AIDS, Poverty Reduction and Debt Relief - A Toolkit for Mainstreaming HIV/AIDS Programmes into Development Instruments (UNAIDS, 2001, 48 p.): Appendix 1. Links between HIV/AIDS and Poverty

AIDS, Poverty Reduction and Debt Relief - A Toolkit for Mainstreaming HIV/AIDS Programmes into Development Instruments (UNAIDS, 2001, 48 p.)

		(introduction...)
		Acronyms and abbreviations
		Foreword
		Summary
		1. Introduction
		2. The National AIDS Programme as a Contribution to Poverty Reduction
		3. The Essential HIV/AIDS Content in the PRSP and HIPC Documents
		4. Uses of Funds Released Through HIPC - Earmarking, Channeling, and Accountability
		5. Influencing Policies
		6. Conclusions
		References
		Appendix 1. Links between HIV/AIDS and Poverty
		Appendix 2. Indicators
		Appendix 3. Selected Websites on AIDS, Poverty and Debt Relief
		Back Cover

Appendix 1. Links between HIV/AIDS and Poverty

AIDS causing or deepening poverty

The relationships are examined at the levels of the individual, the household and the national economy. Once infected, the individual faces direct catastrophic costs in terms of health and social care, plus indirect costs in terms of lost productivity. The household is more likely than not to experience reduced income. Business productivity is more likely than not to decline, due to lost productivity, high absenteeism, increased payments for treatment and funerals, as well as increased costs of training and retraining of replacements for dead workers. Figures A1 and A2 indicate the pathways from HIV infection to increased poverty.

Figure A1. HIV/AIDS induces and deepens poverty

Poverty and income inequalities increasing the likelihood of HIV infection

The plausible pathways by which poverty and income inequalities increase an individual’s chances of becoming infected with HIV are perhaps indirect. Increased vulnerability to HIV infection is important because it increases the probability of transmitting or becoming infected with HIV. In this regard, poverty may reduce an individual’s ability or willingness to avoid becoming infected. For example, income poverty may lead people to engage in high-risk income-generating activities such as commercial sex work. Commercial sex workers may engage in sex without condoms for the sake of higher fees. Poverty is often associated with lower education, which may in turn be associated with lower awareness of effective measures to prevent HIV infection. Figure A2 and Box A1 indicate the plausible pathways through which poverty leads to increased risks of HIV infection. As yet, there is not sufficient systematic evidence to support an assertion that poverty causes AIDS. While it is highly likely that some of the characteristics of poverty (e.g. lower educational level, fewer livelihood choices, lower capacity to negotiate safe sex) also increase the risk of being infected with HIV, it would be overly simplistic to see HIV purely as a “disease of the poor”. Many groups and individuals at increased risk of being infected with HIV in Africa (urban elite who purchase sex, travelling businessmen who have casual sex, officers in the armed forces) are not among the poor. At this stage of the epidemic, HIV/AIDS continues to cut across household economic boundaries.

For prevention, it is evident from the literature that in the short to medium term, the high-impact interventions are those that reduce the risk of transmitting the virus or the risk of becoming infected. Risk factors are those elements that increase directly the probability that an individual will become infected with HIV or transmit HIV to another person. Interventions focusing on vulnerability reduction are structural or more deep-seated development challenges. They could have indirect effects on the dynamics of the epidemic. Clearly, they need to be addressed for medium- to long-term success against HIV/AIDS. However, the dynamics of the epidemic are such that failure to act on risk reduction would result in a substantially larger number of infected persons, further limiting the gains from structural interventions against vulnerability.

Figure A2. Poverty increases the likelihood of HIV infection and AIDS

Box A1. Does poverty increase the likelihood of HIV infection?

In the early years of the HIV/AIDS epidemic, persons of higher socioeconomic status were more likely than others to become infected with HIV. As HIV/AIDS becomes endemic in most African countries, the positive correlation between socioeconomic status and HIV infection could be expected to disappear. The evidence is mixed, as indicated in the following paragraphs. Among the issues needing attention is the combined effect of poverty and income inequalities in social transactions -including sex, patterns of vulnerability and patterns of risky behaviour in relation to HIV infection.

· UNAIDS analysed the results of studies conducted mostly among 15-19-year olds in 17 African and four Latin American countries. A risk pattern, seen in both sexes, was that better-educated individuals were generally more likely to have casual partners (UNAIDS, 2000a). The results also suggested that the best-educated people in the hardest-hit countries in Africa may be shifting towards less risky behaviour (UNAIDS, 2000a). Although it is too soon to tell, this pattern seems like that in Brazil, where there has been a shift in the socioeconomic distribution of AIDS cases: in the early 1980s, three-quarters of those newly diagnosed with AIDS had a secondary or university education; by the early 1990s this share had fallen to one-third (Parker, 1998).
· Poverty and illiteracy might be expected to raise the probability of infection with sexually transmitted diseases, including HIV/AIDS, since people with low incomes may be less able than those with higher incomes to afford condoms or STI treatment and those with little education may have less access to information about the dangers of high-risk behaviour or may be less able to understand prevention messages. This explains why, for most STIs, the poor and uneducated have higher infection rates (Lacey et al., 1997). It also appears to be the case for the spread of HIV in industrialized countries (Cowan et al., 1994; Krueger et al., 1990; McCoy et al., 1996).
· In the first decade of the HIV/AIDS epidemic in Africa, HIV infections did not follow this pattern. A number of studies showed a positive correlation between HIV infection and socioeconomic status, measured by schooling, income or occupation (Ainsworth and Semali, 1998). Analysis of data from demographic and health surveys carried out during the early 1990s and surveys of sexual behaviour sponsored by the WHO Global Programme on AIDS (GPA) conducted in 1989-1991 shows that the probability of having a non-regular or commercial sexual partner rises with education, potentially increasing exposure to contracting STIs, including HIV (Filmer 1998; Deheneffe et al., 1998). The demand for commercial sex and/or the ability to support multiple partners would rise with income. Also, persons with higher education and higher incomes have more disposable cash and are more likely to travel - thus having more opportunities for casual sex.

· Aggregate income alone is not a predictor of trends in HIV prevalence: intra-country social and cultural factors play important roles in the dynamics of the epidemic. While well-meaning expressions like “poverty causes” AIDS may appear implicitly pro-poor, they may actually hamper condom promotion and other on-the-ground prevention efforts (Halperin, 2000).