economic resources. Care and support for orphans will be a growing concern, and traditional inheritance and other legal rights will be challenged.

AIDS is one of many diseases with potentially great economic significance for developing countries. Diseases such as malaria and measles are far more prevalent in Africa, yet there are reasons to believe that the economic impact of AIDS will be greater. First, the fatality of AIDS and the duration of the illness increase its impact per case relative to other causes of morbidity. The long incubation period of HIV implies that the economic impact of existing levels of infection will be felt for 10 years or more, even if all infection were to cease today. The benefits of averting a case of HIV (19.5 discounted healthy life-years) are very high relative to other diseases (Over and Piot, 1993). By this measure, HIV ranks lower than neonatal tetanus, but higher than other widespread illnesses such as malaria, tuberculosis, and measles.

Second, HIV is likely to have a greater economic impact than other endemic diseases because it affects primarily adults in their economically most productive years (see also Chapter 3). In Africa, illness and death due to AIDS are concentrated among two age groups: newborn children, who acquire it perinatally, and adults between ages 15 and 50, who acquire it largely through sexual transmission. If one were to weight the years gained by averting a case of HIV by their productivity, HIV would rank highest among all diseases in terms of the value of preventing a case (Over and Piot, 1993). Adults aged 15 to 50 are usually the economic backbone of their families and their communities, on whom both young children and elderly parents rely for support. The illness and death of these economically active prime-age adults result not only in lower incomes for surviving family members, but also in all the other sequelae of poverty, including worsened health and reduced investment in the survivors' future productivity.

Third, unlike many other endemic diseases, AIDS does not spare the elite. Levels of HIV prevalence among high-income, urban, and relatively well-educated men and women are as high as those among low-income and rural groups, if not higher. Because wealthier, more-skilled, and better-educated subsets of the population have higher levels of consumption and investment, command higher wages, and are more likely to be employers, any disease affecting this group relatively more than other groups is likely to have a greater economic impact per case.

It is becoming increasingly evident that there is considerable divergence of opinion between industrialized and developing countries about the appropriate allocation of resources among various components of an African national AIDS control program. Industrial countries prefer to respond to the current and impending impact of the epidemic in Africa by donating their energy and resources to biomedical research and various prevention activities, while African governments feel an obligation to allocate resources not only to prevention, but also to mitigation of the direct impact on individuals and households already affected by the virus.



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