Trade union involvement can greatly improve workers’ access to suitable healthcare. Romano Ojiambo-Ochieng outlines the options

Many countries with high HIV prevalence either lack national health schemes or have schemes that do not function properly. Trade union leaders are therefore left with the essential challenge of negotiating with employers for the provision of free or subsidised medical treatment for workers.

A general HIV/AIDS policy calling for the care and protection of HIV-positive workers will not in itself be enough to ensure that they get access to proper support via the workplace, and does not guarantee that they will feel confident enough to come forward and use the services on offer.

NUTRITION AND HIV TREATMENT Proper nutrition helps to boost the body’s immune function, reducing the risk of chronic illnesses and contributing to a better overall quality of life. On the other hand, food and nutritional insecurity can precipitate HIV/AIDS, prevent effective treatment and undermine efforts to provide care and support. The significance of adequate food and nutrition in mitigating the effects of HIV and AIDS is a well-established fact that is increasingly gaining recognition. While antiretroviral therapy (ART) is being scaled up to reach those most in need, a preliminary survival period of positive living is necessary for large numbers of other people living with HIV. Adequate and nutritious food plays a central role in the care and support of people with HIV. In order for HIV positive people to remain active and healthy they need approximately 10 to 15 per cent more energy and 50 to 100 per cent more protein per day than non-HIV-infected people. Integrating food security with universal access to HIV/AIDS care would not only mean a longer life for many individuals, but could have important spill-over effects by enabling more HIV positive people to continue living active and productive lives. Supported by a healthy lifestyle, people with HIV can continue contributing to household income, caring for families and adding to the general wellbeing of their communities. Adherence to ART, and its effectiveness, are significantly influenced by access to adequate food and nutrition. It is evident that people on ART who receive food supplementation recover much faster.   Yet little progress has been made in integrating nutrition interventions into HIV/AIDS programmes and policies. In June 2006, the United Nations General Assembly Special Session dedicated to HIV/AIDS (UNGASS) took a major step forward with the inclusion of Article 28 in the Declaration of Commitment on HIV/AIDS. The article underlines the resolve of governments to ensure that “…as part of a comprehensive response to HIV/AIDS, all people at all times, will have access to sufficient, safe, and nutritious food to meet their dietary needs and food preferences for an active and healthy life”. Much as the evidence is clear, and an effective campaigning tool is now available, the challenge still remains. Work needs to be done first to raise awareness of the existence of Article 28, and then to explore the potential for using it to secure action in the workplace. Labour unions should engage employers and governments in advocacy for the provision of adequate food and nutrition to workers as part of their campaigning to fight HIV/AIDS at work. Workplace HIV/AIDS policies and programmes should, as much as possible, address this aspect.

In Africa, most companies offering healthcare provision require that an employee should get a referral letter from the company’s human resources section in order to access treatment. This can be a source of stigma for HIV-positive employees, who will often therefore seek facilities outside the workplace, where they can act without the knowledge of the employer.

Reducing fear

Labour unions should negotiate not only for the provision of care and support services for their members, but also for measures to ensure that employees who access them have no fear of job loss or stigmatisation.

In some organisations, for example, an employee seeking treatment or support need only present positive identification and a letter of employment at any contracted facility offering these services. The facility then sends a bill to the company using an anonymous identification number, which does not disclose the particulars of the employee. Other employers use an insurance company to administer the scheme on an anonymous basis, as part of the general health insurance.

- Collaboration with the public sector for the provision of services is another option -

In essence, the method used should ensure that the employer does not come to know the identity of individuals seeking the services, unless the worker personally volunteers information. The employer should be in a position to know only the total number of employees accessing the services, for statistical and planning purposes.

Mobilising resources

Some organisations can afford to provide in-house services for their workers and dependants. They may form linkages and partnerships with other organisations, such as local governments, NGOs or donor agencies, for provision of those services that they cannot provide themselves or that are best provided outside the workplace, such as home-based care. These types of partnerships are usually contractual arrangements.

Organisations may also adopt contracted-out financing options, such as health insurance and HIV disease management programmes. The contracted-out services may be fully paid for by the company or through employer and employee contributions.

Other employers set up “solidarity funds”, whereby employee contributions cover the cost of treatment and care. Contributors pool their resources, and understand that the fund will be used to pay for treatment or care when individual members need it. This scheme is especially helpful where the employer cannot afford the cost involved in providing care and support, and for self-employed workers or those working in the informal economy, where financing health care is a challenge.

The International Labour Organization’s Global Programme on Strategies and Tools against Social Exclusion and Poverty (STEP) is promoting a similar approach. This entails the development of programmes known as “mutual health funds”. Small enterprises and informal economy operators (such as informal trade associations, informal economy cooperatives, women’s and youth associations) in a number of countries are establishing these schemes.

Taking the test? HIV testing and counselling is a gateway to HIV treatment, care and support and can greatly contribute to prevention by reducing high-risk sexual behaviour among individuals who already know their HIV status. In 1998, the United Nations issued guidelines on HIV/AIDS and human rights, which strongly support voluntary HIV testing as a critical part of the fight against AIDS. The ILO Code of Practice on HIV/AIDS and the world of work also supports this approach. Consequently, most official national and workplace policies on HIV/AIDS recognise and emphasise that people should get tested on a voluntary basis. Of late however, a number of voices calling for mandatory HIV testing have started emerging from both individuals and organisations. Proponents of compulsory testing believe that forced testing for HIV can help to stem the spread of HIV/AIDS by alerting infected people of the need to get treatment and act responsibly. Some suggest mandatory annual HIV tests as a requirement for medical insurance programmes and that all employers should insist on proof of an HIV test (though not the result) before offering a candidate a job. Critics of such proposals however, argue that mandatory testing would violate human rights and could leave HIV-positive people open to social stigmatisation should their status become widely known. Given the rampant discrimination and threat of job loss against those who test positive, many workers will find the practice of mandatory HIV testing discomforting, however well intentioned it may be. Even with voluntary counselling and testing, some workers have been hesitant to take the test, as they fear that the employer will come to know the results and may use this to discriminate against them. This is especially so where testing is initiated by employers and/or carried out at the workplace. Reassurance and incentivisation Despite their fears, large numbers of workers do choose voluntarily to be tested for HIV in workplaces where proper sensitisation has taken place. The task for unions is to encourage workers to know their HIV status, while being in a position to reassure them not only that a positive result will not be used against them at work, but that it will trigger a process of treatment, care and support that will allow them to live a longer and more productive life. A number of ITF affiliates have already negotiated and/or lobbied for workplace programmes that advocate for job protection and non-discrimination against HIV-positive workers, as well as for information and education on HIV/AIDS for all workers. Some unions have gone one step further and initiated education activities that encourage their members to go for HIV testing. It is essential that any move by unions to encourage testing by their members, should be backed up by the guarantee of care and support for those found to be positive.

Collaboration with the public sector for the provision of services is another option, particularly for companies in countries that have extensive public sector treatment programmes. Here organisations align their treatment and care efforts with government programmes and facilities, as well as purchasing care services – such as access to voluntary counselling, testing and diagnostic services – from the public sector.

Help with costs

While planning workplace care and support programmes there is a need to consult with insurance companies and pension plans to gain a wider understanding of the costs that can be incurred in making these programmes operational. This is particularly useful when workplaces are restructuring employee benefit schemes as part of their response to HIV/AIDS.

In some cases, the existence of an HIV/AIDS workplace programme can be used to negotiate lower insurance rates. Some medical insurance schemes run by health care providers include “free” HIV/AIDS counselling, testing and treatment services.

Labour unions can use collective bargaining to mobilise workplace action in the area of care and support. A collective bargaining process can take place in parallel with the development of a workplace HIV/AIDS policy, or it can be modified when the workplace policy is in place.

The participation of labour leaders in the formulation and implementation of workplace policies and programmes on HIV/AIDS will enhance the acceptability and uptake of the care and support services they provide.


Romano Ojiambo-Ochieng is the general secretary of the Amalgamated Transport and General Workers’ Union of Uganda (ATGWU).