Health management in the private sector in the context of hiv aids 366 ftp

Sustainable Development
Sust. Dev. 17, 19–29 (2009)
Published online 29 October 2008 in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/sd.366

‘Health Management’ in the Private Sector in the
Context of HIV/AIDS: Progress and Challenges
Faced by Company Programmes in South Africa
Gavin George* and Tim Quinlan
Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, South Africa

ABSTRACT
‘Health management’ of employees is becoming a common imperative for companies that
do business in regions where there is an HIV epidemic. Private sector initiatives in South
Africa have evolved considerably. However, core components of HIV/AIDS-oriented work-
place programmes, voluntary counselling and testing and anti-retroviral treatment, are not
as effective as expected, despite considerable investment in them. There is some evidence
to suggest gradual improvement in employee participation, yet this is coupled with employ-
ees defaulting from treatment programmes. This article explores reasons for these develop-
ments, the focus being on the economic and ﬁnancial challenges facing private sector
workplace health programmes. Copyright © 2008 John Wiley & Sons, Ltd and ERP
Environment.

Received 11 February 2008; accepted 18 February 2008
Keywords: treatment; ART; VCT; private sector; HIV/AIDS; adherence

Introduction

A
GAINST THE BACKDROP OF A CALAMITOUS AIDS EPIDEMIC IN SOUTH AFRICA, WHERE BETWEEN 11 AND 20% OF THE
adult population suffers HIV infection (Shisana and Simbayi, 2002), voluntary counselling and testing
(VCT) is a foundation of prevention and care intervention. By 2002 the Department of Health had estab-
lished over 450 VCT centres (Shisana and Simbayi, 2002), and by 2005 VCT had become core compo-
nents of workplace health management programmes of the large corporations and parastatals that operated
throughout southern Africa (George, 2006). Some of the larger corporations have also invested considerably in
workplace treatment facilities, providing anti-retroviral therapy (ART) for HIV infected employees and clinical care
for other diseases such as tuberculosis (TB) and sexually transmitted illnesses (STIs).
However, there is little evidence to show that these workplace programmes are achieving the desired results
(George, 2006). Many companies report low levels of worker participation in their VCT and ART programmes.
This inability to ﬁnd out and, thereafter, to maintain the health of employees, notably to identify and treat HIV
infection in the pre-symptomatic stage of AIDS, leads to high operational costs for both the programmes and
business production. Programmes that have been operating for several years do show increases in VCT ‘uptake

* Correspondence to: Gavin George, Senior Researcher, Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-
Natal, South Africa. E-mail: georgeg@ukzn.ac.za

Copyright © 2008 John Wiley & Sons, Ltd and ERP Environment

20 G. George and T. Quinlan

rates’, but this is not the case with ART. Furthermore, ensuring adherence to treatment amongst those employees
who are enrolled in a programme has become a challenge. While most ART programmes show a gradual increase
in numbers of employees on treatment, they also reveal an increasing number of defaulters. This article explores
reasons for these developments.

Workplace Treatment Programmes

VCT has become an integral component of HIV prevention programmes in developing countries (Coovadia, 2000;
Kalichman and Simbayi, 2003). This is due to demonstration of its efficacy in promoting behaviour change (Vol-
untary HIV-1 Counselling and Testing Efficacy Study Group, 2000), in decreasing rates of sexually transmitted
infections (Kamb et al., 1998), and as a precursor for treatment of HIV-infected individuals (WHO/UNAIDS,
1998). In sum, VCT is an entry point for a continuum of health care, rather than merely a means of screening for
HIV.
Anti-retroviral treatment (ART) is also becoming integral to health management strategies where HIV/AIDS is
widespread. This is due to ongoing improvements in medicinal therapies (Harrington and Huff, 2005; Jensen-
Fagel, 2004), lessons learned in programme design (Mnguni, 2003; Pemba et al., 2003), reduction of treatment
costs (Eley et al., 2003; Science in Africa, 2004) and initiatives of the USA and international agencies such as
WHO, UN and the Global Fund for AIDS, Tuberculosis and Malaria.
VCT and ART are components of a still-evolving framework for health management of employees. For instance,
the need to incorporate sound nutrition, to complement treatment (and prevention), is now being addressed.1 In
the private sector, especially amongst the larger companies in Southern Africa, there is a discernable shift from
orthodox occupational health programmes to designing and implementing ‘employee wellness’ or ‘health manage-
ment’ programmes. Put schematically, programmes commonly begin with ‘education and awareness’ campaigns
and, thereafter, incorporate VCT services, possibly adding in ART and including provision of food supplements
and ART for spouses.
Dr McDonald2 (2004) has summarized the factors that contribute to this situation in South Africa.
Maturing epidemic. An increasing number of HIV infected employees are falling ill and employers are starting
to experience the financial effects of the epidemic by way of rising absenteeism and increasing staff turnover
rates.
Falling costs of treatment. The cost of treating an HIV infected person has dropped considerably. In 1998, the
annual cost of treating an HIV infected individual was approximately R48 000 (US$6857)3. In 2005, these treat-
ment costs ranged from R20 400 (US$2924) to R10 980 (US$1569).4
Activist pressure. Civil society, trade unions and NGOs have lobbied the government to provide treatment to
HIV-infected individuals, which has influenced companies to act, indeed to take the lead ahead of the public health
services.
The government anti-retroviral treatment programme. The establishment of the public health service ART pro-
gramme during 2003, and its implementation in April 2004, prompted more companies to investigate provision
of treatment to employees.
Corporate social responsibility. Companies are beginning to acknowledge the need to be accountable not only to
shareholders but also to employees and to society at large on issues such as the social and environmental effects
of their business and to demonstrate their contribution to the public good. Consequently, companies have begun
to factor workplace health programmes into their business plans and budgets.
The underlying economic imperative is that provision of ART can enable infected employees to remain produc-
tive and, indirectly, contain recruitment, training and absenteeism costs. A study by the Bureau of Economic
1
In 2005, two international conferences signalled this imperative: the International Food Policy Research Institute’s HIV/AIDS and Food and
Nutrition Security: from Evidence to Action Conference, and the WHO Consultative Meeting on Nutrition, Health Services and HIV/AIDS, both
of which were held in Durban in 2005.
2
Dr McDonald is executive manager of health risk management consultancy, Qualsa; on the board of governors of the SA Business Coalition
of HIV/AIDS and on the executive committee of the Southern African HIV Clinicians’ Society.
3
1$ = R7.
4
Anglo American group costs.

Copyright © 2008 John Wiley & Sons, Ltd and ERP Environment Sust. Dev. 17, 19–29 (2009)
DOI: 10.1002/sd

‘Health Management’ in the Private Sector in the Context of HIV/AIDS 21

Research (2006) indicates the extent to which South African companies have begun to invest in workplace pro-
grammes. The study found that 71% of large companies and 38% of medium-size companies were providing some
form of care, support and treatment. The study also revealed that 40% of large and 17% of medium-sized compa-
nies were providing ART services.
The form of these services varies. There are currently four models of workplace treatment programmes in South
Africa (Connelly and Rosen, 2004; BER, 2004).
• Model 1: employer provider. The employer finances and delivers treatment for HIV-positive employees using a
‘closed’ health insurance service (i.e. one designed only for employees and their dependents) and company clinic
facilities.
• Model 2: medical aid scheme. Employers subsidize health insurance premiums for HIV treatment via ‘medical
aid schemes’. The insurance companies that provide services under these ‘schemes’ usually contract with a
disease management programme (DMP) (see Model 3 below); hence, scheme members typically have to enrol
separately with the DMP and there are additional premiums.
• Model 3: independent disease management programme (DMP). A specialized HIV/AIDS management company is
contracted by an employer to manage the costs and treatment of HIV-positive employees.
• Model 4: clinic provider. The employer contracts a medical NGO or general medical practitioner to provide HIV-
related services either at the workplace or at an outside clinic.5
Regardless of the options, many large companies report low uptake rates for VCT and ART, despite sophisticated
programme designs and substantive financial investments. Table 1 shows that the problem is widespread.
The problem extends beyond South Africa, as indicated in Table 2.
Furthermore, employees who do come forward for treatment commonly do so when they are unable to work
(George, 2006). This confounds a fundamental reason for the programmes: to reach workers before they become
too sick to work so that cost of treatment is offset by maintaining labour productivity, and to avoid costs such as
loss of experience, institutional memory, recruitment and training that are incurred in replacing dying and
deceased workers.
This finding affirms those of other studies in and beyond South Africa. The majority of persons who use public
health and workplace VCT facilities do so because of illness (Day et al., 2003; Kalichman and Simbayi, 2003). In
other words, VCT services are reaching infected and symptomatic persons more than individuals who may be

Industry Number of Number of Number of % of Number of % of all
companies employees employees in employees employees employees
reporting uptake HIV DMP in HIV DMP on ART on ART

Retail 3 44 900 70 0.2 52 0.1
Mining 9 275 300 24 066 8.7 2954 1.1
Manufacturing 4 36 700 Insufficient data* n.a. 518 1.4
Financial serv. 4 112 500 910† 0.8 330† 0.3
CSPS 0 n.a. n.a. n.a. n.a. n.a.
TSC 3 119 000 824 0.7 6 0.0
Construction 0 n.a. n.a. n.a. n.a. n.a.
Agriculture 2 8 475 140 1.7 48 0.6
Total 25 596 875 26 010 4.4 3908 0.7

Table 1. Cross-sectoral rates of employee participation in company treatment programmes (end 2004)
*
Two of the manufacturing firms did not provide information about DMPs. One did not have an HIV DMP and the other did
not know how many employees were enrolled.
†
Utilization figures for the four financial companies include dependents.
Source: Connelly and Rosen, 2006.

5
There is little information on the effectiveness of the different models with regard to enrolling HIV-positive workers and providing quality
care and treatment, as these data are kept out of the public domain (George, 2006).

DOI: 10.1002/sd


Case study Treatment Workforce HIV prev. Start of No. on ART programme
model (%) ART prog. Approx No. eligiblea
at time of study

Anglo-American employer provider 121 113 23 2002 3034b employees on treatment as at
end 2005
>7000 eligible
Goldfields employer provider 50 000 32 2004 No information available at time of
study
4000 eligible
Namdeb DMP 2500–3000 7 40 (end of 2003)
min. 50 eligible
Old Mutual medical aid scheme 13 000 5 38 (as of the end of 2002)
160 eligible
Debswana DMP 6534 20.1c 2001 280 employees on ART while a further
32.4d 69 were just being monitored (as at
31 October 2003)
474 eligible for ART
Tongaat Hulett employer provided 750 10–12 2003 39
20 eligible
Zambian Breweries clinic provider ±900 19–20 20
45 eligible

Table 2. Summary statistics of ART uptake in seven corporations operating in Southern Africa
*
Two of the manufacturing firms did not provide information about DMPs. One did not have an HIV DMP and the other did
not know how many employees were enrolled.
†
Utilization figures for the four financial companies include dependents.
a
The assumption was that in contexts of advanced HIV epidemics about 25% of HIV positive people need to receive ART.
b
Anglo Report to Society 2005 – HIV and AIDS.
c
Permanent workforce.
d
Contractor workforce.
Source: George, 2006.

uninfected or infected but asymptomatic. In South Africa, Shisana and Simbayi (2002) revealed that only one in
five individuals who knew about VCT had opted to be tested for HIV. Subsequent studies have revealed that
amongst those who use VCT facilities many do not return for their test results and further counselling (Day et al.,
2003; Wolff et al., 2005).

Barriers to VCT Uptake

There are many reasons for the limited use of public health and workplace VCT facilities. These can be summa-
rized as the following.
• Limitations in the design of VCT services, such as difficulty of access, service charges, perceived hostile attitudes
of facility staff and violations of confidentiality (Day et al., 2003; Ginwalla et al., 2002; Kalichman and Simbayi,
2003; Lie and Biswalo, 1994; McKenna et al., 1997; Nuhawa et al., 2002). There is conflicting evidence on
whether provision of ART affects VCT rates. Baggaley et al. (1998), Nuhawa et al. (2002), and Sweat et al. (2000)
indicated that lack of ART services was a barrier. Other studies (Ginwalla et al., 2002; Sangiwa et al., 2000)
stated that clients saw value in VCT services even if not coupled with access to ART.
• Emotional and cognitive barriers, such as little knowledge of VCT, denial of personal risk of HIV infection, percep-
tions of little benefit from VCT and fears of testing positive and the implications for future employment (Baggaley
et al., 1998; Day et al., 2003; Ginwalla et al., 2002; Kalichman and Simbayi, 2003; Nuhawa et al., 2002; Wolff
et al., 2005).

DOI: 10.1002/sd


VCT uptake 2004 (%)

AngloGold Ashanti 10
Anglo Platinum 15
Anglo Coal 63
Anglo Ferrous Metals & Industries 17
Anglo Base Metals 87
Anglo Paper and Packaging 69
Corporate Centre 70
Weighted Average 21

Table 3. T uptake in Anglo American in 2004
Source: Brink (2005).

• Social barriers, such as the influence of sexual partners in decisions to use the VCT service, stigma and social
marginalization if presumed to be HIV positive by attending workplace facilities (Day et al., 2003; Ginwalla
et al., 2002; Kalichman and Simbayi, 2003; Nuhawa et al., 2002; Wolff et al., 2005).
Dr Brink (2005), the Vice-President of Health at the Anglo American Corporation, has highlighted the critical
need to improve use of VCT services because the latter
• are an important opportunity for reinforcement of prevention messages through individual counselling;
• enable a company to initiate CD4 count monitoring in HIV+ individuals;
• are the means to ensure early access to treatment and reduction of the risk of employees suffering AIDS associ-
ated illnesses, and hence to ensure the cost effectiveness of ART provision for the company.
Furthermore, the common rationale for VCT is that individuals who voluntarily seek and find out their HIV status
are more likely to change their behaviour accordingly and so contribute to reducing the spread of the virus.
Dr Brink voiced his concerns in view of the experience of the Anglo American group of companies, as repre-
sented in Table 3. Nonetheless, the weighted average rate was a 100% improvement from 2003, and in 2005 the
average VCT uptake rate rose to 31% (Brink, 2005). In 2006, at AngloGold Ashanti, 75% of its South African
employees took HIV tests compared with 10% in 2004.6
Sean Jelly, Chief Executive of Lifeworks, a disease management company, stated in a telephonic interview (13
March 2006) that the key factor affecting VCT participation, in his experience, was the extent of in-company
support and/or sabotage, be it at management or at shop floor levels. He did not think that stigma was a major
factor on the grounds that Lifeworks had achieved 80–90% participation in VCT campaigns where there was firm
support from the client company. Furthermore, in arguing against the supposed effects of stigma, he noted that
the use of incentives (e.g. raffling a weekend family holiday amongst those who attend a VCT exercise) greatly
increased uptake rates.
In summary, there are indications of improvement in workforce participation in VCT programmes but little
substantive evidence on trends and, as importantly, on lessons learned on how to achieve high participation
rates.7

Barriers to Accessing ART

In South Africa, the number of people who were receiving treatment was below 50 000 in 2005 (Quinlan and
Willan, 2004; Sengwana and Veenstra, 2005). This figure rose to approximately 280 000 in 2006 (Grimwood

6
2006 Annual Report: AngloGold Ashanti.
7
DMP companies are generally unwilling to share ‘trade secrets’ in what is has become a very competitive service industry.

DOI: 10.1002/sd


Company Company size by Estimated HIV Target Registered Enrolment
employee numbers prevalence (%) patients patients rate (%)

A 200–500 18–20 62 47 76
B 500–2000 10–12 97 63 65
C 200–500 27–29 58 25 43
D 2000–3000 10–12 213 107 50
E 3000–5000 10–12 400 258 65
F 3000–5000 4–6 201 86 43

Table 4. ART uptake in 2006 in companies where Lifeworks manages treatment
Source: Sean Jelly, Chief Executive, Lifeworks, 2006.

3000

2500
Number of employees

2000

1500

1000

500

0
2002

Feb

Feb

Feb
Jun

Aug

Apr

June

Aug

Apr
April

Oct

Oct
Dec

Dec
Started on ART Remaining on ART
Figure 1. Anti-retroviral therapy coverage in Anglo American (2002–2005)
Source: Brink (2005).

et al., 2007, p. 83) and 36 000 in 2007 (ITPC, 2007, p. 104). These figures are still below the estimated number
of people needing treatment (600 000 plus in 2006; Grimwood et al., 2007).
Stigma and other social factors are frequently cited as barriers (Chesney and Smith, 1999; Moss et al., 1999;
Raveis et al., 1998; Valdiserri, 2002; Stall et al., 1996; Government of South Africa, 2000) and, indirectly, to sus-
taining patient adherence to treatment regimes (Government of South Africa, 2003, 2004). However, there is little
research on actual rates and variations over time and in different settings, or on reasons for success or failure of
the programmes. For instance, De Coito (2005) and George (2006) noted that stigma and discrimination were
frequently attributed reasons for low uptake of VCT and ART, but no company had conducted research to verify
this perception. Furthermore, Lifeworks, the disease management company cited earlier, has reported relatively
high ART uptake rates in companies where it works. Due to the sensitive nature of the data, company names
cannot be disclosed.
An emerging challenge is finding ways to sustain patient adherence to treatment. Figures supplied by Anglo
American are illustrative. By April 2005, the corporation had 2936 employees enrolled on ART, but for various
reasons, including non-adherence (45%), 858 (29%) of employees had been lost from the programme. Figure 1
represents the Anglo American experience.

Economic Cost of Low Uptake

The economic benefit of VCT and ART has been established in South African studies (Gow, 2002; Rosen et al.,
2003; SABCOHA, 2003). However, there is little public research on the cost effectiveness of programmes over

DOI: 10.1002/sd


time, on means to reduce the opportunity costs, and on how to increase the benefits to companies and workforces.
These costs and benefits need to be measured if companies are to grasp what interventions are and are not
working.
Put differently, from a company management perspective, assessments of the value of VCT and ART should
include a ‘bottom line’ in the form of a monetary equivalent measurement of all benefits and direct and indirect
costs of a programme. A programme may provide benefits that are not directly expressed in monetary terms, but
there is some amount of money the recipients of the benefits would consider just as good as the programme’s
benefits. For example, programmes provide infected employees with both free VCT and access to ART; the value
of this benefit to an infected employee is the minimum amount of money that the recipient would take instead of
the medical care. Similarly, there are costs and benefits to the company of uptake and non-uptake of the services,
which can be calculated through cost impact and auditing techniques.
However, in the absence (and difficulty) of calculating accurately total costs and benefits at any one time
and over time, the general yardstick is that low VCT and ART uptake rates mean the programmes are not as cost-
effective as they should be. In response, the general trend has been for companies to elaborate their programmes
with new interventions in the quest to improve these rates.
With regard to cost effectiveness, the history of Aid for AIDS (AfA), the largest disease management programme
(DMP) in South Africa, is informative. AfA manages the initiation of therapy, adherence to treatment, laboratory
monitoring, clinical response and costs (Martinson et al., 2002). Total benefits per annum per person range from
R5000 ($714) to R40 000 ($5714) depending on the health insurance scheme that uses its services. Between AfA’s
inception in 1998 and 2003, approximately 27 000 patients had enrolled in its programme, most of whom have
been eligible for ART (Cowlin et al., 2003).
However, late enrolment of patients (i.e. when the individual is suffering frequent bouts of AIDS-related ill-
nesses) proved to be a costly factor. There was a steady monthly increase in uptake between 1998 and 2001. There
was concern about a trend of late enrolments, particularly of individuals with CD4 count less than 50 cells/mL (an
indicator of advanced AIDS,8 but the expectation was that this would reverse over time due to the following factors
(Hislop, 2004):
(a) decrease in stigma surrounding HIV infection and treatment;
(b) gradual reduction of the size of the ‘late enrolment’ population;
(c) greater public awareness of the role of the DMP and the benefits of ART.
However, this reversal did not happen, as is represented in Figure 2.

Figure 2. Percentage beneficiaries from selected open medical schemes registering on Aid for AIDS with a CD4
count < 50 cells/mL
Source: Hislop (2004).

8
CD4 refers to the cells in the human immune system that the HI virus penetrates and gradually destroys. CD4 count refers to the number
of CD4 cells per microlitre of blood (mL), normally 1200 cells/mL, and measurement of the number is a means to assess a person’s status
between being HIV infected and suffering AIDS. A person with a CD4 count of less than 200 cells/mL is regarded as having AIDS (Barnett
and Whiteside, 2002, pp. 30–32).

DOI: 10.1002/sd


$800

Per patient per month cost
$700
CD4>350
$600
CD4<50
$500
$400
$300
$200
$100
$0
0 3 6 9
Months relative to enrolment

Figure 3. Cost benefits of early enrolment
Source: Adapted from Cowlin et al., 2003.

Hislop points out that 44% of AfA’s patients enrolled later than minimum guidelines for commencement of
ART, defined as a CD4 count of less than 200 cells/mL. Fifteen percent of patients enrolled with a CD4 count of
less than 50 cells/mL.
In other words, medical aids schemes contracted to AfA’s programme had to continue to cover hospitalization
costs that, in principle, were avoidable if beneficiaries had enrolled for treatment in earlier stages of AIDS-related
illness. Length of hospital stay was over three times higher for patients with CD4 count < 50 cells/mL than patients
with entry CD4 counts between 200 and 350 cells/mL (Hislop, 2004).
Figure 3 illustrates the difference of the actual per patient per month costs incurred as a result of early and late
enrolment. In contrast, the Anglo American Corporation9 experience shows what can be achieved with effective
treatment. In 2003, the corporation calculated that initial costs of providing ART were R29 294 ($4185) per patient
per year. This was due to the initial treatment of opportunistic infections together with the added pathology tests
and frequent monitoring. These initial costs were similar to those experienced by AfA. However, after the first
year of treatment, and adherence of patients to therapies, the cost of providing ART decreased on average to
R10 620 ($1517) per patient per annum.

Key Problems and Issues for Consideration

The general expectation of workplace health programmes is that ‘start-up’ costs are very high, but the unit cost of
providing prevention, treatment and care services decreases significantly over time. Furthermore, setting up and
implementing programmes is part of a broader social process to gradually overcome people’s fears and stigma
associated with HIV infection and establishing partnerships between management and workers.
However, evidence to date reveals
• limited use of VCT services by workers;
• limited numbers of individuals on ART presenting a very high cost ratio for individual care;
• tendency of individuals to seek treatment once they are sick;
• high costs in time and resources expended to enrol employees in programmes.
These are significant problems. They show that South African workplace health programmes have yet to achieve
their core purpose: to prevent spread of HIV and to ensure that HIV infected employees obtain treatment before
they are too ill to work.
Stigma and discrimination are frequently cited by company managers as the causes, but so too are more prosaic
reasons by employees. Fear is a common obstacle because to take a test or admit to needing treatment means that
9
Information can be found on www.angloamerican.com

DOI: 10.1002/sd


one knows one’s status, and that knowledge entails responsibility to change one’s behaviour. Other reasons
include
• lack of ‘buy-in’ from management, for example, when line managers and supervisors view interventions such as
peer education and ‘know your status’ campaigns (VCT and company-wide sero-prevalence surveys) as factors
that disrupt daily production demands and so they reluctantly support employee participation in them,
• insufficient training, time or means given to peer educators to interact with employees,
• disincentives such as when contract or casual employees see that they are entitled to VCT services but access to
treatment is restricted to permanent employees,
• workers not seeking treatment if they have not disclosed to their spouses and/or the latter do not have access
to treatment and
• interventions that ‘do not speak’ to the individual, taking into account factors such as age, gender, social
circumstances and culture.
Whatever the reason, the fact that workers often seek treatment ‘too late’ suggests lack of integration of VCT and
ART in some way with other components of a workplace programme. This lack of integration, we suggest, is the
nub of the problem that companies face. ‘Health management’ is not simply a matter of co-ordinating different
activities. Companies have adopted an instrumental approach with sound intent but the results have not been as
expected. They have had to recognize that promoting ‘behaviour change’ is a complex task. The adaptation evident
in companies experimenting, refining and broadening the scope and content of their programmes reflects an
awareness of the scale of the challenge. However, this approach, in essence adding components, obscures a deeper
understanding of what integration means. It means working from a premise of changing the workplace environ-
ment and recognizing the need to anticipate the new challenges and demands that arise inevitably. Therefore,
co-ordinating activities and adding programme components to change people’s behaviour are actually subordinate
to a broader agenda of social engineering.
To illustrate, the limitations of current constructions of workplace programmes are expressed in private sector
support for conducting workforce sero-prevalence and Knowledge Attitude and Practice (KAP) surveys.10 These
surveys are a standard means to measure progress of a programme; initial surveys provide a baseline while sub-
sequent surveys, after a programme has been implemented, are a basis for assessing effectiveness of a programme.
However, we have noticed that sero-prevalence surveys are frequently implemented without redefinition of purpose
and, specifically, in relation to a company’s experience of, and information derived from running a programme.
Likewise, there is widespread interest in the South African private sector in continuous workplace, HIV/AIDS-
focused education and training. This is coupled with an emphasis on setting and improving the standard of this
education and training (i.e. courses that are accredited with, and meet the standards of, the government national
quality assurance legislation). However, sometimes missing from company training agendas is consideration of
the need to update the training given to peer educators and lack of attention to revising the selection criteria for
these posts (i.e. ensuring that they are representative of the demographic profile of the workforce or include HIV
positive workers who have disclosed their status).

Conclusion

Companies have little reason not to set up workplace health programmes but for the fact that they are costly exer-
cises. This article has illustrated some of the challenges and their long term nature. The South African business
sector is acquiring experience and hence working knowledge of what works and what does not work. However
imperfect this knowledge, it is evident that workplace programmes cannot be static. The demands on programmes
have changed and will continue to change; hence the design and operation of these programmes must evolve. In
sum, the orthodox notion of occupational health has become outdated and is being redefined substantively with

10
KAP surveys are usually questionnaire based, and probe for self-reported information on knowledge about HIV and AIDS, attitudes with
regard to the disease and working and socializing with HIV infected persons, and social and sexual practices. Repeat surveys enable, in prin-
ciple, assessment of changes in levels of knowledge, attitudes and practices.

DOI: 10.1002/sd


the advent of ‘employee wellness/health management’ programmes. However, evolution of these programmes
does not mean simply adding on components. The inclusion of new components presumes that demands have
changed, and so a programme as a whole may require recalibration. This is a point that private sector programmes
in South Africa have yet to reach.

References
Almeleh C, Grimwood A, Hausler H, Hassan F. 2006. HIV/AIDS and tuberculosis treatment update. South African Health Review 65–
76.
Baggaley R, Kelly M, Wedirrich S, Kayawu I, Phiri G, Mulonoo W, Phiri M. 1998. HIV counselling and testing in Zambia: the Kara counsel-
ling experience. SA/AIDS News 6: 2–8.
Barnett A, Whiteside A. 2002. AIDS in the Twenty-First Century: Disease and Globalization. Palgrave Macmillian: Pietermaritzburg, South
Africa.
Brink B. 2005. An interim appraisal of the anglo american aids treatment programme. Presentation at the 2nd SA AIDS Conference,
Durban.
Bureau for Economic Research (BER). 2000. HIV/AIDS and the South African Economy. Stellenbosch.
Bureau for Economic Research (BER). 2004. The Economic Impact of HIV/AIDS on Business in South Africa 2003. Stellenbosch.
Bureau for Economic Research (BER). 2006. The Impact of HIV/AIDS on Selected Business Sectors in South Africa, 2005. Stellenbosch.
Chesney MA, Smith AW. 1999. Critical delays in HIV testing and care: the potential role of stigma. A Behavioural Scientist 42(7): 1158–1170.
Connelly P, Rosen S. 2005. Will small and medium enterprises provide HIV/AIDS services to employees? An analysis of market demand.
South African Journal of Economics 73: 613–626.
Connelly P, Rosen S. 2006. Treatment for HIV/AIDS at South Africa’s largest employers: Myth and reality. South African Medical Journal 96:
128–133.
Coovadia HM. 2000. Access to voluntary counselling and testing for HIV in developing countries. Annals of New York Academy of Science 918:
57–63.
Cowlin RG, Regensberg LD, Hislop MS. 2003. Counting the Cost of Care: do HIV/AIDS Disease Management Programmes Deliver? AIDS Man-
agement Report, 2003. 1(3): 20–23.
Day JH, Miyamura K, Grant AD, Leeuw A, Munsamy J, Baggaley R, Churchyard GJ. 2003. Feasibility and acceptability of a specialist clinical
service for HIV-infected mineworkers in South Africa. AIDS Care 15(5): 665–672.
De Coito T. 2005. Factors Affecting Enrolment onto an HIV/AIDS Workplace Anti-Retroviral Treatment Programme, MBA Research Report. Wits
Business School: Johannesburg.
Deloitte and Touche Human Capital Corporation. 2002. Evaluation of Workplace Responses to HIV/AIDS in South Africa. A Rapid Situation
Analysis, mimeo.
FHC. 2002. Software Futures Delivers Aid for AIDS Web Interface for Medscheme. Johannesburg.
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.
Ginwalla SK, Grant AD, Day JH, Dlova TW, Macintyre S, Baggaley R, Churchyard GJ. 2002. Use of UNAIDS tolls to evaluate HIV voluntary
counselling and testing services for mineworkers in South Africa. AIDS Care 14(5): 707–726.
Government of South Africa. 2000. HIV/AIDS/STD Strategic Plan for South Africa 2000–2005. National Department of Health: Pretoria.
Government of South Africa. 2003. Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa.
National Department of Health: Pretoria.
Government of South Africa. 2004. National Anti-Retroviral Treatment Guidelines. National Department of Health: Pretoria.
Gow J. 2002. Cost Impact of HIV/AIDS in the Workforce, mimeo. Daimler Chrysler South Africa: Durban.
Harrington M, Huff B (eds). 2005. What’s in the Pipeline: New HIV Drugs, Vaccines, Microbicides, HCV and TB Treatments in Clinical Trials.
Treatment Action Group: New York.
Hislop MS. 2004. Enrolment Experience and the Measurement of Survival in a Private Sector HIV/AIDS Disease Management Programme.
South African Journal of HIV Medicine: 15–17.
International Treatment Preparedness Coalition (ITPC). 2007. Missing the Target. www.aidstreatmentaccess.com [December 2007]
Jensen-Fagel S. 2004. The effectiveness of highly active antiretroviral therapy in HIV-infected patients. Danish Medical Bulletin 51: 371–392.
Kalichman SC, Simbayi L. 2003. HIV testing attitudes, AIDS stigma, and voluntary counselling and testing in a Black township in Cape Town,
South Africa. Sexually Transmitted Infections 79: 442–447.
Kamb MI, Fishbein M, Douglas JM et al. and Project RESPECT Study Group. 1998. Efﬁcacy of risk reduction counselling to prevent human
immunodeﬁciency virus and sexually transmitted diseases. Journal of the American Medical Association 280: 1161–1167.
Lie G, Biswalo P. 1994. Perceptions of the appropriate HIV/AIDS counsellor in Arusha and Kilimanjaro regions of Tanzania: implications for
hospital counselling. AIDS Care 6: 139–151.
Martinson N, Radebe B, Mntambo M, Violari A. 2002. Anti-Retrovirals. South African Health Review 2002. Health Systems Trust: Durban.
McDonald L. 2004. HIV/AIDS Treatment for Employees – Do We Wait for Governments’ Programme? Aids Analysis Africa Vol. 15(2). Metropoli-
tan Life: Cape Town.

DOI: 10.1002/sd


McKenna S, Muvinda G, Roth D, Mwali M et al. 1997. Rapid HIV testing and counselling for voluntary testing centres in Africa. AIDS 11:
S103–S110.
Mnguni M. 2003. Collaborating to provide palliative care in resource poor settings – integrated community home-based care. Paper presented
at the South African AIDS Conference, Durban.
Moss W, Bentley M, Maman S, Ayuko D, Egessah O, Sweat M, Nyarang’o P, Zenilman J, Chemtat A, Halsey N. 1999. Foundations for effec-
tive strategies to control sexually transmitted infections: voices from rural Kenya. AIDS Care 11(1): 95–113.
Nuhawa F, Kabatesi D, Muganwa M, Whalen CC. 2002. Factors influencing acceptability of voluntary counselling and testing for HIV in
Bushenyi district of Uganda. East African Medical Journal 79(12): 626–632.
Pemba L et al. 2003. Model for providing antiretroviral treatment in an industrial setting. South African AIDS Conference, ICC, Durban. 3–6
August 2003. Abstract [T3-S8-A52]
Quinlan T, Willan S. 2004. Finding ways to contain the HIV/AIDS epidemic: South Africa 2004–5. In State of the Nation Review 2004, Daniel
J, Southall R (eds). HSRC: Pretoria; 227–251.
Raveis VH, Seigel K, Gorey E. 1998. Factors associated with HIV-infected women’s delay in seeking medical care. AIDS Care 10(5): 549–
562.
Rosen S, Vincent J, MacLeod W, Fox M, Thea D, Simon J. 2003. The Cost of HIV/AIDS to Businesses in Africa. Center for International Health
and Development, Boston University School of Public Health: Boston, MA.
Sangiwa G, Straten A, Grinstead O and the VCT Study Group. 2000. Clients perspective of the role of VCT in HIV/AIDS prevention and care
in Dar Es Salaam, Tanzania: the Voluntary Counselling and Testing Efficacy Study. AIDS and Behaviour 4: 35–48.
Science in Africa. 2004. www.scienceinAfrica.co.za/2004/june/aidstests.htm [December 2007].
Sengwana M, Veenstra N. 2005. Phase 1 and Phase 2 Reports of the Burden of HIV/AIDS on Public Health Services in KwaZulu-Natal. HEARD:
Durban.
Shisana O, Simbayi L. 2002. Nelson Mandela/HSRC Study of HIV/AIDS: South African National HIV Prevalence, Behavioural Risks and Mass
Media, Household Survey 2002. Human Sciences Research Council: Cape Town.
South African Business Coalition on HIV/AIDS (SABCOHA) and Deloitte and Touche Human Capital Corporation. 2003. Rapid Assessment
of the Private Sector Response to HIV/AIDS in South Africa. http://www.eldis.org/static/DOC11766.htm [April 2007].
South African Business Coalition on HIV/AIDS (SABCOHA). 2004. The Economic Impact of HIV/AIDS on Business in South Africa 2003.
Stellenbosch: Bureau for Economic Research.
Stall R, Hoff C, Coates TJ, Paul J, Phillips KA, Ekstrand M, Kegeles S, Catania J, Daigle D, Diaz R. 1996. Decisions to get HIV tested and to
accept antiretroviral therapies among gay/bisexual men: implications for secondary prevention efforts. J Acquired Immune Deficiency
Syndromes and Human Retrovirology 11: 151–160.
Sweat M, Gregorich S, Sangiwa G, Furlong C, Balmer D Kamenga C, Grinstead O, Coates T. 2000. Cost effectiveness of voluntary HIV-1
counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania. Lancet 356: 113–121.
UNAIDS. 2004. 2004 Report on the Global AIDS Epidemic. Fourth Global Report. Geneva.
Valdiserri RO. 2002. HIV/AIDS stigma: an impediment to public health. Editorial. American Journal of Public Health 92(3): 341–342.
Voluntary HIV-1 Counselling and Testing Efficacy Study Group. 2000. Efficacy of voluntary HIV-1 counselling and testing in individual and
couples in Kenya, Tanzania and Trinidad: a randomised trial. Lancet 356: 103–112.
Wolff B, Nyanzi B, Katongole DS, Ruberantwari A, Whitworth J. 2005. Evaluation of a home-based voluntary counselling and testing interven-
tion in rural Uganda. Health Policy and Planning 20(2): 109–116.
World Health Organisation (WHO)/UNAIDS. 1998. Guidance Modules on Antiretroviral Treatment. 1: Introduction to Antiretroviral Treatments,
WHO/ASD/98.1. WHO: Geneva.

DOI: 10.1002/sd

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