Internationally, the drive to scale up HIV & AIDS testing and increase the number of people who know their serostatus has gained increasing impetus. The Millennium Development Goals (MDGs) highlight as their sixth objective the drive to combat HIV & AIDS, Malaria and other diseases. Specifically, they seek to “have halted by 2015 and begun to reverse the spread of HIV & AIDS” and “achieve, by 2010, universal access to treatment for HIV & AIDS for all those who need it.”^(2,3) In responding to this endeavour, the United Nations (UN) has called on communities worldwide, at both macro- and micro-levels, to respond to this challenge. HIV Counselling and Testing (HCT) represents a central mechanism in mobilising and capacitating the process of discovery and action in this regard.

It is clear that society and industry alike are deeply and pervasively affected by HIV & AIDS. In addition to the numerous personal, relational and socio-cultural impacts of the virus, its far-reaching consequences pose a significant economic burden in the workplace.⁽⁴⁾ Priya Bery, director of policy and research at the Global Business Coalition on HIV & AIDS (GBC), has highlighted that corporations do not function in isolation. Not unlike the nations they serve, they are deeply affected by the global HIV & AIDS crisis.⁽⁵⁾ Of particular relevance here is that HIV & AIDS affects the labour force in a number of ways- the most productive segment of the working population is depleted, productivity and earnings decrease, labour costs increase and skilled, experienced workers are often lost. It is a combination of these factors that cause enterprises across the board to suffer.^(6,7) With the majority of those affected by HIV being in the prime of their working lives, it is becoming increasingly clear that workplace interventions are a critical forum for prevention activities. Thus the call to action is a timeous one, and the efficacy of HCT in this context cannot be undervalued.

Given this increasing focus on the importance of HCT in the workplace, it is of interest to assess the current state of HIV & AIDS activities in the business sector. This paper therefore begins by describing current activities and policy developments that are taking place in the business world. Thereafter, HCT is contextualised within workplace programmes. Barriers to progress due to stigma continue to present a threat to these programmes and therefore the nature of this dynamic is discussed, and compared with positive steps that have been taken. A number of success stories in workplace HCT programmes are highlighted, and the paper closes with a reflection on the potential implications of HCT in the corporate world.

Taking action in the business sector

The International Labour Organisation (ILO) has set forth a code of practice regarding HIV & AIDS and the working world. The first tenet of this code states: “HIV & AIDS is a workplace issue, and should be treated like any other serious illness/condition in the workplace. This is necessary not only because it affects the workforce, but also because the workplace, being part of the local community, has a role to play in the wider struggle to limit the spread and effects of the epidemic”.⁽⁸⁾ This statement highlights the integral role that businesses must play in catalysing action to prevent further spread of the virus. Furthermore, Bery suggests that in sub-Saharan Africa, at the epicentre of the problem, corporations simply must become involved in prevention efforts.⁽⁹⁾ For example, the South African Business Coalition on HIV & AIDS (SABCOHA) has begun to establish a community fund which aims to make HCT services available to vulnerable employees and industries, as well as their families and broader communities.⁽¹⁰⁾

Consistent with this, a number of businesses have begun to incorporate HIV & AIDS programmes into their organisational policies. HIV education campaigns and wellness days have become integral parts of employee well-being curriculums.⁽¹¹⁾ Additionally, a smaller proportion of these enterprises have endeavoured to increase the number of employees aware of their serostatus, and have developed supportive care and treatment services, including HCT for employees and their family members.⁽¹²⁾

HCT and organisational testing programmes

As highlighted previously, HCT is widely regarded as one of the central intervention and prevention strategies against the spread of the HIV & AIDS epidemic. Further, HCT has come to be seen as one of the core aspects of national HIV & AIDS plans in a number of developing countries. This is due to its ability to act as a risk behaviour assessment and education forum, as well as being a relatively cost effective intervention when compared with other strongly resource dependent programmes.⁽¹³⁾ In addition, and complemented by the drive to increase the accessibility of antiretroviral therapy (ART), the counselling and testing environment has become crucial opportunity for counsellors to make appropriate and timely referrals to the newly diagnosed.⁽¹⁴⁾

Dependent on the nature of the organisation, different mechanisms for the operationalisation of this process exist. Some businesses, and particularly larger corporations, offer specific on site testing facilities- normally within employee wellness centres. In other instances, testing services might be made available to employees by mobile testing units facilitated by external service providers. In this context, counsellors conduct HCT in mobile facilities, for example vans, tents or containers, which provide a compact setting for these services.

Stigma as a barrier to testing for HIV & AIDS

Despite the touted importance of testing, the number of people who are actively aware of their serostatus remains low. Recent studies have indicated that the median percent of people who know their serostatus in sub-Saharan Africa remains below 40%.⁽¹⁵⁾ It has also been noted that even when structured testing programmes have been put in place, it is often the case that the number of employees who make use of these services is too low.⁽¹⁶⁾

Stigma, as well as the associated discrimination, continue to present one of the most influential and detrimental barriers to individuals’ decisions to test for HIV. Stigma in this context refers to a particular discrediting attribute which by its possession reduces and casts the individual as tainted and deserving of denigration.⁽¹⁷⁾ It has been shown that people infected with or affected by HIV & AIDS continue to experience stigma, discrimination and social marginalisation on a daily basis.⁽¹⁸⁾ Skinner and Mfecane have highlighted how stigma is strongly linked to dominant social, political and economic power systems, and has the capacity to significantly affect the global health of the individual, as well as their specific functioning within each of these contexts.⁽¹⁹⁾

In response to this facet of the lived HIV experience, the second tenet of the ILO’s code states that “In the spirit of decent work and respect for the human rights and dignity of persons infected or affected by HIV & AIDS, there should be no discrimination against workers on the basis of real or perceived HIV status. Discrimination and stigmatisation of people living with HIV & AIDS inhibits efforts aimed at promoting HIV & AIDS prevention.”⁽²⁰⁾ However, despite the ethical clarity and inclusivity inherent in this statement, as well as that found in most workplace policies with regard to HIV positive employees, stigma remains an intimidating barrier to the success of testing and treatment interventions.

It is therefore of interest, within the context of this discussion, to consider the nature of intra-organisational stigma, both actual and anticipated. Stigma and discrimination have been found to hamper the implementation and success of workplace HIV & AIDS programmes.⁽²¹⁾ While the potential for efficacy of these endeavours is great, a fear of stigmatisation by colleagues and/or senior staff members presents an often insurmountable barrier to employees’ willingness to test.⁽²²⁾

In one example drawn from a large South African company, stigma and discrimination as well as their impact were assessed.⁽²³⁾ The findings of this study revealed three types of workplace interactions in which HIV & AIDS-related stigma and discrimination might manifest. Firstly, institutional-level stigma reactions include all facets of employees’ experiences with their organisation’s policies and practices. The second category included stigma related to the capabilities of the HIV positive individuals to fulfil their job roles, as well as the risk of casual contact within the work setting. The nature of social interactions within the workplace was the third scenario which emerged. The respondents noted how HIV positive persons would be the targets of gossip and social isolation, and in some cases, even verbal abuse. Problematically, and likely linked to the fear of such discrimination, over 60% of workers indicated that they felt it inadvisable to disclose their HIV serostatus.⁽²⁴⁾

The diagnosis of being HIV positive is regarded as a traumatic and life changing experience, and it is likely that the fear of the anxiety which precedes, and the complicated emotional state in which one might find oneself after the testing experience, may influence an individual’s decision to test. Interestingly, while the provision of workplace HCT is driven in part by the need to enhance accessibility of services, the logistics and specifically, the location thereof can become a confounding variable. Employees may feel intimidated to actually walk into the testing centre for fear of discrimination by their colleagues. The results of a study at a South African mining company note that structural factors like the onsite nature of an HCT campaign caused some concern.⁽²⁵⁾ Workers feared that the results of the test would be publically available as confirmed by the length of the tester’s post-test counselling session. Many workers feared that should others see a negative response or reaction, this would be interpreted as a non-verbal disclosure of a positive serostatus. Confidentiality was seen to be deeply valued by workers, both at a personal level and a company level, with concerns being expressed as to the true aim of the programme (i.e. they feared that the company would discriminate against them as a result of their HIV status).⁽²⁶⁾

A study in Zimbabwe on the uptake of mobile testing services noted that most interviews with those who electively underwent HCT contained themes of stigma.⁽²⁷⁾ Participants noted that a person who is seen to have presented for HCT risked being stigmatised as sick or HIV positive. They further suggested that the consequences of such stigma and discrimination would potentially contribute to ill health on the part of the tester.⁽²⁸⁾ Whilst in the public arena, mobile testing has shown some significant successes,⁽²⁹⁾ it is suggested here that the interaction between workplace ethics and policy structures, and the fear of the types of stigma and discrimination within the workplace discussed previously may affect employees’ willingness to present for testing.

The stigma and discrimination surrounding HIV & AIDS has been described as being not only contrary to human rights, but as can be seen in the above case, a significant impediment to the establishment of efficacious workplace programmes.⁽³⁰⁾ In order to maximise the potential of existent programmes, it seems that tackling intra-organisational stigma- both anticipated and experienced- is becoming an area of concern.

Positive steps and success stories

Consistent with the themes of the ILO Code mentioned previously, research has indicated the pressing need to accompany the implementation of HCT services in the workplace with drives to decrease stigma and discriminatory practices in this context.⁽³¹⁾ The complementary actions of such endeavours would serve to enhance the efficacy of any workplace intervention and prevention programmes.

Some positive strides have been made. A report by the GBC in 2006 suggested that Africa is leading the way internationally with the implementation of HIV & AIDS workplace programmes.⁽³²⁾ Additionally, a number of multi-national corporations are becoming increasingly involved in such programmes. For example, in 2009, Anglo Coal South Africa received the GBC Workplace Counselling and Testing Award. Their programme follows a five pillar approach which includes a focus on “voluntary counselling and testing; awareness, education and prevention; care, support and treatment; partnerships; and commitment to One Anglo's six values.”⁽³³⁾ The value of a multilevel strategy in creating effective interventions is clearly valued in this instance. Further, they note a continuing commitment to creating awareness around its HIV non-discrimination policy- the aim of which is to concurrently reduce stigma and encourage testing. The programme has shown measured success – 94% of the workforce has been tested for HIV & AIDS, including the CEO and executive staff members, who have tested publically to show their commitment to, and investment in, their prevention endeavours.⁽³⁴⁾ The ILO and International Finance Corporation (IFC) have together highlighted how an investment from senior management represents an important source of motivation for other employees.⁽³⁵⁾ One of the most unique and valuable aspects of Anglo Coal’s programme is its commitment to providing ART to all employees and their families should they require it.⁽³⁶⁾ Implicit here is the knowledge that appropriate intervention has both socio-cultural and economic benefits, on macro- and micro-levels, beneficial to both the organisation and the individual employees.

In another example, the 2010 GBC Workplace Award was won by Newmont Ghana Gold Limited. They have been acclaimed for their Malaria and HIV & AIDS programmes, remarkable in their comprehensive cover, and dedication to their employees and their families. With the assistance of the IFC, they have engaged a number of the small and medium enterprises with whom they work, and provided HIV & AIDS training and education.⁽³⁷⁾

Concluding remarks

It is clear that investment at the organisational level has the potential to make a considerable impact on the workplace environment, as well as the attitudes and behavioural practices valued therein. For this to succeed, it is imperative that businesses endeavour to create an environment which encourages employees to know their HIV serostatus. With efficacious programmes in place, the corporate world has the ability to contribute to sustained efforts - both internationally and at local levels - to combating the spread and effects of the epidemic.

Additionally, the possibility for combating the effects of workplace stigma and discrimination towards individuals infected with or affected by HIV & AIDS cannot be undervalued. While progress has been made, there remains considerable room for improvement. Novel interventions, including mobile testing units and onsite testing facilities, represent core resources in mobilising the workforce to take action against stigma, discrimination, and the consequences thereof. The implications of an improved workplace behavioural ecology around HIV & AIDS therefore resonate with the production and maintenance of health, within both the individual and broader corporate and socio-economic sectors.

NOTES:

(1) Contact Deanne Goldberg through Consultancy Africa Intelligence's HIV & AIDS Unit (hiv.aids@consultancyafrica.com).
(2) ‘Goal 6: Combat HIV & AIDS, Malaria and Other Diseases’, MDG Monitor, 2011, http://www.mdgmonitor.org.
(3) ‘Achieving the Millennium Development Goals in Africa’, United Nations, June 2008, http://www.mdgafrica.org.
(4) ‘Fighting HIV & AIDS in the Workplace: A Company Management Guide’, International Finance Corporation (IFC) & The Global Business Coalition on HIV & AIDS, Tuberculosis and Malaria (GBC), 2011, http://www.gbcimpact.org.
(5) Bery, P., 2004. The Changing Role of Business in the HIV & AIDS Crisis. Human Rights: Journal of the Section of Individual Rights & Responsibilities, 31(4), p.17.
(6) Ibid.
(7) ‘An ILO code of practice on HIV & AIDS and the world of work’, ILO, 2001, http://www.ilo.org.
(8) Ibid.
(9) Bery, P., 2004. The Changing Role of Business in the HIV & AIDS Crisis. Human Rights: Journal of the Section of Individual Rights & Responsibilities, 31(4), p.17.
(10) ‘The SABCOHA community fund’, SABCOHA, 2011, http://www.sabcoha.org.
(11) Zellner, S., & Ron, I., 2008. HIV & AIDS services through the workplace: A survey in four Sub-Saharan African Countries. Bethesda, MD: Private Sector Partnerships-One project, Abt Associates Inc.
(12) Ibid.
(13) Morin, S.F., et al., 2006. Removing barriers to knowing HIV status: Same-Day Mobile HIV testing in Zimbabwe. Epidemiology and Social Science, 41(2), pp.218-224.
(14) Ibid.
(15) Bery, P., 2004. The Changing Role of Business in the HIV & AIDS Crisis. Human Rights: Journal of the Section of Individual Rights & Responsibilities, 31(4), p.17.
(16) Ibid.
(17) Skinner, D., & Mfecane, S., 2004. Stigma, discrimination and the implications for people living with HIV & AIDS in South Africa. Journal of Social Aspects of HIV & AIDS, 1(3), pp.157-164.
(18) WHO, 2010. Towards universal access: scaling up priority HIV & AIDS interventions in the health sector: progress report 2010. Geneva: WHO Press.
(19) Ibid.
(20) ‘An ILO code of practice on HIV & AIDS and the world of work’, ILO, 2001, http://www.ilo.org.
(21) Purlewitz, J., Greene, J., Esu-Williams, E., & Stewart, R., 2004. Addressing stigma and discrimination in the workplace - The example of ESKOM, South Africa. Sexual Exchange, 2, pp.9-10.
(22) Mahajana, A.P., Colvin, M., Rudatsikira, J., & Ett, D., 2007. An overview of HIV & AIDS workplace policies and programmes in southern Africa. AIDS, 21(0), pp.S1-S9.
(23) Purlewitz, J., Greene, J., Esu-Williams, E., & Stewart, R., 2004. Addressing stigma and discrimination in the workplace - The example of ESKOM, South Africa. Sexual Exchange, 2, pp.9-10.
(24) Ibid.
(25) Bhagwanjee, A., Petersen, I., Akintola, O. & George, G., 2008. Bridging the gap between VCT and HIV/AIDS treatment uptake. African Journal of AIDS Research, 7(3), pp.271–279.
(26) Ibid.
(27)Morin, S.F., et al., 2006. Removing Barriers to Knowing HIV Status: Same-Day Mobile HIV Testing in Zimbabwe. Epidemiology and Social Science, 41(2), pp.218-224.
(28) Ibid.
(29) Ibid.
(30) Setswe, G.K.G, 2009. Best practice workplace HIV & AIDS programmes in South Africa: A review of case studies and lessons learned. African Journal of Primary Health Care & Family Medicine, 1(1), pp.82-87.
(31) ‘An ILO code of practice on HIV & AIDS and the world of work’, ILO, 2001, http://www.ilo.org.
(32) Mahajana, A.P., Colvin, M., Rudatsikira, J., & Ett, D., 2007. An overview of HIV & AIDS workplace policies and programmes in southern Africa. AIDS, 21(0), pp.S1-S9.
(33) ‘Workplace Testing and Counseling Award Winner (2009): Anglo Coal South Africa’, GBC, 2011, http://www.gbcimpact.org.
(34) Ibid.
(35) ‘An ILO code of practice on HIV & AIDS and the world of work’, ILO, 2001, http://www.ilo.org.
(36) ‘Workplace Testing and Counseling Award Winner (2009): Anglo Coal South Africa’, GBC, 2011, http://www.gbcimpact.org.
(37) 'Workplace Award Winner (2010): Newmont Ghana Gold Limited’, GBC, 2011, http://www.gbcimpact.org.

Written by Deanne Goldberg ⁽¹⁾