key: cord-0702233-dcdc6sqi
authors: Kimball, AM; Thant, Myo
title: “What, me worry?” Businesses and AIDS at Davos
date: 2005-04-05
journal: Lancet
DOI: 10.1016/s0140-6736(05)74792-9
sha: d5208380a201891499a679b310f2dc33b7229781
doc_id: 702233
cord_uid: dcdc6sqi

nan

At the Davos Summit in February, 2005, the World Economic Forum released its current survey on businesses and HIV/AIDS. 1 In 1996, we outlined the case for business in Asia to play a pivotal role in preventing the epidemic. 2 At that time, an estimated 3 million people in Asia had been infected with HIV. Today that number is estimated at 8·2 million. 3 AIDS is a preventable disease. The survey finds an absence of alarm in the business sector which, if true, bodes poorly for success in controlling this epidemic.

Beyond the tragic human costs, the economic and financial tolls of this epidemic are well known. Costs to employers include: increased insurance premiums, larger expenditure on welfare benefits, decline in productivity, and increases in hiring and training costs. Loss of skill base, institutional knowledge, and potential conflict in the workplace because of stigmatisation are more difficult to measure. At the macro level, the business environment, including markets and disposable income of consumers, savings rates, interest rates, and general education of the labour force, are put at risk.

The findings in the survey from 8000 firms worldwide are a subset of global business surveyed annually by the World Economic Forum. Firms appear less concerned this year than last year. This lack of concern is accompanied by conjecture rather than science as a basis for decision-making. Informal policies prevail except in high-prevalence areas such as sub-Saharan Africa. Why such complacency? The global epidemic has shown its inexorable nature in community after "What, me worry?" Businesses and AIDS at Davos pregnancy to any antiasthmatic drug), there is still much be learned. This need for information is particularly the case for systemic glucocorticosteroids 6 and for recently introduced medications, such as salmeterol, formoterol, and leucotriene-receptor antagonists. One negative point is that, when systemic glucocorticosteroids are administered during the first trimester, the risk of an orofacial cleft is increased by about 3, although the power of the studies is poor and many confounding factors persist. One positive point is that more than 11000 women have been exposed to inhaled corticosteroids (mostly beclomethasone and budesonide) during pregnancy with no increase of outcomes in the infant (including congenital malformations). 2 The higher reported risk of hypertension and pre-eclampsia in steroid-treated pregnant women is not related to the drugs but to uncontrolled asthma. 8 Thus, because many clinical trials on inhaled corticosteroids have shown efficacy in pregnant asthmatic women in terms of symptoms, lung function, and reduction of asthma exacerbations, maintaining asthma control during pregnancy is the goal; and, when the indication is clear (eg, severe asthma exacerbation), the benefit of systemic glucocorticosteroids is far greater than the risk.

The main message of the update 2 is that it is safer for the asthmatic pregnant woman to be treated with asthma drugs than to suffer from asthma symptoms and exacerbations, and that obstetricians and asthma-care providers should work together. Guidelines for asthma during pregnancy should not differ from the guidelines for all asthmatic patients, but fetal toxicity should be monitored and an evidence-based search for drug treatment should be continued. community, country after country; will it now be business after business? In Asia, the prospective new epicentre of the epidemic, the efforts of the Thailand Business Coalition on AIDS and the Tata Group in India highlight roles business can play: prevention and education for workers; workplace programmes to prevent discrimination; and public-private collaboration and funding for effective programmes. The Thailand Business Coalition on AIDS offers a range of tools for businesses to assure good-quality programming at all organisational levels. The Tata group has focused on a full range of workplace programmes to ensure the sexual health of their employees, including an emphasis on nondiscrimination. Leadership at the top of firms, coupled with government commitment, is key.

The most populous countries in the global community, China and India, are now in the cross-hairs. Projections for India are alarming: 20-25 million people living with HIV by 2010, and a potential of 50 million cases by 2015. 4 The epidemic is driven by commercial sex-work, and clients include businessmen who could benefit from education programmes in the workplace. There are peer-to-peer strategies that are effective in condom promotion. 5 Thai experience suggests that also addressing the clients ensures success. Workplace programmes to secure the safety of the workforce would be a valuable contribution at this critical time.

Many economies are rural in Asia; the effects of HIV on the household level are profound. 6 The health infrastructure in China is crumbling, 7 especially in rural areas, even as market reforms have created unprecedented economic growth. The business sector in China should lead the reinvigoration of preventive and health services. The March 18 Summit of the Business Coalition on AIDS, in Beijing, was a perfect launch. 8 The expansion of access to antiretroviral treatment in Asia will not be a panacea. US experience shows that the reprieve from HIV is not forever, efficacy is not 100%, and people living with HIV face many obstacles in returning to work. 9 From a business perspective, proactive prevention coupled with compassionate policies in the workplace and coverage of treatment through insurance is the wisest choice.

There is a gulf between the public and private sectors that must be bridged in the fight against AIDS and other emerging infections. The urgency of robust public-private partnering is clear in the Asia-Pacific region, where the threat of new human infections, such as severe acute respiratory syndrome and avian influenza, challenge systems that have not received adequate investment to scale-up to successfully meet these new threats. The economics of intervention by the private sector are not always self-evident. Much depends on the ability of the public sector to induce private firms to act for the common good. Market incentives, such as tax breaks and subsidies, can lower the cost of training and help businesses provide information and education for workers. The reduction in duties and taxes on imports of equipment and reagents could reduce drug costs. The cornerstone of partnership is for each sector to understand the needs and motivations of the other.

The World Economic Forum's survey is a pioneering work in progress. The kind of information it is positioning itself to capture is very important in the fight against the HIV epidemic. Business has brought innovation, energy, and investment in creating value in economies across the globe. The ongoing struggle against HIV and other emergent infections requires no less.

In South Africa, where less than 3% of people who need antiretroviral treatment actually get it, 1 private-sector companies are stepping in to fill the need. A growing number are supplying such drugs directly to employees who are HIV-positive or are facilitating access to drugs via third parties such as non-governmental organisations. While businesses in the rest of the world are becoming less concerned about AIDS, the contradictory trend in South Africa is being driven, on the face of it, by two imperatives. The first is heightened social awareness in the postapartheid society. The second is more bankable: an often-compelling economic argument.

Behind these two driving factors, however, lies the darker reality of the South African Government's slow and reluctant concession that it needed to intervene with drugs in the country's AIDS crisis, and its underperformance in rolling-out treatment with antiretrovirals since being pressed into doing so by, among other things, court rulings. This is where, increasingly, private companies are stepping in. "The corporate sector is shouldering more responsibility for the health of its workforce than it ever has in the past", says Bernie Clark of the health-care consulting team of Alexander Forbes, a firm that advises businesses on employee benefits and has helped several companies to develop AIDS policies (Clark B, Alexander Forbes, Johannesburg, South Africa, personal communication). About AIDS, specifically, Clark adds: "The perception is that the state is doing precious little to assist the formal work sector to stay at work."

So the lesson is that necessity is the mother of drugs' provision. The unadorned bottom-line is that it is cheaper for a firm to supply antiretrovirals than to have an untreated AIDS patients die while on the payroll. The bottom-line is especially true when the prevalence of HIV positivity runs as high as 30% 2 -as it does in many of South Africa's mining companies which, not surprisingly, have pioneered inhouse AIDS treatment.

For the same reasons of prevalence and financial reckoning, it may be that South African firms are presently leading where others elsewhere in the world will in time follow. A leading example of AIDS management in Asia is Thailand, where strong political backing for awareness and prevention campaigns has held the infection rate to 1·5% 3 -compared with South Africa's 22%. 4 In Thailand, the Thailand Business Coalition on AIDS has spawned its own umbrella organisation in the Asian Business Coalition on AIDS. The coalitions' activities, though, are limited to education and prophylaxis, and do not include inhouse treatment. 5 The most recent survey of the World Economic Forum's Global Health Initiative 6 shows that awareness by business that AIDS will affect operations and profits reflects the level of efforts to combat the disease. South African business leaders are well ahead of the rest of the world at 72% awareness; south and south-east Asia, where the Thai and Asian coalitions are active, lags at 37%. Then the levels fall off even more dramatically: in east Asia, where, in China, one of the most worrying prevalences is developing, awareness is at a low 21%, as it is in Latin America. 6 The Global Health Initiative worked with several South African firms to organise case studies, which vividly illustrate the imperatives and benefits for companies offering antiretrovirals to their employees. Gold Fields, for example, a mining house with 48 000 mainly low-skilled workers in South Africa, calculated that-with one in three of its miners HIV positive-failure to intervene would lead to losses of up to 10% of 2002 earnings by the year 2006.

We declare that we have no conflict of interest.

Global business surveybusiness and AIDS: commitment and action? World Economic Forum

A role for business in HIV/AIDS in Asia

Fact sheet: Asia

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The economic burden of illness for households in developing countries: a review of studies focusing on malaria, tuberculosis, and human immunodeficiency virus/acquired immunodeficiency syndrome

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Ministry of Health and Global Business Coalition on HIV/AIDS joint summit on business and AIDS in China

Perceived barriers to employment among persons living with HIV/AIDS