HIV/AIDS and Economic Development

Enrique González

Introduction

When AIDS first appeared at the beginning of the 1980s, it was mostly considered a problem of public health. And because infection of the HIV virus was associated to determined sexual practices, in some countries there was even the dilemma of regarding AIDS as a question of ethics and morality or of public health. Of course, the discussion of that dilemma missed the point, for besides being a problem of public health, AIDS has become a concern for economic development.

With 26 million infections projected by the end of the century(1), the HIV/AIDS epidemic is at present one of the world’s most pressing concerns. The dimensions of the epidemic are changing dramatically, and the need for long-term care and prevention, especially for the growing population of youth and women infected, is leading to new approaches to what has become both a health and a development concern.

In this essay we analyze, in the next section, the impact¾ present and potential¾ of the HIV/AIDS epidemic in economic development. We pay particular attention to the fact that at present the epidemic is concentrated in adults in their most productive years, and seems to be shifting to adolescents; which would imply a concentration in that group in future years. The extraordinary expenses of the HIV/AIDS treatment and losses due to the epidemic are analyzed in third section, since this is a topic that deserves ample discussion.

The fourth section deals with the importance of devoting more resources, and using them in more effective ways, to prevention efforts. This is particularly important for Latin American countries, and in general for developing nations, since a country does not have to be rich to be successful in prevention. Finally, the fifth section presents the conclusion.

Impact of HIV/AIDS on development

The per capita product is adversely affected

In the long run, productivity (output per worker) is almost all that matters for economic development. A country’s ability to improve its standard of living over time depends almost entirely on its ability to rise its output per worker. To be fair, as a matter of pure arithmetic and at least in a closed economy(I), there are three ways to raise a country’s consumption per capita:

a) Increasing productivity, so each worker produces more.
b) Putting a larger portion of the population to work.
c) Putting a smaller fraction of the country’s output aside as investment for the future and devoting more of the country’s productive capacity to manufacturing goods for current consumption.

Indeed, AIDS affects the three ways to improve a nation’s welfare, and the following arguments might contribute to reinforce the denomination of economics as "the dismal science". First, AIDS affects productivity because, as an illness, it implies fewer work days, lesser opportunities to obtain better-paying jobs, and shorter working lives(II). Besides, healthier workers earn more because they are more productive. It is worthwhile to point out that when AIDS strikes, an individual’s lost output and earnings often go undetected in economic statistics because they are borne by the household. This is because in many developing countries unemployment (or disability) insurance is rare, and healthier members of the household work harder or longer to make up for the loss in family income. Also, the effects of losing an adult to AIDS persist into the next generation as children are withdrawn from school to help at home.

As a matter of fact, AIDS remains much less common in the developing world than diseases such as malaria, but its economic impact per case is greater for two reasons:

1. It mainly affects adults in their most productive years. AIDS, affecting as it does mainly people in economically productive adult years, has powerful negative economic effects on households, productive enterprises, and countries. In Latin America, for example, about 90 percent of HIV/AIDS cases are concentrated in men and women¾ -but mostly the former¾ between 25 and 45 years old. Also, because so many of its victims are heads of households or parents, AIDS devastates families.
2. The infections resulting from HIV/AIDS lead to heavy demand for expensive care. Heavily infected countries have found their health systems burdened with costly cases of AIDS-related opportunistic infections. If the HIV/AIDS epidemic continues unchecked, the accelerated demand for health care for AIDS patients will crowd out the needs of other patients. Section 6.3. analyses in more detail the costs of HIV/AIDS.

About the next clause (putting a larger portion of the population to work), this is a good opportunity to discredit the argument that, in labor-intensive and high-unemployment developing countries, AIDS is not a real problem because dead or ill workers will be replaced with unemployed-eager-to-work people. This argument can work as long as there are enough unemployed and eager to work people to replace unable to work persons, but even in countries with the highest unemployment rates, this "reserve army" would eventually disappear in the presence of a non-cure-as-yet illness, such as AIDS. In the presence of such an illness full employment would finally be achieved. What would be next? If a cure remains elusive (or even if a cure is available but prohibitively costly for developing countries, as could very possibly be the case of an AIDS cure), and if AIDS cases grow¾ as they have the potential to do¾ faster than the labor force, then production will be adversely affected, since total labor force in the full employment economy will start to decline, and again social welfare will suffer.

In a study about the costs of AIDS in El Salvador, Nicaragua and Guatemala,(2) it was found that an employee with AIDS is active in the labor force for only 10 years, compared to 25 to 30 years for an average Central American worker, suggesting a 60-70 percent decline in a worker’s lifetime production. The study reports that approximately 1 in 300 to 350 adults are currently infected with HIV in the three countries under study, and it projects that for the year 2000 this prevalence rate is likely to double, so that by then there will be 70,000 to 160,000 HIV infections.

What about the third clause? To start with, putting aside a larger fraction for consumption purposes, and in detriment of investment, is not a long-term way to increase consumption, since we can consume more for a while by investing less now, but that will surely cut into our ability to consume in the future. But even if the present generations choose to consume more now at the expense of their consumption later or their descendants consumption, AIDS hinders this possibility. This is so because the extremely high costs of AIDS treatment divert resources from consumption.

As a corollary, these same very high costs would prevent investment to rise¾ in case society as a whole would choose to defer consumption now¾ since those costs will impede people from saving for future higher living standards. The costs of HIV/AIDS deserve indeed a wider discussion, since diversion of scarce resources in capital-starving developing countries is a matter of considerable importance.

Corporations would do well getting involved

It is important to recall that, just as AIDS has become a concern for economic development, it must also become a concern for the private sector¾ not only for the public sector¾ , since private firms might be severely affected by the epidemic. Because of AIDS, the expenditures of businesses might rise due to increased health care, retraining and insurance, while revenues can be expected to decline due to absenteeism and the reduced productivity of replacement workers.

Although much of the formal employment in developing countries¾ including Latin America¾ is assembly type (for example the "maquiladoras" or in-bond firms in the northern Mexican border) rather than in research and development, the horizon of corporations aims to maintain an inexpensive, flexible work force with competitively low overhead costs. This leaves little room for planning for the effects of an infection with a 10-year latency period.

Multinational corporations, which may have active health programmes in their home offices in North America or Europe, unfortunately have not extended their efforts to the overseas subsidiaries(3). Despite the growing threat from AIDS, corporations continue to see the epidemic as a health issue for public health authorities to deal with, and not their business.

So the task is to convince the private sector¾ both multinational and domestic companies¾ in developing countries that it ignores the HIV/AIDS epidemic at its own peril. The reality of the costs of AIDS to business is not now a part of strategic thinking in the corporate community involved in developing countries. However, if unchecked, the HIV/AIDS epidemic will rob business of highly trained and expensive to replace workers.

Furthermore, as more and more people spend their money on healthcare for AIDS, they will have less available income, and companies will find shrinking markets for their goods and services. In Thailand, one of the most affected middle-income developing countries, the economic impact on household expenditure has been significant when a family member is affected by the disease. More than half such households have had their consumption of goods and services reduced by 40-60 percent by the direct costs of the disease. One-third of households also suffered a loss in family income, and 60 percent of households were forced to draw on their own savings(4).

Youth and AIDS

According to Dr. Chittick(5), there is a developing, potentially devastating wave of HIV/AIDS quietly spreading among the world’s sexually active adolescents. This new wave does not discriminate. Any adolescent who is currently having unprotected sex, especially with more than one partner, is at greater risk of becoming infected in the near future. And the threat is growing more dangerous as the teenage pool of sex partners becomes increasingly contaminated with HIV over the remaining years of this decade.

The problem of HIV/AIDS among youth becomes more complicated because current AIDS prevention programs that target high-risk (by behavior) groups have had little impact on adolescents who believe in their youthful invulnerability. Since AIDS among teen-agers is currently not perceived in most communities, it is easy to assume that HIV poses little danger to adolescents even when they are sexually active. Not only does AIDS go unnoticed but usually most parents and communities rarely discuss the threat with young people.

While some prevention campaigns have contributed to safer sex practices and to the postponement of sexual activity among teen-agers, AIDS prevention instruction in school programs is commonly ineffective and infrequent, if not completely absent, particularly in developing nations. The reality is that youth are increasingly at risk because adults choose to ignore their responsibility to give adequate information to teen-agers. Until the risk is made real, HIV/AIDS has the potential to expand exponentially among youth.

Over the last fifteen years of the HIV/AIDS epidemic, median ages for AIDS cases have been dropping incrementally. UNAIDS and the Harvard´s AIDS Institute now report higher HIV infection rates among youth(5). Indeed, many people who develop AIDS-related diseases in their twenties or in their thirties probably contracted HIV in their teens. Economically, since plentiful young labor is one of the few economic assets of developing countries, and the resources for capital substitution are very limited, the relative effects in terms of economic productivity are likely to be markedly greater than in developed countries.

Today’s youth travel more widely than previous generations. Many adolescents are leaving rural homes in search of urban jobs, often crossing borders and migrating to different parts of the world in search of better living opportunities. This is the case for several Latin American countries¾ particularly Mexico¾ where young people migrate mainly to the United States looking for better job opportunities. As a result, these young people¾ who are in their sexual prime¾ find themselves strangers in a foreign environment where new customs replace familiar traditions. Often without parental and societal structures to guide them, newly bicultural teen-agers are more vulnerable to unknown dangers. Unable to quickly master a new language and the nuances of a different culture, young immigrants remain uniformed about the consequences of their high-risk behaviors. If they later return to their family homes, as often indeed happens, HIV/AIDS travels with them, which is a factor in the rapid spread of AIDS globally.

HIV/AIDS costs

AIDS has a heavy macroeconomic impact due partly to the high costs of treatment, which divert resources from productive investments. Because individuals with AIDS are typically more prone to pneumonia, diarrhea, and tuberculosis, the cost of medical care is high even though there is no effective treatment as yet for the disease itself. More specifically, the costs of HIV/AIDS are commonly classified into direct and indirect:

Direct costs

These are the costs of health and social care, including both personal care, and non-personal services such as blood screening, health education, staff training and research. According to the World Bank(1), in 1992 developing countries spent about $340 million to care for AIDS patients. Although this is only a small fraction of the $4.7 billion spent by industrial countries to care for their AIDS patients, it is still nearly twice the amount the dveloping world spent on AIDS prevention. If spending per patient remains constant, the amount spent on the care of AIDS patients in developing countries will more than triple, to $1.1 billion in 2000.

Other estimates of the treatment costs of persons with AIDS in developing countries include those of Over et al.(6). These estimates, however, are based on expert opinion due to the absence of data and should therefore be considered preliminary Nevertheless, the results presented in Table 1 are indicative of the range of AIDS treatment costs prevailing in developing countries.

Table 1. Treatment Costs of AIDS in Selected Developing Countries*

*Note: Brazil, estimates are 1988 U.S. dollars; Mexico, 1985 U.S. dollars; Tanzania and Zaire, 1986 U.S. dollars. All estimates include both inpatient and outpatient treatment costs. The low and high estimates correspond, respectively, to the most modest and the most comprehensive health care options available in the country. The average cost will typically be closer to the low than to the high end of this range.

Source: Over et al 1988; Tapia and Martin 1990; Over and Piot 1993.

A main finding of these estimates is that the cost per patient varies considerably, both across countries and within a country. Most cross-country variation in costs is caused by differences in wage rates paid to health-care providers which tend to vary with levels of per capita Gross National Product (GNP). Treatment costs per case exhibit a range within a country for two main reasons: (i) variation in the clinical symptoms which manifest themselves and (ii) variation in the socioeconomic characteristics of the patient and the medical and institutional characteristics of the available health-care options(7) .

Table 1 also shows that, with the exception of the high limit of treatment cost in Zaire, the low and high limits of that cost represent a higher proportion of GNP for the Latin American sample countries than that for the African nations. Treatment costs for AIDS patient go as high as almost 6 times GNP per capita in the case of Brazil.

The poorest countries tend to exhibit greater cost variation on a percentage basis, because only a small proportion of all illness episodes are treated in a relatively high-cost hospital setting. Cost variation exists in industrial countries, but to a lesser degree, because widespread insurance coverage provides better access to hospital care for a greater proportion of the population and standard treatment is used on a wider basis.

Estimates of costs of treatment of AIDS patients have also been calculated for Central American countries. Galia(2) reports that the cost of treating each patient with AIDS during the final stage of illness is estimated to be between $600 and $3,000 in El Salvador, Nicaragua and Guatemala, with costs as high as $6,000 at some private hospitals.

The macroeconomic impact of HIV/AIDS in developing countries has also been investigated. Hancock(8) estimates how the disease is likely to affect the macroeconomy of Kenya. The analysis takes into consideration morbidity effects (increased spending on health services and increased absenteeism) and mortality effects ( a smaller and less experienced labor force) to determine how AIDS may affect Kenya’s Gross Domestic Product (GDP).

The study projects that by the year 2005, Kenya’s GDP will be nearly 1/6th smaller than it otherwise would have been had AIDS never occurred. Furthermore, per capita income is projected to decline by 10 percent as a result of AIDS. This loss was attributed to a loss in labor productivity, a reduction in investment and savings, and changes in the labor market supply and demand. The study also predicts that Kenya’s savings rate will decrease by 15 percent by the year 2005 as a result of AIDS.

Indirect costs

These are the costs of economic production lost through morbidity and mortality, including estimates for the value of unmarketed production, such as housekeeping tasks and subsistence agriculture. Health authorities have tended to ignore these costs. However, as a fatal disease of young, mainly male adults, AIDS represents a substantial loss of working years. Studies in industrialized countries suggest that these costs might be five to six times higher than the costs of health care and research(9,10).

Some estimates of the indirect costs of the AIDS epidemic use the so-called "human capital approach"(III, 11,12) according to which morbidity costs are wages lost by people who are unable to work because of illness and disability, and mortality costs are the present value of future earnings lost by people who die prematurely.

Mortality costs are concentrated among males in theirs most productive years, and they have been found to represent about 94 percent of total indirect costs, which in turn were estimated at around US $55.6 billion in the United States or almost seven times the direct medical care costs(9).

The human capital approach admittedly underestimates the value of the healthy life year of under-employed and unemployed individuals and perhaps overestimates the relative value of a life-year of an individual whose salary is based more on monopoly rents than on contribution to society. Nevertheless, measuring the productive years of healthy life lost to a disease by the average income per year can at least provide some provisional guidance to the decision-maker faced with the problem of inter-sectorial resource allocation.

Other costs

If indirect costs are often ignored in calculating the AIDS burden, there are still other HIV/AIDS related costs that are even more often ignored, but that must be taken into account:

1. Direct invisible costs. These are represented by services provided by family, friends and charities. Although unpaid, these services nevertheless represent a real consumption of resources, and hence a real cost. These costs are commonly ignored, since they are not covered by health agencies´ budgets, and also because there are often no available data from which to estimate them. However, their omission can lead to suboptimization in choosing care strategies.
2. Indirect invisible costs. These are the costs of intangible reactions and lower quality of life through factors like pain, incapacity, fear, anxiety, isolation, stigma, depression, etc. These costs are clearly important for AIDS, but are so difficult to evaluate that no study to date has attempted to estimate them.

Why more resources should be allocated to prevention

Prevention yields enormous benefits

The good news is that the potentially devastating effects of the HIV/AIDS epidemic can be checked through prevention with relatively modest resources. As was stated before, a country does not have to be rich to be successful in prevention efforts. The desireability of prevention in the case of HIV/AIDS is considerably important given the vast benefits of preventive action and the enormous future costs incurred in the absense of it. Indeed, since there is no vaccine or cure for AIDS, primary prevention is the only way to fight the disease.

According to Over and Piot(6), case management of HIV or AIDS through the prophylactic administration of an antiviral agent like azidothymidine (AZT) is clearly not a cost-effective option in developing countries. This situation could change dramatically, if the price of antiviral therapy drops dramatically, but at present, drugs such as AZT are enormously expensive, have severe side effects, and may, at best, delay the onset of AIDS and prolong life to some extent. One year of AZT costs more than $3,000, a prohibitively high figure. Treatment options in many low-income nations are therefore limited to alleviation of pain and management of the opportunistic infections¾ most commonly, tuberculosis, diarrhea, and candidiasis¾ that afflict HIV-infected persons. Strategic planning can greatly reduce costs through the use of a small number of less expensive drugs and outpatient or community treatment where possible.

Prevention might involve relatively modest costs and, if effectively implemented, yield enormous benefits. The World Bank reports that research in nine developing and seven high-income countries suggests that preventing a case of AIDS saves, on average, about twice GNP per capita in discounted lifetime costs of medical care, and in some urban areas the saving may be as much as five times GNP per capita(1).

The benefits of prevention must also take into account that in the case of communicable diseases, and especially of epidemics like that of HIV infection, calculation must include the fact that each primary case prevented also prevents secondary and tertiary cases.

Current annual worldwide expenditure on AIDS prevention is about $1.5 billion a year. Perhaps less than $200 million of this is spent in developing countries, where 85 percent of all infections occur. A recent study for The World Health Organization´s (WHO) Global Program on AIDS suggested that comprehensive AIDS and sexually transmitted diseases (STDs) prevention services for all developing countries would cost $1.5 billion to $2.9 billion a year. This is ten to fifteen times current spending, but it would yield enormous benefits. The estimated number of new adult HIV infections averted by such spending between 1993 and 2000 would be about 9.5 million¾ -4.2 million in Africa, 4.2 million in Asia, and 1.1 million in Latin America(1).

Worldwide experience during the past decade has demonstrated that successful HIV prevention requires three basic elements: (i) information and education, (ii) health and social services, and (iii) a supportive social environment. Some lessons that have been learned from past efforts of prevention and community care include the following (IV, 13):

1. The widely observed weak efficacy of information-based education for HIV prevention is the result of too little attention to predisposing conditions of risk in the social environment. And, furthermore, similar social risk factors also affect HIV disease progression.
2. The implication for practice suggests a shift in emphasis from risk behavior to risk conditions¾ the psychosocial, contextual factors which set up risk of transmission and unnecessarily rapid disease progression.
3. Because so little is known about the influence of particular risk situations, and since risk conditions are so much influenced by local social dynamics, AIDS prevention efforts should shift in emphasis from information distribution activities to information exchange activities, highlighting dialogue and analysis of experience among participants.
4. An enormous community development task must be undertaken in raising consciousness in society, in affected communities and in AIDS organizations about the health implications of the social environment related to HIV.

"Core" groups and prevention

Although it is important to give priority to the social conditions that might favor the spread of VIH/AIDS, it is also important to recognize the convenience of identifing people at particularly high risk of acquiring and transmitting HIV infection (core groups). High-risk groups may include sex workers, migrants, members of the military, truck drivers, and drug users who share needles.

It is important to note that the cost-effectiveness of interventions drops sharply when infections cross from high-risk groups to the general population. In the absence of adequate preventive action, AIDS spreads rapidly in the "core" groups, followed by a slower and then accelerating spread in the general population. Early and effective targeting of HIV interventions is critical because the cost-effectiveness of these interventions diminish as the infection moves out of the high-risk, high-transmission core groups. The large number of new sexual contacts in the core groups means that each HIV case avoided in this group can avert more than ten times as many additional infections as can a case avoided in the general population.

A combination of strategies, backed up with adequate resources, is required for stemming the spread of AIDS. Crucial elements in these strategies are providing information on how to avoid infection, promoting condom use, treating other sexually transmitted diseases, and reducing blood-borne transmission. These measures are especially cost-effective when targeted at the relatively few people in the core groups.

On the other hand, even knowing that it is highly cost-effective to address prevention efforts as early as possible to populations at highest risk, it is also essential to provide universal messages to the general population to prevent discrimination against those being targeted, to convey information to those who intermittently practice high-risk behavior, and to build up popular support for the lifting of restrictions on sales of condoms, needles, and syringes.

Preventive efforts must reach populations with diverse needs; for example, core groups, young people, and women. Preventive programs for the population at large are less cost-effective than targeted programs but are needed to increase awareness and understanding of AIDS and STDs, to reduce discrimination against infected persons, and to prepare the way for subsequent interventions when levels of infection rise. Monogamy might be encouraged as part of public information efforts to curb the spread of HIV, but it cannot be the only strategy; even where it is the societal norm, not all individuals adhere.

Prevention among youth

Since, as said before, there is presently no cure nor vaccine for HIV/AIDS, the only viable tool we have to stop the increasingly rapid spread of HIV/AIDS among youth is education. Research suggests that before teen-agers commit themselves to changing their high-risk behaviors, they need to experience the reality of AIDS. Since HIV is not readily apparent in the adolescent population because of the time-lag between HIV seropositivity and the appearance of AIDS-related diseases, the messenger becomes more crucial to the process. Evidence is mounting that peer AIDS teachers can have a major impact on youth decision-making which is already heavily influenced by peer pressure and by the desire for independence from adult authority figures.

Vulnerable teen-agers want to hear the best medically-sound information from well-trained peers -- and whom they can trust explicitly to provide unexpurgated facts about HIV´s sexual transmission and the safer precautions they could choose to take. Many teen-agers report that they feel a close affinity for their peers and are willing, even eager, to become peer AIDS educators.

Different studies suggest that prevention among teen-agers does have positive results. For example, Jingqi reports that: "We can see that the HIV/AIDS prevention education at secondary school is essential, feasible and effective in China [and that] sex education does not lead to early sexual activities for adolescents"(14). Similarly, other authors have found that peer pressures and cultural messages about sex affect adolescents´ decisions about their sexual behavior (V, 15, 16).

In particular, a community-based project known as H.E.A.R.T. (Health Education and Research Team) in Belle Grade, Florida(17) was begun in 1992 to reduce the spread of HIV among African-American and Haitian adolescents aged 13-18. Through peer education and outreach, the intervention aimed to change adolescents´ behaviors by increasing i) awareness of HIV transmission and prevention, ii) access to and use of condoms, and iii) access to adolescent clinic services. The results were very favorable, with teenagers in Belle Glade significantly increasing their knowledge about HIV and dramatically changing their behavior toward safer sexual practices.

Projections

The urgency of increasing prevention efforts becomes evident when we look at the projections available, which, if anything, indicate that the HIV epidemic is bad and is getting worse. It is difficult to predict the future course of the epidemic because so little is known about the dynamics of HIV transmission. An estimated 9 million people worldwide carried the HIV virus in 1990 and as many as 26 million could be infected by 2000, when 1.8 million people would die of AIDS each year, according to WHO estimates. More than 80 percent of those infected lived in developing countries in 1990; by 2000 this figure will increase to an estimated 95 percent.

These estimates are conservative, since they assume that the rate of new infections in Africa will slow somewhat and that new transmission will be concentrated in India and in other Asian regions. If no effective interventions to slow transmission are introduced, and given the short time it takes infection rates to double in many developing countries and the rapid spread of the disease to countries that previously had low numbers of infections, total figures in 2000 may be two or three times higher than the above projections.

If, however, sexual behavior changes dramatically over the next decade, even the conservative projections given here may prove too pessimistic. Relatively modest reductions in numbers of casual sexual partners, or in the prevalence of STDs¾ or, alternatively, substantial increases in condom use¾ could reduce transmission significantly. Early (and still tentative) findings from Thailand are encouraging; perhaps behavior really will change.

AIDS has to be approached as a national development issue. National leadership is crucial; the most effective programs, such as Thailand’s, pursue strategies that involve many agencies, in and outside government, in an atmosphere of openness and frankness.

Indeed, in 1991 researchers projected that the aggregate direct and indirect cost of AIDS could be as high as $8 billion over the next decade and that AIDS could have negative effects on tourism, foreign investment, and labor remittance receipts from abroad. They argued, however, that a major preventive effort, with the goal of reducing numbers of sexual partners by at least one-half, doubling condom use, and treating STDs, could mean 3.5 million fewer infections and more than $5 billion in savings by 2000.

A global coalition is needed that will encourage and assist governments to take bold action before it is too late. Without a substantial increase in political commitment and leadership¾ as well as additional resources to support the effective prevention of AIDS¾ the HIV epidemic could cause a health disaster and an enormous setback for development.

Conclusion

In this essay we have exposed a problem¾ the potentially devastating effects of the HIV/AIDS epidemic on public health and economic development¾ and we have proposed a solution to check that problem, namely, to increase prevention efforts, concentrating them on core groups.

It is of utmost importance to increase without delay the prevention efforts, which involve a very modest cost when compared with the direct and indirect costs of an uncontrolled HIV/AIDS epidemic. The decision maker has the alternative of taking bold actions now using relatively small resources, or suffer tomorrow, having to use considerably higher amounts of resources.

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I. An open economy, i.e,.one which trades goods and services abroad, can also increase its welfare by: (i) borrowing abroad, and then importing more than exporting, or (ii) getting a better price for its exports so it can afford more imports without borrowing abroad. See Krugman (1994).
II. This is true for all illnesses, but below we will see why AIDS is a special case and its economic impact per case is greater.
III. See for example Hardy (1986) and Scitovsky (1986).
IV. See AIDS Vancouver (1996).
V. See Sells and Blum (1996) and Post and Botkin (1995).

Suggested References

Krugman P. The Age of Diminished Expectations. The MIT Press, Cambridge, Mass, 1994.

Over M, Bertozzi S, Chin J, N´Galy y Nyamureykunge. The Direct and Indirect Cost of HIV Infection in Developing Countries: The Cases of Zaire and Tanzania. En: In A.F. Fleming et al eds. The Global Impact of AIDS. New York: Alan R. Liss Inc., 1988.

Tapia R, and Martin A. "The Costs of AIDS in Mexico", Trabajo presentado en la VIth International Conference on AIDS, 1990 June 20-23, San Francisco, CA, USA.

References

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3. Alberts C, Tarantola D, Bezmalinovic B. The Response of Multinational Corporations to HIV/AIDS. Xth International Conference on AIDS, Yokohama, 1994, Japan.

4. Janjareeon WS. Economic Impact of Adults AIDS Related Death on Rural Households in Chiang Mai Province. Regional AIDS Conference Asia and the Pacific. Chiang Mai, Thailand, 1995 Sep. 17-21. (Abstract B804).

5. Chittick JB. The Rationale Behind TeenAIDS-The Coming Wave. Harvard University Lecturer and Speaker 11th International AIDS Conference Session ("Prevention in Youth"), Vancouver, Canada, 1996 July 7-11.

6. Over M and Piot HIV Infection and Sexually Transmitted Diseases. En Jamison D, Mosley H, Measham A, Bobadilla JL, eds. Disease Control Priorities in Developing Countries. New York: Oxford University Press, 1993.

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16. Post SG, Botkin JR. Adolescents and AIDS Prevention: the Pediatrician´s Role. Clin. Ped 1995; 34:41-45.

17. Fox L, Bailey P, Johnson H, Odom D J. Adolescents in Belle Glade, Florida. XI International Conference on AIDS, 1996 July 7-11, Vancouver, Canada.