Business' role in exercising leadership, promoting equity, embracing accountability, and developing partnerships

Introduction The World Economic Forum [1], the Global Business Coalition on HIV/AIDS [2], and the South African Business Coalition on HIV and AIDS have placed the role of business in HIV/AIDS prevention and care high on their agendas. These groups have secured endorsement from leading companies for specific policies related to HIV/AIDS in the workplace. Business involvement in HIV/AIDS activities can occur at several levels. Industries and businesses can adopt policies and recommendations regarding HIV/AIDS in the workplace. They can spearhead treatment initiatives and routinely offer prevention and diagnostic services, such as voluntary counselling and testing, in the workplace and in communities. They can examine policy, economic, and structural barriers and facilitators to prevention and care, and engage in structural changes to produce better health outcomes. They can engage as leaders in advocating for similar businesses or their suppliers to adopt workplace policies and programmes. They can also engage in philanthropy that might stimulate and support government programmes, provide pilot grants to initiate programmes and research, build facilities and structures, or promote programmes that governments or other funders might avoid. In an effort to advance the discussion and implementation of business action on HIV/AIDS, the UCLA Program in Global Health at the David Geffen School of Medicine at the University of California, Los Angeles, USA, hosted a think tank in Durban, South Africa, from 21 to 23 June 2006. The meeting brought together businesses, civil society organizations and academic researchers from southern Africa, the United States, and Europe. Its goals were: To review and consider available evidence on the epidemiology and impact of HIV/AIDS in the workplace; To establish how businesses have responded to the HIV/AIDS epidemic, and document what is known about the efficacy of workplace prevention and care programmes; To assess the wider role of the private sector in advancing the key goals of accountability, equity and leadership in the fight against the virus; To determine future research needs and how those needs can be met; To make evidence-based programmatic and policy recommendations to maximize the contributions that the business sector can make towards HIV/AIDS prevention and care in South Africa. The rationale for business action There are three main motivating factors behind private sector involvement in HIV/AIDS: To limit the potential negative macroeconomic impact of HIV/AIDS in the country or region in which the business is located; To reduce the direct costs to firms by decreasing the number of sick and deceased staff and the negative impacts on productivity, enhancing worker retention, and maintaining quality of services and products; To fulfill business's responsibility under the framework of good corporate citizenship, the ‘triple bottom line’ that asks companies to consider their financial, social and environmental performance. An interesting irony regarding business and HIV/AIDS has been the lack of negative macroeconomic impact. In previous years, predictions of the collapse of economies such as South Africa's were commonplace. In fact, the opposite has happened. Not only has the economy of South Africa not collapsed, it is thriving. Nonetheless, within this context, unemployment remains at 50% in some segments of the population, and is higher than 60% among young African men. This has led some to hypothesize that HIV/AIDS is disproportionately affecting those at lower income levels, and that the growing divide between rich and poor also includes a disease divide (see article by Marais, in this issue). Participants at the think tank therefore examined in depth business' motivations for action, looking at economic and other driving forces (see article by Matthews and two articles by Rosen et al. in this issue). We examined how AIDS might impact in different ways large multinationals, small, medium and micro enterprises, the public sector, and parastatal organizations (see articles by Rosen et al. and Weston et al., in this issue). Finally, we looked at the moral case for business involvement (see articles by Oppenheimer and Brink and Pienaar, in this issue). Leadership, equity, accountability, and partnerships The Ford Foundation launched its Global HIV/AIDS Initiative under the leadership of Deputy Vice President Dr Jacob Gayle to advance and raise the profile of HIV/AIDS work. The Foundation's four priorities for HIV/AIDS are Leadership, Equity, Accountability, and Partnership. These four priorities guided the discussions at the think tank. Leadership Leadership involves creating deeper talent pools of professional and community leaders who are knowledgeable about best practices for preventing and treating HIV/AIDS. There is no greater need in the AIDS epidemic, domestically and globally, than leadership development. Leadership needs to be replenished in all sectors: science, programme management, community organizing, and policy and advocacy. In the developing world, in many cases, the first generation of leaders will need to be cultivated, supported, and mentored. A second kind of leadership transfer must occur, namely the transfer of leadership in the fight against HIV to the communities and countries hardest hit by the epidemic. This will require some individuals, institutions, and countries to step back from the limelight in order to allow those hardest hit by the epidemic to take charge of the response, defining both the nature and form of the response and leading others in that effort. Equality Equality means that all individuals will have access within their own countries to HIV-related services and evidence-based approaches most appropriate for their circumstances, unaffected by their sex, social or economic status. It means that individuals will be able to gain access to HIV-related services they need without having to jeopardize their human rights. This means encouraging equal access to prevention and treatment across all axes of social inequality, including sex, age, socioeconomic status, religion, race, ethnicity and sexual orientation. Accountability Accountability means pressing developed and developing country governments, civil society (including business) and global agencies working on HIV/AIDS to make their programmes more accountable to the public. Gregg Gonsalves' talk at the International AIDS Society meetings in Toronto in 2005, in the special session entitled ‘25 Years of AIDS – Reflecting Back and Looking Forward’, highlighted three important points. First, he stated that ‘…the largely unaccountable, self-justifying infrastructure (which has come about in response to AIDS) privileging the policy preoccupations of the major industrialized countries, privileging generalized, international responsibility instead of specific local political accountability, privileging technical skill and experience over local knowledge; promoting “development” or assistance instead of social change.’ Second, he stated ‘…facing the structural and environmental factors that are the fuel for this great fire of an epidemic and watch the flames grow higher because to act on these issues moves beyond charity and far too close for comfort to them to politics.’ Third, he stated clearly that ‘AIDS is essentially a crisis of governance, of what governments do and do not do to and for their people. We have the drugs to treat HIV infection, we have the tools to confront the risks that drive HIV transmission and prevent infection itself. What we don't have is national political will necessary to scale up our response. We have demanded too little from our leaders, excused far too much.’ Partnerships Partnerships means conducting all work in partnership with countries and organizations most affected by the HIV/AIDS epidemic in such a way that the partnership is equal or, even better, puts the developing country into a leadership position. Dr Lawrence Altman, reporting on the Toronto AIDS Conference in The New York Times commented that the principal talks at the conference were given by individuals in the developed world, who were speaking, albeit eloquently and passionately, for the individuals in the developing world. Unfortunately, the President of Liberia cancelled because of the failure of the Prime Minister of Canada to appear at the conference. She would have been the only major African leader to speak at the conference. Partnerships means that those who are directly affected by the epidemic will be fully equipped for and actively engaged in the development, implementation, and management of the HIV programmes and policies within their countries and regions. The meeting opened with a keynote speech by Jonathan Oppenheimer of De Beers (see Commentary, in this issue). The first day was devoted to presentations on the epidemiology of HIV/AIDS in the workplace (Colvin et al. and Marais et al., in this issue), evaluations of its impact on business (Rosen et al., in this issue), and evaluations of policy, prevention, and care programmes (Mahajan et al. and Charalambous et al., in this issue). Breakout groups then answered questions about programmatic, policy, and research priorities (see Weston et al., in this issue). We present here our major overarching policy and programmatic recommendations. Some might argue that these recommendations are not different from the needs of society in general. We believe that these recommendations, emanating from this meeting, are important to highlight, especially from the perspective of the role that business can plan in advancing the fight against HIV/AIDS not only within its workforce but also in the larger community. It should be noted that these recommendations represent the thinking of the authors of this paper, that no attempt was made to reach consensus regarding these recommendations, and that these ideas should not be construed as the opinion of anyone attending the meeting or the policy or opinion of any of the think tank sponsors. Overall recommendations Leadership Business leadership is essential in fighting the HIV/AIDS epidemic in South Africa and in sub-Saharan Africa. Various programmes to develop leadership within business, but also within universities and especially business schools in Africa should be undertaken. Business should be encouraged to: Take leadership and join with advocacy groups in moving government towards effective testing, prevention, and care services; Develop, export, and sell products, skills and services that will provide more efficient testing, prevention, and treatment; Lead the way in teaching public sector workplaces how to devise, implement, and evaluate testing, prevention, and treatment programmes; Implement supply chain strategies to encourage HIV/AIDS programmes among suppliers; Examine its own business practices and determine if those practices provide social, economic or contextual factors that fuel the spread of HIV or fail to deter its progression. Examples that need to be addressed include the role of alcohol in the spread of HIV, migration and the status of migrant workers, commercial sex work, disparities in pay because of sex or other factors. Encourage HIV testing We recommend bringing together a broad group of organizations and individuals from various sectors in southern Africa to debate strategies for encouraging HIV testing, including routine, opt-out, mandatory, incentivized and community-based testing. From this should come agreement about a series of experiments to determine whether or not fears and concerns associated with various strategies are borne out. The uptake of HIV testing remains low, even with the availability of antiretroviral treatment. This is partly a result of the heavy stigma associated with HIV/AIDS, but also the enormity of the meaning of an HIV diagnosis. It is possible that much more could be done to encourage, incentivize or mandate testing, and thereby ‘normalize’ testing and reduce stigma. Increased testing and a greater number of individuals knowing their HIV status will contribute to reduced transmission and increased treatment uptake. Technological research to increase clinical efficiency Work is needed to encourage technological research to increase the efficiency of testing, prevention and treatment services without sacrificing quality. Each step of this process implies financial, human and opportunity costs. For example, Oppenheimer (this issue) observes that CD4 cell testing not only requires financial resources for the assay itself, but also that individuals take time away from work for the blood draw as well as to secure the results and determine the next steps. It might be possible to develop technologies that enable individuals to test for HIV at home, determine if CD4 cell counts or viral loads are above or below some cutoff for treatment consideration, and access helplines and other strategies so that they do not lose time at work. Just as an engineering process needs to be scrutinized to make it maximally efficient, the process of delivering testing, prevention, and treatment needs to be analysed to determine how financial, human, and other efficiencies can be attained. Male circumcision and new prevention strategies Business should plan now for incorporating new testing, prevention and treatment technologies. The evidence from studies in South Africa that male circumcision reduces HIV transmission is encouraging, and has been replicated by studies in Kenya and Uganda. Other studies are underway examining the efficacy of pre-exposure prophylaxis, acyclovir for the suppression of herpes simplex virus 2, other barrier methods such as the diaphragm, and microbicides. Many businesses still do not provide female condoms, and acceptance studies of female-controlled methods need to be bolstered. Business should be ahead of the curve in its preparations for the outcomes of these trials and the incorporation of these methods into an overall workplace strategy. Business influencing communities Business should lead the way in developing and evaluating new methods for delivering testing, prevention and treatment services. Brink and Pienaar in this issue describe a programme undertaken by Anglo American to develop prevention and care strategies for entire communities affected or influenced by a given industry. The Global Business Coalition on AIDS has developed and is evaluating strategies whereby small, medium and micro enterprises can group together, much as in a group insurance scheme, to provide prevention and treatment services that are affordable and well adapted to that kind of workplace. The World Economic Forum has developed policies and strategies for supply-chain management of HIV/AIDS. Additional novel strategies might include the use of traditional healers to deliver HIV voluntary counselling and testing services, directly observe antiretroviral or prophylactic therapy in patients, or provide other prevention services. Philanthropy Business should consider ways in which it can use its philanthropic funds and expertise to make specific inroads against HIV/AIDS. Examples might include the expansion of educational opportunity as a way to fight HIV/AIDS, the stimulation of micro enterprises, or the use of economic and incentive models to encourage education or the avoidance of risk taking. Business can also use its philanthropic funds to build structures within society to sustain the fight against HIV and the social forces that propel it. This includes stabilizing educational institutions, medical research institutions and facilities, as well as civil society structures needed to counter HIV. Public relations and advertising Business should use its messaging, public relations, and advertising expertise to send out a new message both to its workforce and to the population, namely that one should avoid HIV, but one can live productively with HIV. Equity and partnerships: for black Africans, for women, and for youth A think tank should be assembled to discuss the reasons for and ways to relieve the heavier burden of HIV infection among black Africans and women. Focus should be placed on important contextual factors such as income, migration, alcohol and other such especially those under the of of HIV infection among black Africans are two to three higher than those of or South Africans, or those of the reasons behind this is key to the Equity for those not in the workforce There is a need to in HIV between those in the workplace and those not in the workplace to determine prevention and care resources might need to be workplace and those from national a lower workplace of HIV. is in large in the work sector and is towards poor in the most communities. The sector will therefore need to be examined for the to which it is to build HIV/AIDS prevention and treatment into its and to evaluate programmes. This is important given the to which and sexual to the of the epidemic in South Africa. Equity for and There is a need to develop and policy for individuals under or so that they can from testing, and prevention programmes. African youth There is more than the HIV epidemic among African An to step up prevention must be New of the high and of HIV in South Africa and in southern Africa are In to sexual should be placed on other risk factors such as other alcohol and risk factors. the by which forces and contribute to high and is also We recommend a think tank to review the known on risk and risk factors of various southern African communities. The of these for prevention policies should be and evaluate workplace programmes We recommend that more research be to assess the impact of workplace testing, prevention and treatment programmes. should also on of in programme outcomes with a to the most effective and workplace is needed about the outcomes of testing, prevention and treatment of workplace programmes, and about the barriers to uptake of different programme programmes are not to be for businesses, of across sectors should be among Business should be accountable to civil society under the bottom framework of good corporate citizenship, which asks companies to consider their against financial, social and environmental Business should also be encouraged to use its and to make prevention and care services more Business might also be incentivized to engage in philanthropy to build and support structures needed to fight HIV/AIDS and other Finally, business should be encouraged to lead the effort to that testing, prevention, and treatment services are evidence and that public are and well and in with the best possible A action HIV could be by paper, it would have been is not to more paper, or studies for their own we take a that all research should be action of studies can be to for better programmes as the case of South African or to resources they are needed the of prevention and treatment programmes should be for quality of novel as the case of Anglo Brink and Pienaar, in this issue) can document what is possible with the and be to for more is HIV is not away any time We will all be with and it will for to The first are the and we need to to do all that we can to prevent it from to treat it in those and to the that make both of those to We that this meeting and series of recommendations make some in that The authors would to and for this meeting, and also support for it. They also the other in the the of the the Ford the UCLA AIDS and the UCLA for AIDS the UCLA for HIV and by the of Health and the for HIV and by the of Health of the represent those of the conference or their organizations or or of the or any of the sponsors. Participants Jonathan AIDS University of the Society for Health Ford South on and and the Business on for Health of Medicine in the of Health University of University of School of and International to to the for the AIDS Program of in South Africa South African and South African AIDS Initiative and of Global AIDS of of UCLA David Geffen School of UCLA Program in Global UCLA AIDS for AIDS and David Business University of the Deputy UCLA of HIV for and New York and University and Africa and UCLA Program in Global AIDS of of New York Jacob Deputy Vice Ford Foundation Global HIV/AIDS Initiative Health and HIV/AIDS University of HIV University of the for International of Global of and of Health UCLA Program in Global Health UCLA David Geffen School of Medicine in United for International of of South Africa HIV management AIDS of University of World for African African Program University of California, Los David Marais, South Africa HIV University of the the South African Program of South Africa Global Business Coalition Program for South of University of the and of the and of the HIV for and New York and of and in of and New and of South University of of and University of the AIDS of in South Africa of University of of of Global AIDS for International Health and Health Health University of UCLA Program in Global Health for Health School of Public University of the of Health of Medicine and Health UCLA David Geffen School of Program for HIV, Dr of HIV/AIDS and Health of the of International University School of Public Health UCLA Program in Global Health University of of the International AIDS of United on HIV/AIDS and in Africa HIV University of the of and UCLA AIDS of

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