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Editorial

Investigating the empirical evidence for understanding vulnerability and the associations between poverty, HIV infection and AIDS impact

Gillespie, Stuarta; Greener, Robertb; Whiteside, Alanc; Whitworth, Jamesd

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doi: 10.1097/01.aids.0000300530.67107.45
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It is just over 25 years since the first cases of AIDS were reported. Over this quarter-century, AIDS has become one of most highly studied diseases in history. There have been significant medical advances in understanding the consequences of HIV infection and treating AIDS, as is well documented in many journals, including AIDS. The complex and place-specific social, economic, behavioural and psychological drivers of the spread of HIV remain less well delineated. The consequences of increased illness and death in poor countries and communities are still unfolding.

In 2000, HIV was placed firmly on the global development agenda by UN Security Council Resolution 1308, which stated: ‘the spread of HIV can have a uniquely devastating impact on all sectors and levels of society’. A year later, in July 2001, there was a UN General Assembly Special Session on HIV/AIDS. Since then our understanding of the epidemic and its potential impacts has deepened. This supplement, written by social scientists, looks at how socioeconomic determinants drive HIV spread and how AIDS illness and mortality is impacting on communities.

It is helpful to locate the contents of this supplement in the context of the history of the epidemic. There are three overarching points to be made in introduction. First, the epidemic is complex both in terms of what is driving it and the effects it has. It has been described as a ‘long wave event’. It takes years for the epidemic to spread through society and generations for the full impact to be felt. A recent book highlights the nature of such long wave events [1]. ‘Singled out: how two million women survived without men after the First World War’ describes how in the United Kingdom a generation of women were unable to marry, as the men they would have partnered were dead, killed in the First World War. It is only in the past decade that the last of these spinsters has died. The impacts of AIDS will take even longer to work through the population.

Second, HIV is diverse in its spread. Early fears that the virus would spread rapidly outside Africa have not materialized. For example, the UNAIDS 2006 ‘Report on the global AIDS epidemic’ estimated that there were 5.7 million people living with HIV in India. In July 2007, this was revised downward to 2.5 million, reflecting much less spread of the infection than had been feared [2]. Similar downward revisions of estimates have been made in China. In a recent book, James Chin [3] argued that there are many populations in which heterosexual epidemics will not occur in the general population and the epidemic will remain confined to specific risk groups. Chin's examples of where the potential for HIV epidemics has been overstated are primarily from Asia, and in particular China and the Philippines. This is not to understate the individual tragedy of each infection, but rather to recognize that there are countries where AIDS will have a considerable impact and others where its importance can be downgraded.

It is not just globally that there is wide variation. In mainland sub-Saharan Africa HIV prevalence in adults ranges from 0.7% in Mauritania to 33.4 % in Swaziland. The hardest-hit countries are all in southern Africa; these are shown in Fig. 1, the so-called ‘red’ countries. Adult HIV prevalence exceeds 20% in four of these countries: Swaziland, Lesotho, Botswana and Zimbabwe. South Africa, Namibia, Zambia, Mozambique, and Malawi all have adult prevalence rates in the range of 10–20% [2]. These countries are the focus of this supplement.

Fig. 1
Fig. 1:
Map of adult HIV prevalence in Africa.
Fig. 1
20–34%;
Fig. 1
10–< 20%;
Fig. 1
5–< 10%;
Fig. 1
1–< 5%;
Fig. 1
< 1%.

Third, social science faces problems in addressing the phenomenon of HIV and its consequences. The epidemic is only 25 years old, which means that it, and its effects, are still unfolding. Social science relies on assessing what has happened. This is done through surveys and panel data, and sometimes the picture is at odds with what we expect. For example in the 1980s it was suggested, on the basis of models, that AIDS would cause economies to grow more slowly than otherwise would be the case. In 2007, at the individual country level, this does not seem to have occurred. Uganda had the worst epidemic in the world during the early 1990s yet managed consistent economic growth estimated at 6.5% per annum from 1991 to 2002. Botswana's growth rate over the same period was 5.6%. South Africa has seen steady growth since 1999. Yet it is only through longitudinal and cross-sectional studies that we can hope to understand the impact of the disease. Longitudinal panel data give a picture of what has happened in a population over the period for which the data are collected. An alternative is to gather cross-sectional data: if we can understand what has happened in Uganda will it help predict what might happen in Lesotho? The one thing we have not been good at is predicting the future, although UNAIDS made a brave attempt at this through its ‘AIDS in Africa: three scenarios to 2025’ report launched in March 2005 [4].

A brief history of 25 years of response

1981–1996

The AIDS epidemic was recognized in 1981, initally among gay men in New York and San Francisco [5]. It was officially named ‘acquired immune deficiency syndrome’ (AIDS) in July 1982, and in 1983 the human immunodeficiency virus (HIV) was identified as the cause. The number of cases rose rapidly across the United States and was quickly identified in Europe, Australia, New Zealand and Latin America. In central Africa, health workers were observing new illnesses such as Kaposi's sarcoma (a cancer) in Zambia, cryptococcosis (an unusual fungal infection) in Kinshasa, and there were reports of ‘slim disease’ and unexpectedly high rates of death in Lake Victoria fishing villages in Uganda [6–8]. These illnesses were occurring in heterosexual adults, not just gay men, individuals with haemophilia, blood transfusion recipients, and intravenous drug users, who formed the main groups at risk in developed countries. By 1982, cases were being seen in the partners and infants of those infected [8,9].

The initial response of public health specialists, epidemiologists and scientists was to try to identify what was causing the disease and to understand how it was spreading. This would inform prevention strategies and medical interventions. Early responses were therefore predominantly scientific and technical in nature.

It soon became apparent, however, that this was not enough, and attention shifted to understanding why people were being exposed. This led to early knowledge attitude and practice surveys, which sought to understand high-risk behaviours [3] p.73. This emphasis on prevention gained momentum because medical scientists had not yet discovered drugs that could cure, or even slow, the progress of the disease. Initial optimism for developing an effective vaccine soon faded and is now seen to be many years, if not decades, away.

Internationally, the World Health Organization (WHO) took the lead in response to HIV in 1986; teams visited most developing countries to establish short and medium-term AIDS programmes, which then evolved into national AIDS programmes [10]. International responses to HIV were, however, limited and characterized by denial, underestimation, and oversimplification. HIV was not placed high on the agenda of any other United Nations agency. Although life expectancy was plummeting in certain African countries, for example, the United Nations Development Programme waited until 1997 to take this into account in calculating its human development index [11].

By the 1990s there was a new perspective developing, as interest in the individual, social, and economic milieux that lead to vulnerability to HIV infection began to grow. Academics and programme officers increasingly recognized that social justice, poverty and equity issues were driving the uneven spread of the virus within and between communities and societies [12–15].

1996–2007

In 1996, there were major changes in response to HIV, reflecting and reflected in the scholarship of the time. In the 1994 book ‘AIDS in Africa’ of 33 chapters only three were on preventive strategies and four on socioeconomic impact, the rest were scientific or epidemiological [16]. By 1996, when the second edition of ‘AIDS in the world’ was published, of 41 chapters only approximately 18 were pure science [17].

In 1996, the new UN agency charged with coordinating the response to the epidemic, UNAIDS, began operations in Geneva. This was significant as it acknowledged that the international health body the WHO was not able to respond to the epidemic in all its facets, and there needed to be international coordination for an exceptional disease. At the XIth International AIDS Conference in Vancouver, the arrival of new drugs in developed countries to treat AIDS was announced, and mortality among those being treated plummeted.

At the XIIIth International AIDS Conference in Durban, South Africa, in July 2000, Nelson Mandela, closed the conference with a call for drugs to be made accessible to all. Since then, the response to AIDS has been dominated by new initiatives for making treatment accessible, especially in developing countries. The price of drugs has fallen dramatically with the manufacture of generic drugs.1 In 2001, United Nation's Secretary General, Kofi Annan, called for spending on AIDS to be increased 10-fold in developing countries, and the Global Fund for AIDS, TB and Malaria was established. The same year, President George W. Bush announced the Presidential Emergency Plan for AIDS Relief (PEPFAR) targeting 15 developing countries. In 2003, the WHO and UNAIDS proclaimed the ‘3 by 5’ plan, to treat 3 million people in poor countries by the end of 2005.

Over the decade from 1996 to 2006, more financial resources than ever before were made available for the response to AIDS, with emphasis increasingly on making treatment available in developing countries. In 1996, there was approximately US$300 million for HIV/AIDS in low and middle-income countries; by 2006, this increased to US$8.3 billion. It is noteworthy that this response, largely a result of treatment becoming available and affordable, led to a ‘remedicalization’ of HIV/AIDS.

It is not clear why southern Africa has been so hard hit by HIV. Socioeconomic variables, cultural factors and sexual behaviour all play a role. Poverty, income inequality, sex inequity, long-term concurrent partnerships, the lack of male circumcision, and the prevalence of co-infections are factors that have been identified and need further examination. There are no easy solutions to curbing the spread of the epidemic. There are countries, outside southern Africa, where the epidemic appears to be under control: Uganda brought early hope to Africa by showing how high levels of political commitment and community-led responses can work to stabilize HIV prevalence. In other locations, such as Tanzania, infection rates peaked at a lower level than those currently seen in most of southern Africa.

The focus of this supplement is on bringing together and understanding the data on the socioeconomic dimensions of the epidemic. It came out of a meeting sponsored by UNAIDS and hosted by the Health Economics and HIV/AIDS Research Division of the University of KwaZulu-Natal held in Durban from 16 to 18 October 2006. The aim of the symposium was to bring together people, especially those involved in field research, to share knowledge and experience and to address gaps in our understanding of the spread of HIV and impact of AIDS. In particular, we were looking for community-based longitudinal studies currently being carried out in Africa.

The outputs of this meeting were to be a review of the main longitudinal socioeconomic data collections in Africa with a bearing on HIV, the publication of the participants' best papers, and an opportunity to network and share ideas.

The meeting was a qualified success in that papers were presented and we have this interesting and thought-provoking supplement. There are, however, a number of caveats, and these cut to the heart of the issues we are dealing with. South African research and papers dominate. Of the 10 papers we publish, seven are from South Africa, two compare data from across the continent and one is from Zimbabwe. This is also true of the authors, the vast majority are either South African or based in the developed world. Clearly, there are real issues with developing capacity in African countries. The global emphasis is on delivery not research, but, as this supplement shows, quality data and good science are essential.

Of the ten papers, there is a good thematic spread with four papers focusing on drivers, four on impacts and two on both. What do the papers tell us? Put simply, the causes and consequences of the epidemic are complex and policy needs to take this into account.

Although poor individuals and households are likely to be hit harder by the downstream impacts of AIDS than their less poor counterparts, their chances of being exposed to HIV in the first place are not necessarily greater than wealthier individuals or households. It is too simplistic to refer to AIDS as a ‘disease of poverty’. As an infectious disease, it is appropriate that the primary core response to HIV focuses on public health prevention strategies and on medical treatment and care. But if we are to make further strides in combating the epidemic we need broad-based prevention, that is, prevention that deals with the contextual environment and the underlying socioeconomic, behavioural and psychological drivers of the epidemic. Like the virus, these strategies need to cut across all socioeconomic strata of society.

On the downstream side, although AIDS impoverishes households, its effects are not uniform. Again, appropriate responses need to take account of the context-specificity and dynamic nature of the stresses, shocks and local responses brought by AIDS, so that mitigation measures are appropriately designed.

Finally, as is always the case with a publication, there are people who need to be thanked. In Durban, Marisa Casale took charge of organizing the meeting. UNAIDS sponsored both the meeting and publication. Alan Whiteside's time was largely supported through a DFID Research Partners Consortium grant. Stuart Gillespie's time was supported by the RENEWAL programme through support from Irish Aid and the Swedish International Development Cooperation Agency, and by UNAIDS. We also acknowledge the extensive inputs of Suneetha Kadiyala of the International Food Policy Research Institute throughout the preparation of this supplement.

Conflicts of interest: None.

References

1. Nicholson V. Singled out: how two million women survived without men after the First World War. London: Viking; 2007.
2. UNAIDS. 2006 Report on the Global AIDS epidemic. 2006. Available at: http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp. Accessed: September 2007.
3. Chin J. The AIDS pandemic: the collision of epidemiology with political correctness. Oxford: Radcliffe Publishing; 2006.
4. UNAIDS. AIDS in Africa: three scenarios to 2025. Geneva: UNAIDS; 2005.
5. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep.
6. Bayley A. Aggressive Kaposi's sarcoma in Zambia. Lancet 1984; ii:1318–1320.
7. Hooper E. The river: a journey back to the source of HIV and AIDS. London: Allen Lane/The Penguin Press; 1999. Copyright Edward Hooper 2000.
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13. Gruskin S, Hendriks A, Tomasevski K. Human rights and the response to HIV/AIDS. In: Mann J, Tarantola D, editors. AIDS in the world II. Oxford: Oxford University Press; 1996.
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16. Essex M, Mboup S, Kanki PJ, Kalengayi MR. AIDS in Africa. New York: Raven Press; 1994.
17. Mann J, Tarantola D, editors. AIDS in the world II. Oxford: Oxford University; 1996.

Presentation by Peter Graaf of the HIV/AIDS Department of the WHO to an ‘Informal technical consultation on the relevance and modalities of implementation of an observatory for HIV commodities in Africa’ organized by Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu Natal, the World Health Organization, and Swedish/Norwegian HIV/AIDS Team on 25 June 2007.
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