AIDS amongst workers: What special factors influence the access and adherence of workers?

1. AIDS amongst workers: What special factors influence the access and adherence of workers? Lecture 5

2. Aim of lecture • 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

3. Lecture overview • Background on HIV management in the workplace • The cost of untreated HIV to employers • Models of HIV management • Concrete recommendations that nurses can offer workplaces • Summary • Group discussion

4. 1. Background: HIV among workers • 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.

5. 1. Background: Business responses to HIV • 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

6. 1. Background: Small versus large workplaces • 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

7. 2. Cost of untreated HIV to businesses • 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?

8. 2. Cost of untreated HIV • 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

9. 2. Costs 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)

10. 2. Cost 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)

11. 3. Models of HIV management 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)

12. 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?

13. 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

14. 4. Recommendations for workplaces • Develop and publicise a workplace HIV/AIDS policy • Run a workplace HIV testing and counselling program tailored for high uptake • Make confidentiality a priority • Bring management onside • Help HIV-positive employees visit the clinic and take medicine • Adjust duties for HIV-positive employees when necessary • Support peer educators

15. 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)

16. 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.

17. 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 onsite • Workers have time off • Results at time of testing • Learn about support if HIV-positive • External testing agency • Very clear that management will not be able to access results

18. 4. Recommendations for workplaces 3) Emphasize confidentiality Some 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 right • Workplaces may have to be creative

19. 4. Recommendations for workplaces 4) Management support • Increase VCT The 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 treatment Some 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).

20. 4. Recommendations for workplaces 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

21. 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 medicine • Maintain predictable hours

22. 4. Recommendations for workplaces 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

23. 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)

24. 4. Recommendations to workplaces 7) Peer educators cont’d Right 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)

25. 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

26. 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: • The value of offering workplace HIV support • How to get workers to come for HIV testing • How to support HIV-positive workers access and adherence to HIV management (including ART)

27. 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: AgenceNationale de Recherchessur le Sida.

28. References • 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.

29. 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