American Foundation for AIDS Research, December 2003
Rowena Johnston

Several large companies in Africa have drawn praise for providing HIV medications to employees who could not otherwise afford the up to $20,000 per year price tag. The most comprehensive responses have come from large enterprises, notably beverage and mining companies (see “Global AIDS—The Private Sector Starts to Take Notice” in the July 2003 Treatment Insider). In contrast, the response of smaller businesses has tended to be more modest or even nonexistent. According to a survey commissioned by the UK Department for International Development and the South African Business Coalition on HIV/AIDS, only around 5% of small businesses have a formal HIV/AIDS policy. A workshop this past June addressed the role of small and medium sized enterprises (SMEs) in reacting to the AIDS epidemic in Africa.

Harvard Asks Questions

The June meeting was part of a series convened by several schools within Harvard University, including the Center for Business and Government, the Business School, the School of Public Health, and the Harvard AIDS Institute. About 100 participants drawn from the private sector, government, donors, and non-government organizations (NGOs) gathered to discuss new ways of forming partnerships to help businesses address HIV. “The purpose of a partnership is to achieve what none of the partners alone can,” said Dr. John Ruggie of the Kennedy School of Government and the United Nations Secretary-General's Special Advisor for the Global Compact. While some large transnational firms are currently offering treatment to their employees, “this is a beginning, but not a solution,” Ruggie stated. “There is a huge untapped potential for different stakeholders to work together, each contributing their own strengths and benefiting from the unique strengths of the others.” Participants at the Durban Workshop shared examples of such partnerships while identifying significant challenges.

Dr. Andrea Knigge from the German Technical Cooperation Agency described the Daimler-Chrysler workplace program in South Africa. The program trains community practitioners to treat sexually transmitted infections and tuberculosis, and to administer antiretroviral therapy. Daimler-Chrysler has also collaborated directly with the Ministry of Education to ensure the inclusion of HIV/AIDS education programs in primary and secondary schools.

Ed Hall from the Unilever Foundation described the Thokomala Child Care program, a joint initiative of the Unilever Foundation for Education and Development and the Durban Children's Society. Thokomala is a Zulu word embodying the concepts of “warmth,” “caring,” and “well-being.” Unilever owns and supports households that become homes for children infected or affected by HIV. These homes foster a family environment, providing the love and stimulation that are often lacking in traditional orphanages. In partnership with a local Children's Society, the company purchases a house in a township, and the Children's Society then selects foster parents and matches children to the house. The Thokomala project also helps to arrange government subsidies and secure HIV/AIDS care training and counseling. Company volunteers support the projects by providing clothing and toys, birthday parties, and outings. Hall says the Unilever Foundation is trying to build a brand around Thokomala with business partners in mind. He feels that many companies would like to contribute to the orphan pandemic, but are not sure how to do so. By 2004, Thokomala will be providing care for over 100 children.

Elsa Tshatedi, from the transportation company Transnet, described their “Trucking Against AIDS” initiative. Transnet trains commercial sex workers who work along trucking routes to become peer educators, teaching them how to negotiate condom usage. Transnet also supports the education of traditional healers, who are consulted by about 70% of patients in South African hospitals. As a transportation company, Transnet is in a unique position to provide mobile services—they have a train that travels around the country to teach people how to become peer educators. When broken buses can no longer be fixed, they are donated to the community and used as mobile clinics.

These are just some examples of current interventions from big businesses. But as pointed out by Patrick Connelly of Boston University, SMEs feel less incentive to intervene, not least because there is less pressure to do so from shareholders or peer companies. More importantly, cost is a greater barrier for smaller companies than for large companies. For example, a package of HIV/AIDS services for prevention, awareness, and education may cost about 7 Rand (just under $1) per employee per month for companies with more than 4,000 employees, but rises to 33 Rand (just under $4) for companies with fewer than 100 employees. However, grouping businesses into coalitions might remedy the situation. “Business associations may provide a workable solution to this dilemma,” Connelly suggested. By bringing together a group of businesses, such associations increase the ability of each individual member to provide services. Some business associations—including ones centered on the construction, chemical, and roadway freight industries—are already piloting such a solution. But Connelly asks, “Are SMEs really the right mechanism for expanding HIV/AIDS service delivery? There may be better ways SMEs can expend their energy and resources. The jury is still out.”

Brad Mears from the Durban Chamber of Commerce is also concerned about the role SMEs might play in bringing the epidemic under control. The Chamber has about 4,000 members who represent about 10% of all businesses in Durban, and 80% of them are small businesses. He reports that small businesses are less interested in acting on the epidemic, largely because it is not viewed as an immediate threat to their operations. He, like Connelly, sees a potential solution in the formation of groups of smaller associations, which would in turn have more leverage. “These associations should be regionally or geographically based rather than sectoral,” he adds, since businesses are reluctant to share information with competitors.

In some regions of Africa, such as Uganda, the majority of people are not employed by regulated businesses, but rather in the informal sector. Dr. Dickson Opul, director of the Uganda Business Coalition on HIV/AIDS, described the working conditions in the Owino marketplace in Uganda. The approximately 45,000 vendors earn on average around thirty to fifty dollars per month, and around two-fifths of them are illiterate. Dr. Opul's organization links up market workers with service providers for the treatment of sexually transmitted diseases and opportunistic infections. NGOs also provide condoms and HIV prevention education. Although there are no workplace services, Dr. Opul suggests that loose administrative structures such as umbrella organizations—for example, the department that issues permits to sell at the market—might act as “surrogate” employee associations. “The formation of partnerships involving service providers, umbrella groups, and workers is a vital mechanism for ensuring sustainable interventions,” says Dr. Opul. He is clearly proud of the success they have had so far. “By end of year, we will have trained 5,000 peer educators.”

Partnerships: What Works, What Doesn't

One of the most persistent barriers to providing treatment in Africa is the stigmatization of HIV/AIDS. Proponents for increased access to treatment argue that stigma can only be eradicated when a critical mass of people have access. But even in companies that offer free voluntary counseling and testing as well as access to antiretrovirals, not all eligible employees take advantage of the services. In addition, companies too often work as competitors instead of collaborators in their response to the epidemic. The beer company Heineken was treating its HIV-positive employees around two years before Coca-Cola began doing so, and yet Coca-Cola never approached Heineken for advice on how to roll out its program.

Since the middle of the last century, as vestiges of colonialism in Africa were being stamped out, there was a move away from the “paternalism” of big companies that had been characteristic until then. But businesses are now being asked to step partially back into the role of taking care of their employees, and even to deal with the issue of the employees' sex lives—a situation that makes many employers uncomfortable.

If companies decide to intervene in the epidemic, they will have to come to terms with the fact that success will not come in two or three years, and will be measured in very different terms than traditional business outcomes. The good news is that many CEOs are in principle enthusiastic about initiating workplace programs. Unfortunately, they become less enthusiastic when they learn the costs of such programs.

These are problems that no single entity can face alone, which underscores the importance of public/private partnerships in dealing with HIV/AIDS. Only a tiny fraction of Africans are employed in companies that currently offer antiretrovirals and/or any kind of AIDS treatment, such as opportunistic infection prophylaxis. In order to reach the largest possible number of HIV-infected people, it will be necessary to engage national governments in a comprehensive response. Unlike businesses, government health departments are more likely to have the facilities and expertise to implement widespread and effective treatment, as well as prevention and education programs. The involvement of government is also the only way to ensure the longevity of any intervention.

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