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Squaring the circle: AIDS, poverty and human development
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October 2007
Peter Piot, Robert Greener and Sarah Russell
UNAIDS


It is often asserted that AIDS is at the core of a “vicious circle”, whereby the impacts of AIDS increase poverty and social deprivation, while poverty and social deprivation increase vulnerability to HIV infection. In examining this view, it is important to distinguish between what might be called the “downstream” effects of AIDS on poverty, and the “upstream” effects of poverty upon the risk of acquiring HIV.

The “Upstream Effects”: Poverty and Vulnerability to HIV

Generally speaking, there is a strong association between poverty and ill health—wealthier countries and wealthier individuals enjoy better health as measured by a variety of indicators such as life expectancy or incidence of waterborne diseases. Many researchers have had the same expectation about AIDS, which has often been described as a “disease of poverty” [1].

There is one fundamental difference, however, between AIDS and other health problems generally linked with poverty. Unlike diseases such as tuberculosis and malaria, HIV is mostly transmitted through sex.

This brings into play the economic perspective around reward and dependency, which influences theextent to which individuals are able to make and exercise choices about sexual behaviour. Recent evidence clearly indicates that AIDS is a disease of inequality, often associated with economic transition, rather than a disease of poverty in itself.

Undeniably, more people live with HIV in poor countries than in rich ones. More than 60% of people living with HIV inhabit the world’s poorest region: sub-Saharan Africa. Nevertheless, studies during the early stage of the epidemic suggested that HIV incidence initially occurred not amongst the poorest, but among betteroff members of society in this region. A decade later, infections still appear more concentrated among the urban employed and more mobile members of society, and consequently the more wealthy groups, as can be seen in Table 1 [2].

It is important to note that HIV prevalence is very high in all of the wealth quintiles—including quintile 1, the poorest (the wealthiest is quintile 5). While there is abundant research that documents the mechanisms that lead from extreme poverty to HIV vulnerability [3], the data now indicate that the less well-studied risk factors among the better-off in fact dominate the aggregate picture. The fact that most people living with HIV in the region today are poor simply reflects the fact that the epidemic has now spread throughout the generalized population in a region that has a high proportion of poor people.

Whether the patterns observed in this part of Africa will also emerge elsewhere remains to be seen. In Asia, for example, epidemics have so far been mostly concentrated in sex workers (and their clients) and drug users, who are often very poor. Infection patterns are now influenced by rapid economic development, which has increased the movement of both men and women in search of opportunities within and across borders. And here, as in Africa, mobility correlates to higher rates of HIV infection.

Many researchers now point not to poverty itself but to economic and gender inequalities and weakened “social cohesion” [4] as factors influencing sexual behaviour and hence the potential for HIV transmission. Some, notably Amartya Sen [5], have looked at poverty as an outcome of poor governance. It has been suggested that, by extension, regimes that do not focus on the well-being of populations impoverish their citizens, deny their enjoyment of basic human rights, and erode public health—exacerbating both the upstream and downstream effects of AIDS. This assertion clearly warrants further research.


Footnotes:
  1. afrol News (2002 October 4) WHO calls HIV/AIDS ‘Disease of Poverty.’ Available: http://www.afrol.com/Categories/Health/health026_aids_poverty.htm. Accessed 19 September 2007.
  2. Mishra V, Bignami-Van Assche S, Greener R, Vaessen M, Hong R, et al. (2007) HIV infection does not disproportionately affect the poorer in sub-Saharan Africa. AIDS (supplement). In press.
  3. Kalichman SC, Simbayi LC, Kagee A, Toefy Y, Cain D, et al. (2006) Association of poverty, substance use, and HIV transmission risk behaviors in three South African communities. Soc Sci Med 62: 1641–1649.
  4. Barnett T, Whiteside A (2006) AIDS in the twenty-first century: Disease and globalization. 2nd edition. New York: Palgrave Macmillan. 416 p.
  5. Sen A (2000) Development as freedom. New York: Oxford University Press.

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