities (Figure 2): direct transfer programmes, subsidies, entitlements, credit and social services including housing, feeding and child care programmes. These must complement and support the initiatives which arise within the communities themselves. The striking feature of this epidemic is that wherever the virus spreads, individuals and communities respond. Leaders emerge, caring and coping strategies spring up and programmes are developed.

For the survivors as well as the infected, a supportive legal, ethical and human rights environment is essential if they are to be supported by their communities and if they are to be able to retain their property, inheritance and custody rights. This is particularly true for women and for orphaned children.

The third wave of impact centres around the loss of so many members of the workforce and the impact of the epidemic on household and domestic savings and on foreign exchange earnings (Figure 2). The epidemic will cause a reduction in the quantity and quality of labour available to produce output in both the formal and informal sectors and both measured and unmeasured activities. Women's labour, both productive and domestic, is disproportionately unmeasured. The loss of women's labour will threaten the living standards of households and communities as well as national productivity. Patterns of labour supply and demand will change, the determining factor being the clustering of the virus occupationally and geographically (Figure 1).

There will also be a reduction in and changing patterns of use of savings. The quantity of savings available and how this is employed influences the rate of growth of Gross National Product (GNP). Decreasing levels of savings will occur at the same time as the direct and indirect costs associated with the epidemic escalate.

Economies most vulnerable will be those that depend on a single or a limited number of sectors, agriculture alone or mining and agriculture, for example. The sectors most vulnerable will be those which require a critical number of trained personnel for whom replacements are difficult to find, pilots and mining engineers among many others, or occupations with high infection rates, transport sector workers, construction workers, senior public servants, students, for example.

The transport sector knits together producers and markets, raw materials and finished products, matches migrant labour supply to labour demand, links urban and rural economies, holds families together, enables centralised military and police control. A slow down in this sector will have extensive economic, social and political repercussions.

In the agricultural sector, farming systems which are labour intensive throughout the agricultural cycle or where labour demand peaks at certain times, as well as those with which is associated a strict gender division of labour, are most vulnerable to shortages in the labour supply. In subsistence farming systems, crop mixes are already changing, swinging away from cash crops and certain food crops to less demanding crops such as manioc. Farming systems based on the availability of wage labour, for example, plantation crops, are also vulnerable. Significant changes in patterns of production will adversely affect household nutrition and income levels as well as urban food supplies and foreign exchange earnings.

With growing numbers of women falling ill and dying, and with women being increasingly occupied with the care of the ill, women will have less time for caring for and socialising with their own children and for productive work in the fields, in self-employment or in the paid workforce.

This work is often unrecognised and undervalued. Too much of it does not appear in systems of national accounts nor is much of it included in economic measures such as GNP. It will be difficult to monitor the impact at the macro level of the loosening of these social and economic networks or parenting, providing, coping and caring. However, their absence will be widely felt. This work of women is essential for the economic and social well-being of families, communities and societies.

Increasing morbidity will eventually affect all sectors of the economy: financial institutions, education and health sectors, water and electricity supplies, industry and governance (Figure 2).

The fourth wave of impact is directly linked to the failure of previous interventions. If the spread of the virus is not slowed down as early as possible in the epidemic, and if those affected by it are not adequately supported, then the very survival of communities and nations will be in jeopardy. The survival tactics of the bands of destitute children could lead to the terrorization of populations. Strategic vulnerability will increase with the morbidity rates in the military. Basic services, water, electricity, road maintenance, financial services, will be impaired. Price increases and service decreases will lead to discontent and unrest. National governance could come to a halt. Households, communities and countries will disintegrate.

At this stage, even international interventions to prevent the total disintegration of the nation state may be too late. Such interventions will need to occur much earlier and in an intensive and systemative way.

These longer-term consequences are not inevitable. The extent and seriousness of the consequences will depend directly on the timeliness and effectiveness of behaviour and attitudinal change programmes and of policies adopted to respond to the needs of the infected, the ill and the survivors.

 The phases identified in Figure 1 are not discrete; they overlap. However, there is often a time lag before the problems associated with each stage become visible and the phase recognised. The severity of subsequent phases will depend upon the efficiency of earlier interventions. If this is not understood, competing demands on limited national resources could mean that programs for earlier phases, behaviour change programmes in particular, are not allocated sufficient resources. Furthermore, in each phase there are policy options which are best decided in advance, so that people can be educated to understand and accept them and planning for them commenced.

The proportional costs of delaying the start of an effective HIV programme are shown in Figure 3 (not available on the internet). This displays, on the right hand side, the proportional costs at year thirty of the epidemic in a particular country. The difference in levels of cost depends on the stage that the epidemic has reached before an effective programme is implemented. The cost of starting an effective programme rises with the stage of the epidemic. This is because there will be more sectors and programme components and a greater demand for services. The different levels of cost at thirty years probably differ from each other by factors of ten or more. Thus there is a disproportionate advantage in starting effective HIV programmes early.

Each phase has its own set of policy and programme requirements and these are cumulative rather than sequential. That is, as different phases of the epidemic emerge, a new set of policies and programmes will have to be developed while those for previous phases will need to be continued. Thus the demand on human and financial resources will expand rather than change over time.

Furthermore, as can be seen from Figure 2, responsibility for most of these policies and programmes will lie with sectors and ministries other than health. An early understanding of this can create a broader consensus on the need for timely expenditure on effective prevention programmes. The epidemic then ceases being the responsibility solely of Departments or Ministries of Health and begins to be a multisectoral concern. The earlier this happens, the greater the possibility of minimising the severity of subsequent phases. The most powerful intervention to minimise the impact of the epidemic is an effective programme to reduce the further spread of the virus.

Thus, an effective strategic response to the epidemic would be a phased response consisting initially in support to communities responding to the epidemic and the establishment of an appropriate ethical, legal and human rights framework. Next, the underlying socio-economic causes which determine the pattern and speed of spread need to be identified and programmes to address them established.

As communities mobilize and respond, the demand for technology and services, for voluntary testing sites, condoms, health services, sterile needles, etc., will increase and, at this stage, these should be accessible and affordable. Finally, the socio-economic consequences of the spread of the virus will need to be identified, monitored and minimised.

The spread of the virus initiates an inevitable chain of consequences which will continue for decades, for generations. The nature of these repercussions is so devastating that despair and fatalism would seem to be the only rational responses. However, this bleakness is held at bay by the extraordinary response that the epidemic evokes. Wherever the virus spreads, individuals and communities respond.

THE CHALLENGES OF THE HIV EPIDEMIC

There are a number of challenges for communities and governments (Figure 2), choices which will either minimise or aggravate later waves of impact. The first challenge will be the type of behaviour change and prevention policies adopted and the extent of resources directed to the epidemic in its early stages.

Choices made will affect the number of people infected and hence the numbers who die and the numbers of survivors. They will determine the extent of the impact. For as long as the virus continues to spread in the community, high priority will need to be given to behaviour change and attitudinal change programmes. In the economic situation of most countries, initiating new programmes requires commitment, courage and effective arguments. Cabinet members will need to be convinced of the need for adequate financing and be active participants in policy development and planning processes.

However, even if all future cases of HIV infection could be prevented from today, every year for the next twenty years approximately five per cent of those already infected will develop AIDS and die. Thus, if in a city or country half a million people are already infected, around 25,000 people will die each year for the next two decades. In countries with an already high rate of infection, the impact would be long felt.

The second challenge will be the extent to which the community response is integrated into and is complemented by the governmental response. Affected communities have already begun initiatives that respond to their own needs, build on their resources and use their networks and forms of social organization. They must be given the political and social space and resources to continue. Other players in the community response include community leaders, health professionals, traditional non-governmental organizations, employers, trade unions, religious and political bodies, youth groups, women's organizations and many more.

The most effective national strategies will be based on and give coherence to the diversity of responses arising within the community and will, in balancing, supporting and shaping these initiatives, command widespread support.

Another challenge will be whether and the extent to which governments assist the affected, that is, those infected, their families and carers and those that survive them, to remain an integral part of their communities. For this to occur, there need to be guarantees of confidentiality, protection against discrimination and repudiation, assistance to the infected to live positively and productively, respite and child care, access to health and education services, income and housing maintenance, assistance to families to stay together as long as a parent is still alive and programmes to keep survivors within the community.

Without such policies, increasing numbers of children and the elderly will be without the care and support of their families or communities. The consequent lack of socialization of these children and their isolation could lead, as numbers increase, to a dissolution of social relations and the possibility of civil unrest and lawlessness. Thus the seriousness of the long-term impact is dependent upon responses to the previous challenge.

If the choice is made to assist the infected and their survivors to remain living and cared for within their communities, it will be essential for governments to create a climate of acceptance and support for this policy. People's fears and misconceptions will need to be addressed in education programmes and every means found to lessen rejection, blame and stigma and to oppose discrimination.

A further challenge is whether and at what stage governments, the private sector and others should begin to plan to minimise the adverse social and economic impacts.

The epidemic has come to be in a world already shaped by a multitude of factors and these in their turn influence and determine its dimensions. Poor nations burdened with debt are unable to honour the basic rights of women and men to health care, education, shelter and employment. This has created a backlog of deprivation which both facilitates the spread of the virus and aggravates its consequences. The poverty of individuals, and of women and children in particular, has led to their increasing vulnerability to infection. Poverty caused by HIV-related illness and death deepens existing poverty, creates new poverty and increases indebtedness. This interrelatedness between the epidemic and the setting within which it is occurring will make government attempts to plan to minimise the adverse impact of the epidemic more difficult.

The challenges identified so far all occur at the level of households, communities and nations.

There is a further critical challenge which will occur at the global level: whether the world community will provide the direct foreign investment in human capital and technological development and in social safety nets to allow poor nations and nations rendered poor by this epidemic to survive.

The free working of the global market tends to increase the disparities between rich and poor nations. National governments try to offset such tendencies, nationally, by redistributing income through systems of progressive income tax. They also supplement this with social safety nets to prevent people from falling into absolute destitution.

No such systems operate at present at the global level. The closest the world comes to a global safety net is the current system of development assistance. But this system is fatally flawed, not only in the inadequacy of its extent but because its allocation at present is unrelated to the level of poverty.

Some examples. South Asia receives $5 per person while aid-receiving countries in the Middle East, with more than three times South Asia's per capita income, receive $55 per person. India has 34 per cent of the world's absolute poor, yet receive only 3.5 per cent of total aid flows. Indeed, the 10 countries that together have more than 70 per cent of the world's poorest people receive only 25 per cent of global aid.

If overseas aid is to be able to serve as a social safety net for the world's poor, it will have to be based on principles requiring that aid should be directed to priority concerns for human development.

The final challenge rests with us. Ultimately, our hope lies in understanding the centrality of the will to live, to stay together, to cope and survive at all levels - individuals, families, communities, nations and internationally.

If we keep quiet, if we think that this is not our problem, HIV will change the world despite us. We can make a difference. We can overcome the epidemic by speaking out, by using our influence within our families and communities. By changing our lives and our behaviour, we can create a world in which we can peacefully coexist with the virus.

ACKNOWLEDGEMENTS

An early draft of this paper was presented at the Cluster Meetings of African Ministries of Finance and Planning organized by the UNDP Regional Bureau for Africa in Lusaka, Nairobi, Abidjan and Libreville in July 1991.

BIOGRAPHICAL NOTE

Elizabeth Reid is a Senior Adviser, Bureau for Policy and Programme Support, United Nations Development Programme (UNDP), New York. Before joining UNDP, she worked closely with community groups working within the HIV epidemic in Australia and was responsible for the formulation of Australia's first National HIV/AIDS Strategy. She has extensive experience in development theory and practice, including programme design and evaluation in Africa, Asia, the Pacific, the Middle East, and Latin America and the Caribbean.

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