Development projects may either promote or hinder the spread of HIV. Where HIV/AIDS has not been considered in the design and implementation of a project, factors such as the establishment of labour camps or improving access to previously remote areas may promote the transmission of HIV and spread the epidemic faster than in the absence of the project.  However, if the potential impact of development on HIV/AIDS is anticipated and proactively handled, there can be overall benefit to the community by reducing HIV transmission to lower rates.
The link between development and HIV/AIDS was recognised by the authorities in charge of a large construction project in the small southern African country of Lesotho. Extending over 17 years, this project in the remote mountains involves construction of five dams and interconnecting tunnels that will provide water to South Africa's industrial heartland. For Lesotho, it will be a major source of employment and revenue.
Before construction started, the Lesotho Highland Development Authority contracted the Medical Research Council of South Africa to conduct a baseline survey, describing the distribution of a range of infectious diseases, including sexually transmitted infections (STIs) and HIV, and to propose measures to monitor and prevent the spread of these diseases. This type of baseline survey can assist in the design of HIV interventions by highlighting the key issues to be addressed by targeted interventions. Baseline data are also vital for establishing time trends in disease incidence and behavioural changes, which allows monitoring and evaluation of the impact of interventions. A cross-sectional study was conducted in 1995 among the 7500 inhabitants who lived in 83 villages scattered over rugged mountains. Questionnaires were administered to 526 adults and youths, and urine and blood were tested for a range of STIs including HIV.

The results showed high prevalence rates of STIs with 29% of subjects being infected with chlamydia, 6% with gonorrhoea, 11% with syphilis and 6% with HIV. All cases of HIV infection occurred along the main road. Health seeking behaviour was poor with only 41% of persons with STI symptoms during the last year seeking medical help. A further 21% used herbs or consulted a traditional healer and 33% sought no treatment at all. Condom use was low. Only 3% of women had ever used condoms; none of the 38% of men or 12% of women who admitted having had sex with a non-regular partner during the last three months had used a condom.

While 91% of women had heard about AIDS and knew that condoms protected against infection, misconceptions were common with 48% thinking that HIV could be transmitted through sharing eating utensils. Men had less knowledge of AIDS than women and 25% of men believed the myth that having sex with a virgin could cure AIDS.

Conclusions and recommendations

The study showed a substantial prevalence of STIs, high-risk sexual practices and poor health-seeking behaviour. Poverty levels are high, there are few employment opportunities and health services are not well developed. All the indications are that this community is ill prepared to protect itself from the explosive HIV/AIDS epidemic that has gripped the region. Their situation is now likely to be exacerbated by the dam development programme as this will require the establishment of labour camps and open up access to a previously isolated community. This situation whereby thousands of single men have disposable income and are surrounded by poverty is likely to lead to a rapid growth in the commercial sex industry and an increase in "survival sex" strategies by local women.

The research team made detailed recommendations to protect and promote the health of the workforce and the broader community, including preventive and curative services to be integrated with or complementary to the existing state services. The major recommendation was that all clinics in the area should be able to treat STIs optimally: this requires properly trained staff, adequate facilities and drugs. In addition, all clinics needed to promote and supply condoms and promote partner notification by STI clinic attenders. Expanded access to voluntary counselling and testing for HIV was recommended. Because of the high costs of STI tests, only syphilis testing was recommended for antenatal and STI clinic attenders. All initiatives should be co-ordinated with the Ministry of Health's STI control plan, to ensure integration and sustainability in the longer term, particularly when the construction phase finishes and company health services cease.
An education programme was proposed to increase HIV/STI awareness and to improve health- seeking behaviour. It was also proposed that training programmes for community health workers and traditional birth attendants should be provided in consultation with the national STI programme. A health information system would need to be established to monitor disease trends and a cross-sectional study, similar to the baseline study, should be conducted at the completion of the project to determine the impact of the construction programme.
The report stressed that the proposed measures had to be included in the contractors' contracts as a non-negotiable condition. Attempting to "retrofit" these measures once the contract has started is much more difficult as contractors are obviously resistant to measures that were not budgeted for.

Lessons learned

In hindsight, the recommendations were too biomedically focused. Other suggestions could have included: using local labour and/or bringing in men with their families to avoid having a large predominantly male work camp; employing female workers to reduce gender-related income inequities; having a sex worker outreach programme; providing ready access to STI services and condoms; and making more specific recommendations in regard to care of HIV-infected workers and community members.

All too often these baseline studies are done because it is a requirement of the funding rather than because real action will be taken based on the findings. A major concern was that the recommendations would be shelved and not acted upon. The research team had noted that subsequent to a previous baseline survey for an earlier phase of this development project, almost none of those recommendations had been implemented. Nevertheless, as the economic and social impacts of HIV/AIDS become increasingly apparent, large donors see the importance of taking HIV/AIDS into account in the planning and implementation of the projects they fund. The World Bank, for example, has commissioned South African consultants to assess the feasibility of designing an AIDS Impact Assessment (AIA) toolkit that may be integrated into the existing Environmental Impact Assessments, which are an automatic part of any development project.