Africa: HIV/AIDS and Poverty, 10/31/00

Africa: HIV/AIDS and Poverty, 10/31/00

Africa: HIV/AIDS and Poverty Date distributed (ymd): 001031 APIC Document

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Region: Continent-Wide Issue Areas: +economy/development+ +security/peace+ +gender/women+ Summary Contents: The posting contains an analysis of the two-way connection between HIV/AIDS and failed development, adapted for APIC from a longer paper produced for the United Nations Research Institute on Social Development (UNRISD, Geneva) by Joe Collins and Bill Rau. Rau is an independent consultant and member of the Board of Directors of the Africa Policy Information Center. He has worked on development issues for over 20 years and on policy issues relating to HIV/AIDS for eight years. References have been removed in this version, but are available in the longer paper, which will be available later this year on the web site of the UNRISD (

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HIV/AIDS and Failed Development

Joe Collins and Bill Rau

HIV/AIDS continues to cut into the fabric of African households and societies. It is not uncommon to hear that a quarter to a third of the adult population in several African countries are HIV infected. Against this reality of a rapidly spreading epidemic, some two decades of prevention interventions have met with but limited success. Whatever successes there might be are not to be lightly dismissed. The reasons for those successes, however, are not well understood and thus not readily applicable elsewhere. To date, most prevention efforts have focused on increasing individual awareness about risks of transmission and promoting individual risk reduction through a variety of means.

Far less attention has been given to either understanding or designing prevention programs in light of the social and economic context in which individuals live. It is commonplace for HIV/AIDS program managers to acknowledge poverty as a causative factor, but to then say that "poverty" is beyond the scope of their programs. Instead, top-down analyses and decisions about prevention have shaped public health responses. While the urgency spawned by an epidemic often requires quick decisions and implementation, and while the HIV/AIDS epidemic is of urgent concern in many countries and to many social groups, HIV/AIDS is now too pervasive and too deeply embedded in society to be "managed" through top-down public health approaches alone. Placing the epidemic within the context of a set of development issues and drawing upon the resources and experiences of local initiatives might at first appear to step back from the urgency demanded by an epidemic; in fact, it is the only effective response.

Poverty and HIV/AIDS

Poverty is a key factor in leading to behaviors that expose people to risk of HIV infections. The United Nations Development Program, for example, argues that poverty aggravates other factors that heighten the susceptibility of women:

"A lack of control [by poor women] over the circumstances in which the intercourse occurs may increase the frequency of intercourse and lower the age at which sexual activity begins. A lack of access to acceptable health services may leave infections and lesions untreated. Malnutrition not only inhibits the production of mucus but also slows the healing process and depresses the immune system."

The relationship between poverty and HIV/AIDS is "bi-directional":

* Poverty is a factor in HIV transmission and exacerbating the impact of HIV/AIDS.

* The experience of HIV/AIDS by individuals, households and even communities that are poor can readily lead to an intensification of poverty and even push some non-poor into poverty. Thus HIV/AIDS can impoverish or further impoverish people in such a way as to intensify the epidemic itself.

The extent of impoverishment in the world today is truly staggering. According to an internationally adjusted standard of absolute poverty, sub-Saharan Africa has four times as many poor people as non-poor. 1.2 billion persons are forced to live on less than one dollar a day. Poverty and gender are inextricably intertwined. Women and girls are disproportionately represented among the poor. Seventy percent of the world's poor are women. It is poor women who are most susceptible to HIV infections, for gender alone does not define risk.

When we call people "poor" we are in danger of forgetting that they are made poor. Poor people are really impoverished people. They are impoverished by inequitable socioeconomic structures on the household level, on the village level, on the national level, and on the international level of trade and commerce. This becomes clear as we look at AIDS as one in a series of "shocks" experienced by the majorities of people in developing countries.

Poverty, Migration and HIV

The epidemiological relationship between migration and HIV is well established. A study in Senegal found that 27 percent of the men who had previously traveled in other African countries and 11.3 percent of spouses of men who had migrated were infected with HIV. In neighboring villages where men had not migrated less than one percent of the people were HIV positive. High HIV prevalence rates in areas of high out-migration have been documented in Mexico, Senegal, Ecuador, and in the south-east of Ghana. Rural communities in West Africa known for out migration (mostly to the southern areas of Cote d'Ivoire) such as the area of Tambacounda in Sengeal, Sikasso in Mali, the district of Manya Krobo in Ghana, the area of Mono in Benin and the Otukpo Local Government Area in Nigeria are recording HIV infection rates two to three times that of the national rates. Using 1993 data, a study of migrants in Kenya concluded: "Independent of marital and cohabitation status, social milieu, awareness of AIDS, and other crucial influences on sexual behavior, male migrants between urban areas and female migrants within rural areas are much more likely than non-migrant counterparts to engage in sexual practices conducive to HIV infection. In rural areas, migrants [returning] from urban places are more likely than non-migrants to practice high-risk sex."

The risks of HIV/AIDS associated with migration are well known to both men and women. Women in rural Tanzania a few weeks before Christmas told researchers that they lived in fear of their husbands coming home for Christmas since they thought they would be "bringing AIDS." In some places female sex workers return, also with some money and often HIV, and in search of a husband.

In a related way, sites of large construction projects have been facilitated the spread of HIV. Most of the workers are single men (unmarried or without their spouses). With their wages, usually ready availability of liquor, and peer support, they induce women into either short or longer-term sexual relations. Workers at the Katse Dam construction site in Bokong, Lesotho, were found to have seroprevalence rates nearly seven times as high as people in nearby villages. In Mpumalanga, South Africa, HIV/AIDS and other STDs have increased dramatically, "Thanks to a multi-million dollar infusion of cash to develop the area." Infrastructure construction has not only attracted large numbers of men, but with the wages they can offer rural women and schoolgirls money, food, and clothing in exchange for sexual favors.11 AIDS is but One in a Series of "Shocks"

As a socioeconomic process, HIV/AIDS is just one more problem on top of many others. Tanzanian social scientist Gabriel Rugalema investigated the impact of AIDS in a village in the severely affected northwestern part of his country. He wrote of people's views of the epidemic:

"In general, they did not think of AIDS as something terribly new. Rather, they saw it in the wider context of other crises predating it. During and for a few years after World War II, the study area was struck by famine partly due to drought and partly due to rationing imposed by the British colonial government in Tanganyika. ... Most households had to dispose of their assets."

" In the early 1970s, drought led to widespread food shortages in the area particularly in 1973-1974. This was a generalised hunger throughout Tanzania and the situation was made worse by the world oil price shock. . . . A few years later there was olushengo lwa Amin (Amin's war), that is, the 1978-1979 war between Uganda and Tanzania. Although the village is about 72 kilometers from the border it not only received some of the displaced people from the border villages but it suffered the economic disruption wrought by the war. Much of the period from 1970 has been characterized by poor national economic performance and consequently the decline of the coffee crop in the area. The economic downturn has continued with only brief hiatuses in some years."

The Shock of Economic Reform

The economic hardships faced by most Africans over the past two decades (if not longer) came at a time when HIV/AIDS was emerging and spreading. While a direct link between economic reform programs, including structural adjustment programs, and the spread of HIV/AIDS is difficult to draw, the conditions created by the former definitely facilitated the latter. In general, structural adjustment programs have links with the HIV/AIDS epidemic in several ways. They often:

1) Further undermined the rural economy, at the cost of livelihoods and nutritional status; they also caused or intensified economic recessions and led to increased poverty and class and gender inequality.

2) Fostered the development of transportation infrastructure to support the heightened export orientation of the economy. Numerous studies from countries in Africa and India document the sexual networking and the high HIV prevalence along the truck routes.

3) Increased labor migration and urbanization. Both of these phenomena, as already emphasized, preceded structural adjustment programs but increased with the emphasis on an export-oriented growth.

4) Mandated cutbacks in spending on health care and other social services. At the beginning of the 1990s, when resources were urgently needed for HIV/AIDS prevention programs, the average annual per capita expenditure on health by African governments was a mere US $2. In many countries, most notably in sub-Saharan Africa, nothing could have been more inappropriate than decreasing access to health services, given the already very high rates of untreated STDs and non-specific bacterial and vaginal infections, a now recognized leading factor in the spread of HIV infection. Cutbacks in funding for public clinics reportedly also encouraged the reuse of disposable syringes, potentially contributing to HIV transmission.

The Shock of Gender

We have already discussed some of the links between gender inequalities and HIV/AIDS susceptibility and vulnerability. Here we place a sample of the linkages in the context of structural shocks.

* Breakdown of household regimes and attendant securities: Decades of changes in economic activity and gender relations have placed women in increasingly difficult situations. HIV/AIDS has accelerated the process and made "normal" sexual relations very risky. Although poorly documented, the range and depth of women's responsibilities have increased during the era of AIDS. More active care-giving for sick and dying relatives has been added to the existing work load. Children (girls first) have been withdrawn from school, both to save on costs and to add to labor within the household. Thus, HIV/AIDS is facilitating a further and fairly rapid differentiation along gender lines.

* Loss of livelihood: Whether women received remittances from men working away from home, received "allowances", or earned income themselves, AIDS made the availability of cash more problematic. In Malawi, women and men have increasingly taken on work on farms of larger and/or wealthier farmers in order to earn income or in-kind payments, often neglecting production on their own holdings.

* Loss of assets: Again, although poorly documented, fairly substantial investments in medical care occur among many households affected by HIV/AIDS. These costs are dis- investments to the family and survivors. Household food security is often affected in negative ways. In many parts of Africa, women lose all or most of the household assets after the death of a husband.

* Survival sex: Low incomes, dis-investment, constrained cash flow all place economic pressures on women. Anecdotal evidence and some studies indicate that these pressures push a number of women into situations where sex is coerced in exchange for small cash or in-kind payments. Along the Thailand-Burma border, many of the sex workers are young women, caught up in the "green harvest" in which their work is a means to repay loans made to their families by money lenders who recruit young women for the sex industry. Most of the young women return home HIV-positive.

Taken together, these and existing education, employment, legal, and other structural biases facing women, add to the shocks that have disrupted social institutions over the past decades.

Militarism and Armed Conflict

Wars and civil violence have contributed to situations of increased susceptibility. Epidemiologic data is usually lacking in many of the areas of prolonged warfare or civil violence. Thus, data from the early 1990s continues to be cited to describe the HIV/AIDS situation in Congo. It is worth noting, however, that literally all the countries of Eastern and Southern Africa have been engaged in or have experienced repercussions from wars or major civil violence since the mid-1970s. It is in these regions of Africa that the epidemic is most severe.

Warfare presents major opportunity costs for Third World countries. Resources flow to arms and equipment purchases, military salaries, replacement costs, and hundreds of other large and small expenditures. Arguably, these resources in the mid and late 1980s could have been going for desperately need improved access to health care, especially STD treatment and other forms of HIV prevention. In many countries military expenditures in the 1990s (and today) divert needed resources from health care (including support for home health care) as the epidemic means sharply increased needs. Zimbabwe, for example, in 1999 was spending about 70 times on its military presence in Congo as on HIV/AIDS prevention.

Displaced and refugee populations numbering in the hundreds of thousands (and more) have had their lives disrupted by military actions. During the 1994 genocide in Rwanda, "'virtually every adult woman or girl past puberty who was spared from massacre by the militias had been raped' --along with many younger children." As many as 5,000 Rwandese women have had children as a result of being raped. Many of these children have been abandoned. Life in refugee camps often is precarious for women and girls. For example, a high incidence of rape was reported among Somali refugees in Kenya in 1993. Given the high prevalence of HIV/AIDS among soldiers and the violence of rape, clearly rape has become a mode of transmission of HIV.

The Shock of Disillusionment

Many of the shocks have been reviewed at aggregate levels. Less evidence exists on what might be called sub-shocks, the repercussions of larger changes. For example, agricultural marketing reforms produced a ripple effect of shocks for market-oriented small-scale farmers:

Reductions and delays or cutoffs in credit S Delays in supply of hybrid seeds and fertilizers; Disruptions in agricultural extension and veterinary advice; Delays in collection of crops; Crop losses for lack of storage; Delays in payment for crops. One observer notes: "Farmers have struggled on a daily basis to overcome the combined shocks of cattle disease, years of drought, and marketing reforms. The onslaught of HIV/AIDS has further impaired household responsiveness as it cuts into available labour and household resources." To cope with these shocks small-scale/low asset farmers sold their own labor to other farmers, working for low wages or in-kind payments during peak labor periods and not infrequently contributing to further impoverishment.

For young people, these shocks added to the real or perceived insecurity and low returns from agriculture. The sense that they could improve their material well-being from rural enterprises was further eroded. At the same time, the long-established patterns of migration to employment centers were failing to provide as much opportunity for some employment as in the past. Schooling became less of an assurance of advancement. These structural shocks affected the expectations, hopes, and commitments to work within the prevailing economy in the 1980s and 1990s. The system was not working for many young people who increasingly turned to alternatives forms of income generation and/or social support.

Paul Richards makes this point about young men in Sierra Leone, some of whom have been involved in the war there and in neighboring countries since the late 1980s. Young men from Burkina Faso, Sierra Leone and other West African countries found opportunities constricted by economic crises in labor absorbing countries (Cote d'Ivoire and Nigeria). Young people were blocked from economic opportunity in their home areas (where very limited opportunities existed) and through the migrant labor system. The shocks that ran through the system included: Loss of income, Loss of self-respect and confidence, Rejection as "marginal" and unemployed (i.e. street people, thieves, beggars).

Overall, the shocks of disillusionment and social rejection made the long-term prospects of dying from AIDS far less compelling than the immediate needs for food or companionship and social acceptance in a military unit. Richards writes: "HIV/AIDS cuts short the normal life expectation, and already [c. 1999] young people in Tanzania make it clear that they have to work with the space they will get. Life has to lived to the full but perhaps over 30-40 years rather than a normal three score years and ten." A study of young people in central Ghana uncovered similar attitudes that may not be fully generalizable but definitely reflective of the situations in which many young people find themselves. "Such attitudes to death in the era of AIDS point to apparent misunderstanding or lack of motivation for behavioural change in the existing socioeconomic circumstances." In other words, the attitude can be expressed as: "Why change my sexual behavior when I see little hope for improvements in life's opportunities." It seems that such attitudes are not statements of fatalism, but of disillusionment and realism.

In sum, quick, dramatic, prolonged and stressful shocks have shaped the environment in which HIV/AIDS has found fertile ground. Several of the shocks noted here are a direct outcome of development paradigms pursued by international donor agencies. Other shocks reflect deep structural factors (some social and cultural, others political and economic) that have made many societies and specific groups within society especially vulnerable to conditions conducive to HIV transmission. The HIV/AIDS epidemic is one more disaster visited upon impoverished people. The epidemic calls into question what in so many countries and international arenas has been called "development" as well as the means used to achieve it. As Dr. Roland Msiska, a senior policymaker in Zambia in relation to HIV/AIDS, has stated: "Is HIV a symptom of development gone wrong? If the answer is yes then we need to tackle the disease 'development,' as we deal with the symptom "HIV."

It follows, then, that the ways "development" have been practiced over the past several decades are not appropriate, either for the well-being of most African people or for containing the HIV/AIDS epidemic. Most international development institutions (including USAID) continue to pursue development models that do not address the needs or interests of most population groups, but money continues to be awarded to these organizations. Alternatives do exist, especially in the experiences of smaller, community-based groups, advocacy NGOs, and select development and women's groups. Those alternatives are explored further in the full paper.


Message-Id: <> From: "APIC" <> Date: Tue, 31 Oct 2000 17:31:42 -0500 Subject: Africa: HIV/AIDS and Poverty

Editor: Ali B. Ali-Dinar

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