Workplace Interventions to Prevent HIV
I. Definition of the Prevention Area
Although the effects of HIV in the workplace differ by the size of the company/organization and the type of labor employed, for many companies and government employers HIV prevention efforts are essential to protecting an organization's productivity, profitability, economic growth, and efficiency. HIV in the workplace can lead to disruptions in production or internal processes as workers become ill, require time off for medical or care-giving purposes, or retire for medical reasons. Health care and insurance costs are also likely to rise if employees contract HIV. Existing evidence suggests that small and medium-sized companies experience a small average benefit as a result of their workplace programs.
II. Epidemiological Justification for the Prevention Area
From a public health perspective, the workplace provides a ready audience of both males and females for prevention messages and increasingly for counseling, testing, and referrals for further services. Strengthening prevention efforts in the workplace targets groups who may be mobile as a result of work; these populations have been found to be at higher risk for HIV infection because they are away from their communities and families and have incomes that can be used to establish sexual relationships. Implementing workplace HIV interventions can help to influence norms, combat stigma, and foster a broader sense of community investment in public health. By prioritizing the health of their workers, large employers in particular can set a tone of community responsibility.
III. Core Programmatic Components
Workplace interventions vary according to the size of the workforce, and employment terms, but several core components can be identified.
- Prevention interventions are often incorporated into broader service delivery efforts that include voluntary testing and counseling, treatment and support.
- Programs often extend beyond the employee to include family members, and beyond the workplace to reach out to the local community.
- Workplace HIV interventions can include elements to influence norms, combat stigma, and foster a broader sense of community investment in public health.
- Using peers rather than outside experts to lead interventions is a common approach.
- As well as taking the scale of the employer and the size of the workforce into account, workplace interventions may have to cater to the needs of mobile populations.
IV. Current Status of Implementation Experience
Many large and multinational companies have adopted workplace policies related to HIV and AIDS and have implemented complementary prevention awareness programs. Likewise, numerous government ministries, departments, and universities have adopted HIV and AIDS workplace policies to guide managers and to outline rights and responsibilities of employees. National, regional, and global business coalitions have been formed by the private sector and in collaboration with governments. They provide member companies with information on HIV and AIDS and advocate for expanded responses. Opportunities to engage small and medium-sized enterprises have been underexplored, due in part to the lack of organizations such as chambers of commerce that would bring the scale required.
The impact of the epidemic on private and public sector workforces has been documented in countries with high-level epidemics. Public sector institutions, such as schools and health facilities, have experienced significant labor losses, adding to the burden of service delivery in those areas. In countries or areas with low-level or concentrated epidemics the impact is far less intense. In those areas, few companies report significant losses in skilled labor or increased health care or insurance costs.
It is often expected that private sector firms will supplement public sector funding for HIV and AIDS programs, and this has occurred among some larger firms. However, more often, especially with the increase in contract labor arrangements, workers found to be or suspected to be HIV-infected are dismissed.
Unions and workers' representatives have helped organize workplace HIV and AIDS prevention programs and have added their influence to programs initiated by company managers. Although there are notable exceptions, unions have not made HIV and AIDS benefits a part of their contract negotiations.
This snapshot of 4 regional and 47 national business coalitions demonstrates their role as an accessible channel for the private sector to participate in a multi-sectorial response to HIV. It shares best practices and lessons learned as well as highlighting where coalitions need more donor, academic, and international partner support. The report analyzes the different organizational models used and gives pointers to overcoming concerns about sustainability (put local needs at the forefront, engage stakeholders before launch, keep engaged with the private sector engagement, stay adaptable and foster in-house expertise). It concludes with Business Coalitions Tackling AIDS: Worldwide Directory.
This report highlights key lessons learned from HIV interventions by Indian businesses, such as leveraging local partnerships, and strategies to keep track of highly mobile groups. Countering poor public health infrastructure, social stigma, and message fatigue are also discussed. The case studies of five private and public sector companies describe awareness, prevention, and advocacy interventions typically targeting contract workers, employees, truckers, and local communities. Key messages for those developing corporate responses to HIV are the need for early and decisive action, formal evaluation of cost effectiveness, and ensuring continuity of commitment and financing.
This useful report concretizes the form and content of the work of peer educators. Based on key informant interviews and survey data from peer educators in five South African companies, the report explores such issues as remuneration, turnover and ongoing training, organizational and union support, opportunities for engagement with one another, competing "production pressures," the tension between professionalism and activism, and the threat of too narrowly drawn definitions of a peer.
This report summarizes the findings of private workplace studies conducted in South Africa, Uganda, Kenya, Zambia, Ethiopia, and Rwanda. The authors looked at direct costs to employers (medical expenses, the recruitment and training of replacement workers) as well as indirect costs (absenteeism, reduced productivity). The financial impact of HIV on employers was driven by HIV prevalence in the workforce, the job level of those affected, affected employees' terms of employment, and industrial sector. Treatment of eligible employees with antiretroviral therapy at a cost of $360 per patient per year had positive financial returns for most but not all companies.
This report looks at management of HIV in the workplace, with case studies on experiences from six small- and medium-sized enterprises (SMEs) in South Africa. Three themes are highlighted: HIV risk factors (with length of service, lifestyle stability, and employees' social environment outside of work found to be important determinants), best practices, and measuring the effectiveness of HIV programs. While SMEs are willing to dedicate resources to HIV management, they may lack the skills to sustain programs long-term. In addition to employer case studies, the report includes a literature review on the structure of South Africa's private sector, HIV risk in SME workforces, and the challenges of implementing HIV programs in the workplace.
Based on qualitative and quantitative formative research, the authors identify the manufacturing, mining, sugar, garment, fishing, and construction industries as high HIV risk sectors in Karnataka. Overall findings include low levels of knowledge about HIV transmission and low levels of condom access among workers. Where resources are limited, identification and prioritization of highest risk sectors is recommended. While findings are not generalizable, the structure of a table summarizing sector assessment results may have broader use for program planners. For each sector, the table presents sociodemographics, HIV risk factors, structural characteristics, and recommendations, noting advantages and disadvantages for each.
With a substantial section on prevention programs, this overview of workplace policies in southern Africa includes a review of the scientific literature, working papers, and reports, supplemented by interviews with key informants. The authors identify HIV education, condom promotion, and counseling and testing as the most common workplace prevention interventions. While many private sector organizations may boast awareness programs and eager peer educators, workplace prevention programs are limited by lack of monitoring and evaluation, lack of tailoring of interventions to the company context, insufficient union support, and entrenched stigma. Quality is raised as a possible concern as well.
The Support to the HIV/AIDS Response in Zambia (SHARe) Program aims to support the institutional response to HIV and AIDS by building local capacity, improving the policy environment and strengthening leadership. The program includes collaborations with employers and workplace HIV prevention projects to enhance prevention, treatment and support services for employees, families and the wider community. This factsheet gives an update on four SHARe Project objectives: targeted assistance for workplace and community activities; a standardized planning template for multi-sectoral plans; a tracking tool to assess ministry-level efforts to address HIV; and HIV and AIDS leadership training for politicians.
The "Teachers Matter" project uses a peer-led education program to improve primary and secondary school teachers' HIV-related knowledge and reduce their own risk behavior. This study found that the intervention reached four out of five targeted teachers and despite initial skepticism, the program was well-received. Teachers welcomed the chance to discuss the effect of HIV in their lives (four in ten had first-hand experience of a bereavement due to AIDS), reported greater confidence in coping with HIV-related issues and lowered their perceived risk of HIV. However, fear of the consequences of a positive HIV test result remained, and the program did not have an impact on testing of teachers' partners. To maximize benefits, similar programs should be conducted during school hours or offer incentives for full participation.
This cost-benefit analysis of workplace HIV programs in seven Zambian mining and agricultural companies revealed that six of the companies saw a net benefit to their program (an average saving of US$47 per employee in 2006). Workplace programs can also have a positive impact on the surrounding communities (improving access to information, condoms, testing and sometimes treatment), but employers need to explicitly state that getting tested and treated is viewed favorably by the company and is not a threat to employment. Non-permanent staff should be included in workplace programs and community outreach efforts should be in the local language, the authors write. HIV should be seen as a strategic issue for companies, with tangible and identifiable costs and benefits.
This report highlights key lessons learned from HIV interventions by Indian businesses, such as leveraging local partnerships, and strategies to keep track of highly mobile groups. Countering poor public health infrastructure, social stigma and message fatigue are also discussed. The case studies of five private and public sector companies describe awareness, prevention and advocacy interventions typically targeting contract workers, employees, truckers and local communities. Key messages for those developing corporate responses to HIV are the need for early and decisive action, formal evaluation of cost effectiveness and ensuring continuity of commitment and financing.
Heineken's decision in 2001 to include highly active antiretroviral therapy in its health benefits package prompted criticism of the company's workplace HAART programs. The authors of this paper take each argument, ranging from cost, practicality and sustainability to corporate responsibility, ethics and political considerations, and refute the reasoning behind each one. The paper describes how the Heineken Workplace Programme chose just two HAART combinations and trained medical staff in three stages, starting with a theory workshop, a practical traineeship and regular teleconferences supported by an electronic database. The authors counter critics' question: "Why do you do this?" with their own question: "When will you start?"
Peer-led HIV education programs reach more workers and are more effective than health communicator-based programs, according to this study which randomly assigned 23 construction sites to the two interventions. Contrary to concerns that construction workers would not be capable and reliable peer educators, they contacted more workers and distributed more condoms, had better program retention rates and in time acquired equal or better knowledge about HIV and sexually transmitted infections than the health communicators. Although sexual norms in support of HIV risk reduction were higher at peer educator sites, low reported levels of sexual activity make the impact on risk behavior difficult to assess. Peer education programs cost less than health communicator programs, but management support was crucial.
In 2002 South African mining company AngloGold had an estimated workforce HIV prevalence of 30%. Under its direct service model for workplace HIV prevention, care, support and treatment it allocated a budget of $58 per employee (total $2.6 million) for HIV prevention. It also provided voluntary testing, anticipated providing antiretroviral therapy for a projected 820 patients and fostered community partnerships. Using peer educators and distributing free condoms were two mainstays of the company's HIV prevention program, along with treatment of sexually transmitted infections at company clinics. Key factors include interventions targeting behavior change and a focus on organizational action rather than risk assessment, but applicability of this model to other organizations may be limited by the substantial economies of scale that AngloGold can achieve.
This report describes the response of Botswana diamond mining company Debswana to the country's HIV epidemic, and hails it as a "ray of hope in a bleak situation". The report covers the early years of Debswana's response to HIV in the late 1980s and the process behind the company's first institutional HIV audit. In 2000 Debswana's new HIV strategy comprised six major elements (epidemic containment, economic impact containment, minimizing the impact of living with AIDS, stakeholder engagement, evaluation measurement and communication). The report highlights key lessons for other companies, such as the role of the management information system in monitoring the impact of HIV, identification of critical posts and ensuring ownership of HIV audit results though internal company-wide participation.
This training manual addresses the issues that trade unions must tackle when protecting their members' rights in response to HIV, including the right to information, freedom from discrimination and access to care and treatment, Structured activities are designed to facilitate group discussions and role play on a range of topics, including awareness, voluntary counseling and testing, stigmatization, discrimination, protecting contract workers and community outreach. Exercises help trade unionists compare national laws with the International Labour Organization Code of Practice on HIV/AIDS and the World of Work and develop collective bargaining agreements. A lengthy checklist underlines the importance of attention to detail in HIV-related collective bargaining.
This guide is for human resources managers, employee welfare managers, medical officers and labor representatives in the public sector to help them develop HIV prevention, care and support programs. A basic reference tool, it explains why HIV is a labor issue and how it affects the public sector workforce, calling on useful experiences from the private sector where appropriate. There are chapters on designing and implementing HIV policies in different parts of the public sector, such as health, education and agriculture and on formulating and costing programs. Detailed checklists for designing public sector workplace HIV programs, case studies and links to useful resources complete the guide.
This guide is for human resources managers, employee welfare managers, medical officers and labor representatives to help them develop HIV prevention, care and support programs. A basic reference tool, it explains why HIV is a labor issue. It then looks at the practicalities of risk assessment and how to draft a workplace HIV policy. Workplace HIV prevention and care programs, and managing the impact of HIV on a company are also covered. There are samples of workplace HIV policies, case studies and links to useful resources.
Business Coalitions Tackling AIDS: A Worldwide Review
Sidhu, I.K. World Economic Forum Global Health Initiative (2008).
This snapshot of four regional and 47 national business coalitions demonstrates their role as an accessible channel for the private sector to participate in a multi-sectoral response to HIV. It shares best practices and lessons learned as well as highlighting where coalitions need more donor, academic and international partner support. The report analyzes the different organizational models used and gives pointers to overcoming concerns about sustainability (put local needs at the forefront, engage stakeholders before launch, keep engaged with the private sector engagement, stay adaptable and foster in-house expertise). It concludes with a Business Coalitions Tackling AIDS Worldwide Directory.
View Report (PDF, 2.1 MB)
The ILO Code of Practice on HIV/AIDS and the World of Work
International Labour Organization (2005).
This International Labour Organization Code of Practice provides guidelines for HIV policy development and practice at enterprise, community, regional, sectoral and national levels. It covers all employers and employees whether formal or informal, in both the public and private sectors, and can be used to promote dialogue among stakeholders. The code covers key principles and describes various means of prevention through information and education (e.g., awareness-raising campaigns, gender-specific programs, support for behavior change and community outreach programs), and has sections on training, testing and workplace care and support of people living with HIV.
View Report (PDF, 126 KB)
South African Business Coalition on HIV/AIDS (SABCOHA)
South African Business Coalition on HIV/AIDS (2010).
The South African Business Coalition on HIV/AIDS pilots HIV workplace initiatives and provides resources to equip private sector stakeholders to respond to HIV. Includes resources targeting businesses, including case studies and toolkits, frequently-updated links to media stories relevant to HIV in the workplace, and extensive links to related websites. A section on prevention, which highlights condom distribution, is featured.