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Preventing HIV/AIDS through poverty reduction: the only sustainable solution
Lancet
2004-10-08
Over the past 20 years, HIV/AIDS has had a devastating impact on the lives of millions of people around the world at the end of 2002, an estimated 42 million people were living with HIV/AIDS. Early responses to the epidemic were focused on the identification of individual risk behaviours and the prevention of new infections through modification of these behaviours.
More recently, however, there has been a recognition that individual behaviour needs to be considered within its economic, social, and cultural context, otherwise efforts to alter it will ultimately fail. South African President Thabo Mbeki has highlighted poverty as a factor contributing to the HIV/AIDS epidemic. Although many elements of Mbeki's approach to tackling the epidemic are regrettable, it is useful to consider the role of poverty as a factor contributing to the spread of HIV/AIDS, and the implications of this for prevention efforts.
HIV/AIDS affects many different populations, and occurs in every country in the world however, a disproportionate number of those affected live in the poorer countries of the world. Around 80% of the global population live in developing countries, but these countries are home to 95% of those with HIV/AIDS. At the global level there is a positive correlation between HIV prevalence and poverty, whether this is measured by gross domestic product per person, income inequality, or Human Poverty Index.
The association of poverty with increased HIV prevalence does not necessarily indicate a causal relation, but explanations have been offered at several levels as to how poverty may increase susceptibility to HIV/AIDS. Eileen Stillwaggon has argued that poverty increases biological susceptibility to HIV/AIDS in the same way it does many other infectious diseases. Stillwaggon focuses on malnutrition, parasitosis, and lack of access to health care among the poor, suggesting that these factors undermine epithelial integrity and immunity, and increase the likelihood of having other untreated sexually transmitted infections. All of these influences can increase susceptibility to HIV infection and progression.
Poverty is also often associated with lack of education, and illiteracy can mean that messages regarding risk and prevention are inaccessible. Even with knowledge of the risks, the cost of prevention may be prohibitively high many poor people are unable to afford condoms. Poverty also restricts people's choices and leaves few options but to undertake high risk behaviours. Collins and Rau identify poverty-driven labour migration and commercial sex work as activities likely to increase HIV infection.
Further, perceptions of risk can be affected by the concerns of the present and the probable prospects for the future. When the future is bleak and immediate survival in question, the ability to take a long-term perspective on risk might seem like a luxury. That many people with HIV/AIDS are poor has led some to characterise it as a disease of poverty. However, evidence suggests that in some countries the wealthy are also especially susceptible to infection.
In Africa, HIV prevalence has been shown to be positively correlated with national income, with many of the continent's wealthiest countries, such as South Africa and Botswana, having the most extensive epidemics. Several population level studies have also suggested a positive correlation between HIV infection and socioeconomic status.
There are several possible explanations for these findings. National figures mask the inequalities that occur within countries, and it is likely that the poorest sectors of the population are still the most severely affected. It has also been suggested that in the early stages of the epidemic more wealthy populations were vulnerable to infection because of, for example, greater opportunity to travel. Furthermore, the very occupations that serve to increase individual's socioeconomic status may also increase their susceptibility to HIV/AIDS, for example truck drivers. As awareness of the epidemic has grown, however, wealthier populations have been more able to access prevention messages and the means of prevention, and the pattern of infection might be shifting towards those with lower socioeconomic status.
Thus, poverty is one important factor in increasing susceptibility to HIV/AIDS, and facilitating its spread. HIV/AIDS also increases poverty, at all levels from individual to nation, through its impact on working age populations. The morbidity and mortality among this age group affects household incomes, and is a major challenge to the ability to deliver services such as education. It is important to recognise, however, that there are many other influences besides poverty acting to facilitate the spread of HIV/AIDS. Income and gender inequalities are likely to be as important as absolute poverty, as shown by the high prevalence of HIV/AIDS in countries with large inequalities. Other challenges include finding the political will to combat the epidemic, and the stigma associated with HIV/AIDS.
With respect to policy formulation, there are two conclusions to be drawn from the above observations. First, since poverty plays a role in creating an environment in which individuals are particularly susceptible and vulnerable to HIV/AIDS, poverty reduction will undoubtedly be at the core of a sustainable solution to HIV/AIDS. Therefore, investment in equitable poverty reduction efforts must continue, even in the face of other pressing needs. Second, since poverty is clearly not the only factor contributing to the spread of HIV/AIDS, there is no excuse for taking a fatalistic attitude to the epidemic, in which little can be done until some utopian poverty-free ideal has been achieved.
There is much that can be done now, working within the challenging environment of continued widespread poverty. Political leaders must face up to the issue of HIV/AIDS, and help to create a situation in which the best ways to tackle it can be openly discussed. Stigma must be broken down at all levels. Care, support, and treatment for those already affected by HIV/AIDS are necessary in their own right, and will also help to reinforce prevention efforts.
In this respect the changing attitude of the South African government is to be welcomed, with their recent commitment to work towards access to treatment for all. Reducing poverty will be at the core of a long-term, sustainable solution to HIV/AIDS, as with many diseases. Although efforts to achieve this goal continue, and they must, we also need to consider the immediate steps that can be taken to reduce the spread of HIV/AIDS, and support those affected. (Source: Lancet 2004 364: 1186-87).
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