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Division for the Advancement of Women (DAW)
World Health Organization (WHO)
Joint United Nations Programme on HIV/AIDS (UNAIDS)
13-17 November 2000
Windhoek, Namibia

Stephen Matlin and Nancy Spence

Commonwealth Secretariat
London, United Kingdom

Introduction

HIV/AIDS continues to spread rapidly: among the 33.6 million cases of people living with the virus at the end of 1999, one in six were new infections acquired during the previous 12 months and there were 2.6 million deaths (including half a million children) that year. It now causes more deaths than any other infectious disease, having overtaken TB and malaria. It is the fourth biggest killer in the world (after heart disease, stroke and respiratory diseases) and has become the single largest cause of death in Africa.¹

Across the world, there has been a changing pattern of male/female infections. Early cases in many countries were concentrated in male homosexuals and intravenous drug users, but as the epidemic has spread there has been a progressive shift towards heterosexual transmission and increasing infection rates in females. The reality today is that, globally, more women than men are now dying of HIV/AIDS, and the age patterns of infection are significantly different for the two sexes. ²

Beyond the statistics of sex-based differences in infection rates, there are profound differences in the underlying causes and consequences of HIV/AIDS infections in male and female, reflecting differences in biology, sexual behaviour, social attitudes and pressures, economic power and vulnerability.³ In many ways, the inequity that women and girls suffer as a result of HIV/AIDS serves as a barometer of their general status in society and the discrimination they encounter in all fields, including health, education and employment.

It is for these reasons that HIV/AIDS is inherently a gender-based issue and needs to be seen in this light if it is to be addressed effectively. HIV/AIDS will only be conquered when the effort to achieve gender equality is successful.

Gender analysis is crucial to understanding HIV/AIDS transmission and initiating appropriate programmes of action. Key to this is an understanding of the socially constructed aspects of male-female relations that underpin individual behaviour, as well as the gender-based rules, norms and laws governing the broader social and institutional context. Gender analysis forms the basis for the changes required to create an environment in which women and men can protect themselves and each other.

An important aspect of the effort to achieve gender equality in the relation to HIV/AIDS must be to pay close attention to the language which is used to characterise issues. All too often, the use of gendered language predetermines an attitude that blames or shames a specific group or sex and this need to be avoided:

1. Early examples reflected the perception of HIV/AIDS as a ‘gay disease’.
2. A more recent example is the use of the term ‘mother-to-child transmission (MTC)’ to characterise the vertical transmission of HIV/AIDS. This focuses attention on the mother as the immediate source of the infection, yet it is well documented that the majority of women have acquired their infection solely through a monogamous relationship with their partner. A more appropriate, gender-neutral term is ‘parent-to-child transmission (PTC)’.
3. Frequent reference is made to ‘risk behaviour’. This can be very misleading and misdirect attention. Thus, behaviour may be safe in one circumstance and risky in another - a closer and more specific analysis is needed in many cases, with the emphasis shifting to appropriate behaviour in ‘risk situations’. The characterisation of a particular ‘risk group’ tends to place the focus on them, begging the question of who they are at risk from.

HIV/AIDS and mother and child

Screening for HIV/AIDS of pregnant women attending antenatal clinics is becoming increasingly common, in part as a means of tracking the progress of the pandemic. Screening raises a number of serious human rights and ethical questions:

1. Should screening be anonymous
2. Is testing voluntary/is informed consent obtained
3. Is pre-test counselling provided
4. If results are provided to tested persons, is counselling available for those found seropositive
5. Is confidentiality of results assured
6. Should pregnancy termination be offered to seropositive women
7. Should perinatal anti-retroviral drugs be offered for mother and child to reduce risk of vertical transmission; how are the prospects of preventing perinatal transmission to the new-born balanced against the possible adverse effects of limited ARV treatment on the mother, which may include development of more resistant HIV strains
8. What advice should be given regarding breast feeding: on the one hand it may result in transmission of the virus; on the other hand bottle feeding may adversely affect the health of the infant (e.g. failure to benefit from health-promoting and immune factors in mother’s breast milk; malnutrition; diseases from unclean water supply) and seriously affect the mother and family (expense of infant feeding formulas; stigmatisation as HIV-positive).

HIV/AIDS and education

In many countries with high HIV/AIDS prevalence rates, large numbers of teachers, administrators and other educational employees are becoming infected, with substantial impacts on the supply and quality of education. In addition, the consequences for the planning, administration and management of education are expected to be profound and strategies for the organisation of the sector will require substantial re-thinking. The epidemic is likely to result not only in losses of education personnel but also in significant reductions in government funding for education, as economies decline and the direct and indirect consequences of AIDS-related sickness and death create competing priorities for the available resources.⁴

At the same time, HIV/AIDS is also causing a substantial decline in the demand for education. Numerically, there will be far fewer children needing to be educated than was originally expected (over 25 percent less in some countries):

1. Fewer children are being born as HIV/AIDS infects growing numbers of young adults;
2. Fewer children are surviving to school age as a result of: HIV infection at or following birth; poorer health and nutrition in HIV/AIDS-affected households; less successful immunisation campaigns in highly infected countries;
3. Fewer children of school age are enrolling as a result of poverty, being orphaned, or stigma of having an infected parent or other close relative;
4. Children, especially girls and orphans, are dropping out of schools in increasing numbers to take care of sick family members, or to support their families.

Overall, the available evidence indicates that HIV/AIDS is exacerbating the gender-based disparities that already exist in the education sector, which in most cases disadvantage girls in their access to quality education and disadvantage women in their employment opportunities as educators and administrators. As a result, many countries are likely to fail to meet the internationally agreed targets for gender equality in education and education for all.

Notwithstanding these unprecedented pressures, the education sector has particularly important roles to play in combating HIV/AIDS:

1. Preventing transmission: effective sexual and reproductive health education⁵ aimed at changing behaviour, built into a broader, comprehensive approach of Health Promoting Schools.
2. Mitigating the impacts: ensuring that the infected and the affected are not excluded from education, that they are given counselling and support, and that they acquire life skills that will be critical for their survival; producing an adequate supply of educated people with the skills and training needed to support themselves, their families and communities against a background where there are increasing human resource shortages due to the devastating impact of HIV/AIDS.
3. Influencing social attitudes and cultural norms acquired by young people: alongside the family, peers, religion and the media, education plays a profoundly important part in shaping socialisation.

In all of these areas, gender is a critical factor and distinctly different approaches may be required to address the separate needs of girls and boys and to enable them to adopt the beliefs, attitudes and behaviours that will not only safeguard their immediate situation but contribute to a long-term social re-orientation that ultimately secures gender equality.

As well as giving emphasis to the positive roles that schools can play in helping learners and teachers to cope with the issue of HIV/AIDS, it is important to recognise that schools do not always represent safe environments, particularly for girls. A number of aspects of the school organisation and environment need to be addressed to reduce risk:

Safe transport to and from school for female pupils and teachers

1. Safe school environments that avoid the possibility of sexual abuse or assault by other pupils, school staff, or unauthorised visitors to the school precincts
2. Prevention of sexual relationships between staff and pupils, whether resulting from abuse or exploitation or as a means of obtaining financial or academic reward
3. Children attending boarding schools may be particularly vulnerable

Schools also have important roles to play as focal points for the community. Teachers, parent-teacher associations and governing bodies often command a degree of respect and authority that can be used to advantage in mobilising community action. Local strategies need to be developed that draw on these resources and supplement them by collaborations with NGOs - including women’s organisations - and the private sector to mobilise action. This action can be used not only to support the school but also to ensure that information is disseminated widely in the community and that initiatives are taken to eliminate gender-based discrimination and inequality and create community solidarity in combating HIV/AIDS and mitigating its effects.

Similar considerations apply at the tertiary level of education. Evidence to date indicates that, in heavily affected countries, rates of HIV infection among students and staff in tertiary institutions are similar to those in the surrounding populations. This highlights the need for these institutions to be fully engaged, along with the rest of society, in combating the spread of infection and ameliorating its impact.

Tertiary institutions, and especially universities, have an ethical and intellectual responsibility to set an example by openly debating the issues and finding creative responses to the threat that is posed by HIV/AIDS. They constitute one of the essential components in developing a united and effective response to the HIV/AIDS pandemic because they have the capacity to:

1. introduce strategies to contain the spread of the disease in the higher education sector, and thereby ensure that, in the long-term, economies are neither weakened by a diminishing supply of educated, skilled and professionally qualified young people nor deprived of future leaders
2. set standards of good practice within society as a whole in terms of both the prevention of infection and the care and support of people living with HIV/AIDS
3. give leadership to government and to the community in the development of policies which are founded on human rights and an evidential basis of effectiveness and efficiency, which address the whole range of political, social, economic, legal and management implications of HIV/AIDS

Tertiary education institutions, including universities, polytechnics and specialised colleges of further education and training, have a primary duty to develop strategies to protect the lives of those in their sector who are not yet infected, and the human rights of all affected persons:

1. As with other levels of education, experience suggests that achieving behavioural change requires more than information and communication programmes and will depend on the use of media campaigns, peer counsellors and role models.
2. The safety of the environment in which staff and learners work and live, especially when away from home, needs to be examined and measures taken to reduce exposure to risk.
3. Higher education institutions have an important leadership role to play in openly acknowledging and defending the position that staff and students living with HIV/AIDS share the same rights and responsibilities as all other citizens - including their rights to choose not to disclose their status, to confidentiality in the handling of test results, and to respect for their state of health and sexual preference.
4. In guarding the security and rights of all individuals, special attention must be given to developing a gender perspective that recognises the greater vulnerability of women.

As is the case for schools, tertiary institutions represent concentrations of educated and respected citizens who can act as focal points for out-reach into the community - leading information campaigns, promoting behaviour change and galvanising action to mobilise resources from government and civil society. These institutions therefore have a crucial role to play in combating gender inequalities and discrimination in relation to those infected and affected by HIV/AIDS.

HIV/AIDS and youth

In many of the heavily affected countries, young people represent the most rapidly growing component of new HIV/AIDS infections, with girls outnumbering boys by a substantial factor. The reasons for this vulnerability include factors relating to poverty, lack of information, lack of economic and social empowerment, and lack of availability of protective methods. One of the most glaring deficiencies in many countries in the world is the complete absence of adolescent sexual and reproductive health services. Young people often find it difficult to get accurate and practical information on sexual matters from the parents, teachers or health professionals and are forced to rely on inaccurate or incomplete information circulating in peer groups.

At the 1995 International Conference on STD/AIDS in Kampala, a group of young Africans from 11 countries put forward a series of seven principles which they saw as essential for effective AIDS action:

1. Youth participation in programme planning, implementation, monitoring and evaluation
2. Provision of youth friendly services and centres where young people can access information, support and referral
3. Parental involvement in giving better communication, guidance and support to youth
4. Promotion of skills-based education about HIV/AIDS
5. Protection of girls and women against sexual abuse and exploitation and sensitisation and education of boys and men about their sexuality and behaviour
6. Establishment of networks for young people, including those living with HIV/AIDS, for prevention, protection of human rights and promotion of acceptance by society
7. More commitment and more responsible decision-making by young people themselves about their sexual behaviour and influence on peers.

Engaging youth in addressing the epidemic has become essential. With the addition of the appropriate gender-based analysis and perspective to each of the above priority areas, they provide a sound basis for a youth-centred approach to combating HIV/AIDS.

Initiatives such as the Commonwealth Youth Programme’s ‘Ambassadors for Positive Living’ have demonstrated that peer counselling, including that by young people living with HIV/AIDS, can have a power effect.

HIV/AIDS and the labour market

The rates of employment of women in the formal economy are generally lower than for men, since they are often engaged in subsistence farming as well as in their domestic and reproductive roles. However, recent data shows that women now comprise an increasing share of the world’s labour force – at least one third in all regions except North Africa and Western Europe. In addition, the informal sector is a larger source of employment for women than for men and is growing.

Becoming seropositive often has a disproportionate economic impact on women compared with men. They are more likely to lose employment in the formal sector (in fact, self-employment can have positive advantages in resilience for women who become infected) and to suffer social ostracism and expulsion from their homes. When they are forced to become the main breadwinner due to their partner becoming infected, women lacking education and skills may be forced into hazardous occupations, including sex work, that further increase their vulnerability.

Positive strategies to assist women who are affected by HIV/AIDS might include the encouragement of informal sector entrepreneurship and micro-credits, as well as community action groups and social welfare support mechanisms.

HIV/AIDS and health services

It is now widely recognised that gender-based inequalities in the treatment of women and men permeate health systems in all parts of the world and this situation is mirrored in the specific area of HIV/AIDS. Examples can be found of gender biases in women’s access to services for diagnosis, counselling and treatment; in the training of health professionals and their responses to patients; in the nature and focus of research into new drugs and treatments, including the greatly disproportionate use of men as research subjects to establish the pharmacological effects and efficacy of drugs.

Redressing these biases is not simple. Countries have been struggling for years with health sector reforms in response to a variety of external and internal forces, including structural adjustment, globalisation, economic contraction and shrinkage of state support for the social sector. In health systems that were previously fragile and are now being stretched far beyond their limits by the pandemic, the use of the meagre resources available in a cost-effective and equitable way requires a systematic and comprehensive new approach.

To look on the positive side, this very crisis in the health sector, which is demanding a major re-think about priorities, now affords the opportunity for a new approach built on principles of evidence-based treatment and services and equality of access.

The first step along this road must be the sensitisation of senior health planners, managers and service providers, to create a willing and supportive environment for the necessary reforms leading to gender equality in the health sector. Leading on from this must be action to ensure that women and girls have adequate access to sexual and reproductive health services and that there is equality in the provision of drugs for treating HIV/AIDS and opportunistic infections and of palliative care.

HIV/AIDS and the law

In many countries, women experience substantial discrimination in their legal status and treatment, compared with men. This may include diminished rights to hold, inherit or dispose of property, to participate in democratic processes, or to make decisions about marriage or about the education of their children.

HIV/AIDS is exacerbating the difficulties that women face, when they or their partner becomes HIV-positive, and may make it difficult for them to exercise their rights to their property, employment, marital status and security.

Strategies for action:

1. Urgent review is needed in each country of the legal status of women, to ensure that they have full and equal rights compared with men and that the protection of the law extends to those who become infected, orphaned or widowed as a result of HIV/AIDS.
2. Sensitisation seminars and workshops are needed for the legal profession and law enforcement officers to ensure that the legal provisions for equality are fully implemented.
3. New laws may need to be enacted that deal with specific problems raised by HIV/AIDS, such as: legal sanctions against persons knowingly infecting others; rights to confidentiality; protection of employment, sickness benefits and pension rights.
4. Review is needed of laws relating to the status of commercial sex workers and homosexuals.

HIV/AIDS in situations of conflict and internal and external displacement of populations

Surveys in a number of countries have identified groups of soldiers with seropositive rates 2-3 times those of the general population. In some conflict zones this rises to 50 times the rate. In situations of conflict, the perpetration of sexual violence by soldiers on women and girls is therefore not only a criminal act but now also poses a very serious threat to life. Moreover, even in non-violent situations and where peace-keeping troops are deployed, ‘consensual’ sex with soldiers may be engaged in by those who are hungry, dispossessed or concerned with the survival of their families and dependants.

Strategies for action:

1. Education and training for soldiers that emphasises their own vulnerability to death from HIV/AIDS and discourages a ‘culture of recklessness’ which favours unprotected intercourse with sex workers and acts of sexual violence.
2. Nationally and internationally, promote respect for human rights by soldiers, through combination of training and enforcement of severe penalties for infringements.
3. Provide training in gender, HIV/AIDS and Human Rights for key planners and decision makers involved in post-conflict stabilisation, and for national and international media representatives working in these situations.
4. Include reproductive health services as an essential component of humanitarian assistance in situations of conflict and displaced populations.

 

Inserting gender in the multi-sectoral response to HIV/AIDS

HIV/AIDS was initially seen as a medical problem. However, recognition that the disease required a more broadly based response going beyond biomedical models resulted in the establishment of UNAIDS in 1996. More recently, the UNAIDS cosponsors and other partners have initiated an International Partnership on HIV/AIDS in Africa and the World Bank has launched its strategy on Intensifying Action Against HIV/AIDS in Africa. HIV/AIDS has also become a high priority issue for many of the bilateral donors.

The concept of a multi-sectoral and expanded response to HIV/AIDS is central to current strategies for combating the epidemic:

1. The multi-sectoral approach requires that analysis, priority setting and planning take place across all sectors:
2. All sectors must commit themselves to plan and make available resources for an integrated response to the epidemic.
3. This must include plans within each sector for its own activities that will contribute to the national fight against AIDS: analysis of the factors contributing to the spread of HIV/AIDS, the impact of the disease on its workforce and products and the consequences for both the sector and the community; practical short-term and long-term interventions to protect its workers, to cope with the skills shortages that will arise and to mitigate the adverse effects on society.
4. Responses need to be coordinated between all relevant agencies and in collaboration with UNAIDS.
5. It is important to involve sectors and programmes dealing with poverty alleviation, environmental degradation, urban growth and policy. In all these areas, programmes have to deal with issues economic power imbalances, migrations, economic and social marginalisation, development of community responses, participation and capacity building for sustainability.
6. Education has an especially important role, as a key channel through which knowledge and skills essential for individual, communal and national survival can be imparted.

It is vital that, in developing and applying these multi-sectoral responses, the concept of gender is included at every stage. An understanding of the gender issues and dimensions of HIV/AIDS must be seen as central to all aspects of the analysis of causative and contributory factors and to the planning and execution of responses, whether aimed at prevention of transmission or mitigation of the impacts of the disease.

In short, gender must be ‘mainstreamed’ into the multi-sectoral response to HIV/AIDS.

The implications of this statement are profound, because gender mainstreaming calls for skills in gender-based understanding, analysis and planning; capacities to collect, collate, analyse and interpret sex-disaggregated data; governmental and organisational commitments to action to achieve gender equality; and availability of human, technical and financial resources – some or all of which may be in short supply in countries where they are needed most.

Therefore, as is the case for gender mainstreaming generally, the insertion of a gender-based approach into the multi-sectoral response to HIV/AIDS requires a systematic and comprehensive effort, involving:

1. Building capacity for training in gender-based analysis for all key professionals and workers: requiring developing and producing locally relevant training materials, training of trainers, and allocation of time and resources for training.
2. System-wide processes in each sector that will ensure that programme planning and implementation is rooted in a gender-based approach, with monitoring and evaluation built in.
3. Enhancing capacities for the collection, analysis and use of sex-disaggregated data.

Gender and HIV/AIDS: Roles for National Women’s Machineries

As lead agents for mainstreaming gender, National Women’s Machineries can play a number of key roles in supporting the national response to HIV/AIDS and in safeguarding the position of women.

4. Emphasise the need for special efforts to be made to protect women and girls exposed to the risk of HIV/AIDS.
5. Ensure that the legal, civil and human rights of those affected and infected are protected and that women have access to treatment, counselling and support on an equal footing with men.
6. Advocate for inclusion of gender analysis as an important step in developing multisectoral responses to HIV/AIDS and provide expertise in effecting this approach.
7. Encourage the collection, analysis and use of sex-disaggregated data in all sectors and at all levels.
8. Monitor the progress of HIV/AIDS in their countries, including its specific impact on women and girls.
9. Advocate for improved health education and public awareness and the adoption of all measures that will limit the transmission of the virus including safe sex (increased use of male and female condoms), monogamy and abstinence as appropriate and the use of safe blood products.
10. Liaise with and support the work of the National Commissions for HIV/AIDS in coordinating the fight against the disease across all sectors.
11. Strengthen national capacities for gender analysis and planning through improving the use of sex-disaggregated data, development of gender-sensitive indicators and creating training tools and capacities in local institutions.
12. Encourage the incorporation of systematic gender mainstreaming approaches in all sectors through the insertion of machineries and processes, such as Gender Management Systems, which ensure that continuing attention is given to gender issues in addressing HIV/AIDS.

Footnotes and references

1. Global HIV/AIDS statistics from UNAIDS, December 1999:

1999 1996

People newly infected with HIV	Total Adults Women Children <15 years	5.6 million 5 million 2.3 million 570 000	3.1 million 2.7 million --- 400 000
People living with HIV/AIDS	Total Adults Women Children <15 years	33.6 million 32.4 million 14.8 million 1.2 million	22.6 million 21.8 million 9.2 million 830 000
AIDS deaths in year	Total Adults Women Children <15 years	2.6 million 2.1 million 1.1 million 470 000	1.5 million 1.1 million 470 000 350 000
Total AIDS deaths since the beginning of the epidemic	Total Adults Women Children <15 years	16.3 million 12.7 million 6.2 million 3.6 million	6.4 million 5.0 million 2.1 million 1.4 million

Against this global background, sub-Saharan Africa is the most heavily affected region, now accounting for about 70 percent of the global disease burden, two thirds of new infections and four-fifths of HIV/AIDS-related deaths. The 21 countries with the highest HIV prevalence are all in Africa. The epidemic is most heavily concentrated in East, Central and Southern Africa, where infection rates in the sexually active population now typically exceed 15 percent, but West Africa is also beginning to show substantial increases. In Zimbabwe and Botswana, one in four adults is infected. In at least ten other African countries, prevalence rates exceed ten percent. The bulk of new HIV/AIDS infections are seen in the 15-25 age group, with females accounting for more than half of these. The next most heavily infected region is the Caribbean, where HIV rates have recently escalated dramatically, but other regions including the former Soviet Union countries and South Asia are also showing worrying trends.

Regional HIV/AIDS statistics on people living with AIDS in 1998, using 1997 population numbers: data from UNAIDS/WHO, December 1999:

Region	Adults and children living with HIV/AIDS	Adults and children newly infected with HIV/AIDS	Adult prevalence rate %	% of HIV-positive that are female %
Sub-Saharan Africa	23.3 million	3.8 million	8.0	55
North Africa & Middle East	220,000	19,000	0.13	20
South Asia & South-East Asia	6 million	1.3 million	0.69	30
East Asia & Pacific	530,000	120,000	0.068	15
Latin America	1.3 million	150,000	0.57	20
Caribbean	360,000	57,000	1.96	35
Eastern Europe & Central Asia	360,000	96,000	0.14	20
Western Europe	520,000	30,000	0.25	20
North America	920,000	44,000	0.56	20
Australia & New Zealand	12,000	500	0.1	10
TOTAL	33.6 million	5.6 million	1.1	46

1. Seventy to eighty percent of transmission of HIV occurs as a result of sexual (predominantly heterosexual) intercourse. A further five to ten percent is a result of parent to child transmission, 5-10% as a result of injecting drug use and sharing of needles and equipment, and up to 5% as a result of contaminated blood given during transfusions.

Of the 33.6 million people living with HIV/AIDS at the end of 1999, 46% were women; 50% of the new 16,000 infections/day were female; half of the 12.7 million people who died of AIDS since the beginning of the epidemic were women; 52% of the 2.1 million adults who died from the disease in 1999 were women. In sub-Saharan Africa, women now account for 55% of those living with HIV/AIDS, and the ratio of female/male infections in younger age groups reaches 16:1 in some places.

3. Women’s vulnerability to HIV/AIDS is greater than men’s because:

1. Women are more susceptible to HIV infection on each sexual encounter because of the biological nature of the process and the vulnerability of the reproductive tract tissues to the virus, especially in young women. Men’s and women’s risks of acquiring HIV escalate in the presence of Sexually Transmitted Infections (STIs). STIs in women are less noticed and often go undiagnosed. The stigma of STIs in women also presents a barrier that discourages them from accessing adequate treatment.
2. Cultural, social and economic pressures make women more likely to contract HIV infection than men. Women are often less able to negotiate for safer sex due to factors such as their lower status, economic dependence and fear of violence.
3. There is a large difference in attitudes towards men’s and women’s sexuality before or outside marriage. Promiscuity in men is often condoned and sometimes encouraged, while it is usually frowned upon in women. One of the consequences of this gender difference is that men expose themselves to an increased risk of infection by having multiple partners, and in turn become the vector for transmission of HIV/AIDS to their partners, even if the women themselves are not behaving promiscuously.
4. Young women and girls are increasingly being targeted for sex by older men seeking safe partners and also by those who erroneously believe that a man infected with HIV/AIDS will get rid of the disease by having sex with a virgin.
5. Women and girls tend to bear the main burden of caring for sick family members, and often have less care and support when they themselves are infected.
6. Women known to have HIV/AIDS are more likely to be rejected, expelled from the family home, denied treatment, care and basic human rights.
7. There is also a strong gender difference in the age-related prevalence of HIV/AIDS, with the average age of infected women in Africa typically being several years lower than that for men. For example, 1998 data for Namibia shows that most of the women who tested positive for HIV were in their twenties, while most of the men were in their mid-to-late thirties.

4. Examples of impact of HIV/AIDS on education:

1. In Malawi, Namibia and Zambia, rates of HIV infection among teachers of up to 40 percent have been reported.
2. In Zambia, the accelerating death rate among teachers exceeded 1,000 deaths in 1999, while the Zambian teacher training colleges currently graduate about 1,000 teachers per year.
3. The absence of only one teacher, for even short periods of time, impacts on a large number of children. With up to 30-40% of teachers absent from school, often for long periods, due to HIV/AIDS-related illnesses, there will be major effects on the quality of education. Even if all the affected teachers could be replaced (which is improbable), the reducing age profile and service experience of the teaching force will impact on quality.
4. Learning achievements will also be adversely affected as a rapidly growing proportion of children suffer the impacts of bereavement, stress, poverty, poorer nutrition, the need to work to support family members, etc.
5. At the university level, vice-chancellors from several African countries have noted that rates of HIV infection among both lecturers and students are similar to those in the surrounding population. Illness and absenteeism among staff is adversely affecting both the quality of teaching and the financial viability of institutions that have liability for sickness and death benefits.

5. Sex education: Surveys suggest that there are still no sex education policies to inform the development of comprehensive sex education programmes in many countries and that sex education in schools is left to the discretion of education authorities. At the same time, children are exposed to mass media at an early age and may obtain inappropriate information from various sources. The lesson of experience has been that awareness alone does not necessarily reduce risk-taking behaviour and more sophisticated approaches are needed that are based in an understanding of all the factors that determine behaviour change. A variety of education-based approaches have been initiated, including:

1. introduction of teaching about life-skills
2. peer education by students, popular public figures from sports and music, and young people living with AIDS
3. use of culturally appropriate media such as drama, story-telling
4. use of participatory role-playing approaches to experience and practice behaviour change
5. framing education about HIV/AIDS and life skills within a broader context of Health Promoting Schools