AIDS amongst workers: What special factors influence the access and

adherence of workers?Lecture 5

For nurses to gain a solid understanding of the special HIV-management needs of HIV positive workers to optimize access and adherence

To equip nurses with the resources to advise employers on:◦ The value of workplace HIV management support and/or

services◦ How workplaces can best support HIV positive workers to

optimize access and adherence

Aim of lecture

1. Background on HIV management in the workplace2. The cost of untreated HIV to employers3. Models of HIV management4. Concrete recommendations that nurses can offer

workplaces5. Summary 6. Group discussion

Lecture overview

90% of HIV positive people are adults Adult HIV prevalence rate in 2008 in sub-Saharan Africa

was 5.2% All the 9 most southern African countries have adult

HIV prevalence rates of over 10% Some workplaces have higher than average HIV rates

among their workers ◦Mining, manufacturing, transport

Why do some sectors (such as mining or transport) have higher HIV rates than others (such as financial services)? Discuss.

1. Background: HIV among workers

Until recently, HIV was often not been seen as a major issue by businesses

Survey of 80 enterprises in SA: managers ranked HIV as 9th most important (out of 10 priorities) (Connelly and Rosen 2005)

Out of 860 manufacturing firms about 1/3 invest in HIV prevention (Ramachandra, Shah and Turner 2007)

Responses are improving recently (George 2006)◦ ART more affordable and available◦Maturing epidemic◦ Activist pressure, corporate culture

1. Background: Business responses to HIV

Small and medium companies do less◦ Per-employee cost for HIV assistance higher◦ Losses because of HIV muted by other pressures

Larger companies tend to do more about HIV◦ Better organized human resource departments◦ Pressure worker groups, customers, internationally◦ Partner with NGOs or government health resources◦Of 52 largest employers in South Africa, around 50% provide ART

Helping small and medium sized companies provide more HIV management for workers an important next step

1. Background: Small versus large workplaces

The provision of treatment to HIV infected employees is a response to the epidemic which more and more companies are adopting every year (George 2006)

Discussion point From a business perspective, what are some of

the costs of ‘doing nothing’ about HIV? ◦Financial costs?◦Emotional, social, other costs?

2. Cost of untreated HIV to businesses

Varies from workplace to workplace Direct costs: ◦sick leave, medical care, death benefits,

funeral costs, recruiting and retraining new employees

Indirect costs: ◦workforce strain, staff demoralization, loss of

experienced staff, sick staff are a hazard at physically demanding job sites, bad publicity

2. Cost of untreated HIV

Hard to accurately determine financial costs of HIV to all businesses

For 14 businesses that made this data available, researchers found:◦Losing employee to HIV costs the company 0.5 to

5.6 times that employees annual compensation. ◦Labour costs increased 0.6-10.8%◦Manual workers with HIV 25-30% less productive

over last two years and absent 18-50 more days(Rosen, Feeley, Connelly and Simon , 2007)

2. Costs of untreated HIV

Case study: Côte d’Ivoire Year before ART provision vs. two year period after 3,500 employees, most professional, trained 1-5 years,

annual profits: US$5.6 million Found:◦ 94% decrease in HIV-related absenteeism,◦ 81% decrease in HIV-related hospitalisations,◦ 8% decrease in new clinical cases of AIDS and◦ 58% decrease in HIV-related mortality.

Savings over $500,000, including $287,000 saved because of reduced absenteeism (Eholie, Nolan et al 2003)

2. Cost of untreated HIV

Overall, studies have suggested that, even though it is expensive to run HIV management programs, it’s generally cheaper than doing nothing at all. (George 2006)

Can keep workers healthy and productive for many years Access and adherence must be facilitated Example: Only 3.8% of suspected HIV-positive workers in

workplaces offering ART actually accessed it (Connelly and Rosen 2006)

3. Models of HIV management

Good HIV-management promotes testing, access to management and adherence

Some employers provide care themselves Team up with government or NGO Others provide medical insurance Others link workers to services (i.e. driving them) What about the companies you know? Do they

offer HIV support? How?

3. Models of HIV management

Different workplaces, different models Generally, when the employer provides the care onsite

(like at Anglo America), the most people participate When the employer is providing the health service

they generally also offer outreach, VCT, education All workplaces struggle with low access and low

adherence

3. Models of HIV management

1. Develop and publicise a workplace HIV/AIDS policy 2. Run a workplace HIV testing and counselling

program tailored for high uptake 3. Make confidentiality a priority4. Bring management onside5. Help HIV-positive employees visit the clinic and take

medicine 6. Adjust duties for HIV-positive employees when

necessary 7. Support peer educators

4. Recommendations for workplaces

1) Develop and publicise a workplace HIV/AIDS policy

Minimize worker fear of being fired or demoted

That was my worst fear... I thought I would be demoted and I thought someone would be appointed to take over my job. (CL, 58, supervisor at mine)

I think people should be told that these results will not be used in any way by decision makers in the company (CO, 38, sawmill forklift operator)

4. Recommendations for workplaces

A workplace HIV policy should include:◦An affirmation of the right of all employees to fair access to

benefits, promotions, pay and continued employment regardless of HIV status

◦A clear statement of zero tolerance for discrimination◦Directions for employees on what they can do if they have

an HIV-related complaint ◦ The right for employees to confidentiality and non-

disclosure of their status How can workplaces make sure all the workers know

about this policy? Discuss ideas.

4. Recommendations for workplaces

4. Recommendations for workplaces

2) Implement workplace VCT that employees actually use

Can’t help HIV-positive people until they know their status

Workplace VCT attracts the most people when:It is onsiteWorkers have time offResults at time of testingLearn about support if HIV-positiveExternal testing agencyVery clear that management will not be able to access

results

4. Recommendations for workplaces

3) Emphasize confidentialitySome people are afraid of tests because they

are afraid of losing their jobs. They feel an HIV positive status would threaten their position at work. They think they will be sacked or be removed from their comfortable jobs. (PE, 38, forestry estate gardener)

Confidentiality is a rightWorkplaces may have to be creative

4. Recommendations for workplaces

4) Management support Increase VCTThe company should also encourage the senior management to

take up HIV tests so that everyone knows that they are serious about this issue. (ML, 50, forestry estate sawmill operator)

Help HIV-positive people adhere to their treatmentSome departments are so busy and production oriented that one

cannot take a minute. If a supervisor does not understand they would say: “you AIDS patients you are difficult to work with” because the worker would have asked to be excused for some few moments to take the drugs (TE, 52, tea factory drying department).

4) Management support cont’d Management can help in many ways,

including:◦Setting an example by getting tested ◦Encouraging openness about HIV◦Making it clear that they do not tolerate

discrimination◦Allowing workers time off for clinic visits◦Adapting the workplace for HIV positive workers

4. Recommendations for workplaces

4. Recommendations for workplaces

5) Help HIV positive workers visit the clinic and take their medicine

The major worry is whether we will continue to be allowed to go and collect our medication. So the major worry is being able to visit the clinic (forestry estate worker).

Bring pills to workplace or provide transportation/bus fare

Allow time off to take medicineMaintain predictable hours

6) Adjust duties for HIV positive workers when necessary Most workers want to continue working normally as

long as possible ‘Reasonable accommodation’◦ Lighter work◦ Longer breaks◦ Shorter shifts◦More regular shifts

Avoid reassigning workers without consulting with them

4. Recommendations for workplaces

4. Recommendations for workplaces

7) Peer educators Many HIV-positive workers already play a peer-

educator role Those who are interested have a very helpful

perspective and could really help others

I also encourage the youths here to stay negative and live long. (MO, 35, tea factory foreman)

4. Recommendations to workplaces

7) Peer educators cont’dRight now the HIVAIDS issues are very topical. In our

compound men like to play draft, so I also go there and I find them playing draft but discussing HIV/AIDS issues. Sometimes they will be sharing wrong information, so I sometimes correct them, or just take the opportunity to give them correct information. A lot of them have that blaming attitude whereby they blame the HIV sufferer, so in such cases I just argue that no one would chose to get infected with such a deadly disease. (JA, 35, underground mine scraper machine operator)

5. Summary Millions of people will be HIV positive at their most

productive time With proper workplace support and management,

they can continue working for many years Need support with◦Workplace testing◦Workplace HIV management programs

Good workplace programmes:◦Management support is clear and strong◦ Confidentiality◦Reasonable accommodation, help accessing pills, clinic

6. Group discussion

You work as the head nurse for a forestry estate company’s onsite clinic. A couple years ago the company put up some posters about HIV and encouraged workers to get tested at your clinic. Only a few people came. Since then, nothing has happened. Now, the general manager wants to meet with you and talk about doing more to support HIV positive employees. What advice can you offer about:

1) The value of offering workplace HIV support2) How to get workers to come for HIV testing3) How to support HIV-positive workers access and

adherence to HIV management (including ART)

References Bhagwanjee, A., Petersen, I., Akintola, O., & George, G. (2008). Bridging the

gap between VCT and HIV/AIDS treatment uptake: perspectives from a mining-sector workplace in South Africa. African Journal of AIDS Research , 7 (3), 271–279.

Connelly, P., & Rosen, S. (2006). Treatment for HIV/AIDS at South Africa’s largest employers: myth and reality. S Afr Med J , 96, 128-133.

Connelly, P., & Rosen, S. (2006). Treatment for HIV/AIDS at South Africa’s largest employers: myth and reality. S Afr Med J , 96, 128-133.

Connelly, P., & Rosen, S. (2005). Will small and medium firms provide HIV/AIDS services to employees? An analysis of market demand. South Afr J Econ , 73 (Suppl 1), 613–626.

Eholie, S., Nolan, M., Gaumon, A., Mambo, J., Kouamé-Yebouet, Y., Aka-Kakou, R., et al. (2003). Antiretroviral Treatment can be Cost-saving for Industry and Life-saving for Workers: a Case Study from Côte d’Ivoire’s Private Sector. Economics of AIDS and access to HIV/AIDS care in developing countries, issues and challenges. Paris: Agence Nationale de Recherches sur le Sida.

Feeley, F., Rosen, S., & Connelly, P. (2009). The Private Sector and HIV/AIDS in Africa: Recent Developments and Implications for Policy. In E. Lule, R. Seifman, & A. David, The Changing HIV/AIDS Landscape (pp. 267 - 293). Washington, DC: The World Bank.

George, G. (2006). Workplace ART programmes: Why do companies invest in them and are they working? African Journal of AIDS Research , 5 (2), 179–188.

MoHFW Zimbabwe. (2009). Zimbabwe National HIV Estimates. Harare: Ministry of Health and Family Welfare.

Rosen, S., & Simon, J. (2003). Shifting the burden: the private sector’s response to the AIDS epidemic in Africa. Bulletin of the World Health Organization , 81, 131-137.

Rosen, S., Feeley, F., Connelly, P., & Simon, J. (2007). The private sector and HIV/AIDS in Africa: taking stock of 6 years of applied research. AIDS , 21 (Suppl 3), S 41- S51.

References

Rosen, S., Ketlhapileb, M., Sanne, I., & DeSilva, M. (2008). Differences in normal activities, job performance and symptom prevalence between patients not yet on antiretroviral therapy and patients initiating therapy in South Africa. AIDS , 22 (Suppl 1), S131-S139.

Scott, K., Campbell., C., Skovdal, M., Madanhire, C., Gregson, S. (submitted) “What can companies do to support HIV-positive workers? Recommendations for African workplaces” International Journal of Workplace Health Management

UNAIDS/WHO. (2009). Fact Sheet Sub-Saharan Africa. Retrieved September 10, 2010, from AIDS Epidemic Update 2009: http://data.unaids.org/pub/FactSheet/2009/20091124_FS_SSA_en.pdf

References