Essay Squaring the Circle: AIDS, Poverty, and Human Development Peter Piot, Robert Greener, Sarah Russell*

This brings into play the economic which has increased the movement perspective around reward and of both men and women in search dependency, which influences the of opportunities within and across extent to which individuals are able borders. And here, as in Africa, to make and exercise choices about mobility correlates to higher rates of sexual behaviour. Recent evidence HIV infection. clearly indicates that AIDS is a disease Many researchers now point not of inequality, often associated with to poverty itself but to economic and economic transition, rather than a gender inequalities and weakened disease of poverty in itself. “social cohesion” [4] as factors Undeniably, more people live influencing sexual behaviour with HIV in poor countries than in and hence the potential for HIV rich ones. More than 60% of people transmission. Some, notably Amartya living with HIV inhabit the world’s Sen [5], have looked at poverty as an poorest region: sub-Saharan Africa. outcome of poor governance. It has Nevertheless, studies during the early been suggested that, by extension, t is often asserted that AIDS is stage of the epidemic suggested that regimes that do not focus on the at the core of a “vicious circle”, HIV incidence initially occurred not well-being of populations impoverish whereby the impacts of AIDS I amongst the poorest, but among better- their citizens, deny their enjoyment increase poverty and social deprivation, off members of society in this region. of basic human rights, and erode while poverty and social deprivation A decade later, infections still appear public health—exacerbating both the increase vulnerability to HIV infection. more concentrated among the urban upstream and downstream effects of In examining this view, it is important employed and more mobile members AIDS. This assertion clearly warrants to distinguish between what might of society, and consequently the more further research. be called the “downstream” effects of wealthy groups, as can be seen in Table One indication of the connection AIDS on poverty, and the “upstream” 1 [2]. between poor governance and HIV effects of poverty upon the risk of It is important to note that HIV is the clear pattern of association acquiring HIV. prevalence is very high in all of the between income inequality as measured The “Upstream Effects”: Poverty wealth quintiles—including quintile 1, by the Gini coefficient and HIV and Vulnerability to HIV the poorest (the wealthiest is quintile prevalence across countries in sub- 5). While there is abundant research Saharan Africa—countries with greater Generally speaking, there is a strong that documents the mechanisms that association between poverty and ill lead from extreme poverty to HIV health—wealthier countries and Funding: The authors received no specific funding vulnerability [3], the data now indicate for this article. wealthier individuals enjoy better that the less well-studied risk factors health as measured by a variety of Competing Interests: The authors have declared among the better-off in fact dominate that no competing interests exist. indicators such as life expectancy or the aggregate picture. The fact that Citation: Piot P, Greener R, Russell S (2007) Squaring incidence of waterborne diseases. most people living with HIV in the Many researchers have had the same the circle: AIDS, poverty, and human development. region today are poor simply reflects PLoS Med 4(10): e314. doi:10.1371/journal. expectation about AIDS, which has the fact that the epidemic has now pmed.0040314 often been described as a “disease of spread throughout the generalized Copyright: © 2007 Piot et al. This is an open-access poverty” [1]. population in a region that has a high article distributed under the terms of the Creative There is one fundamental difference, proportion of poor people. Commons Attribution License, which permits however, between AIDS and other unrestricted use, distribution, and reproduction in Whether the patterns observed in any medium, provided the original author and source health problems generally linked this part of Africa will also emerge are credited. with poverty. Unlike diseases such elsewhere remains to be seen. In Abbreviations: GDP, gross domestic product as tuberculosis and malaria, HIV Asia, for example, epidemics have is mostly transmitted through sex. so far been mostly concentrated in Peter Piot is Executive Director, Robert Greener is Economics Advisor, and Sarah Russell is Senior sex workers (and their clients) and Advisor and Speechwriter of the Joint United Nations drug users, who are often very poor. Programme on HIV/AIDS (UNAIDS). The Essay section contains opinion pieces on topics of broad interest to a general medical audience. Infection patterns are now influenced * To whom correspondence should be addressed. by rapid economic development, E-mail: [email protected]

PLoS Medicine | www.plosmedicine.org 1571 October 2007 | Volume 4 | Issue 10 | e314 AIDS kills people in the prime of their working and parenting lives, with a devastating effect on the lives and livelihoods of affected households. Incomes shrink when employed household members become sick or die, and resources are further depleted by medical and funeral-related costs. The impact on poor households is clearly disproportionate, with many struggling to meet demands for treatment and care. (For a comprehensive survey of literature on HIV impacts, see [9].) For example, in India, the financial burden on households living with HIV was 82% of income in the poorest quintile and just over 20% among the richest quintile doi:10.1371/journal.pmed.0040314.g001 [10]. The very poor struggle to afford Figure 1. HIV Prevalence and Income Inequality in Africa even heavily subsidized antiretroviral The Gini coefficient has a value between 0 and 1, representing the extremes of income distribution. treatment. This struggle is particularly A zero value corresponds to the situation where everyone in the population has exactly the same acute for women. Although more than income, whereas a value of 1 would correspond to extreme concentration of income in one person. A high value indicates a more unequal income distribution. half of all adults living with HIV in Note that Figure 1 uses data from only one year and therefore cannot show any dynamic Zambia are women, when the monthly relationship between changes in income inequality (which are slow), and changes in HIV cost for HIV treatment was reduced prevalence. from US$64 to US$8 as a result of funding from the Global Fund to Fight inequality have higher HIV prevalence sexual safety [7]. A study in Kenya AIDS, Tuberculosis and Malaria, many (Figure 1—using HIV prevalence found that higher gender inequality more men than women showed up for and economic data from 2006) [6]. between young women and adult men treatment. In one rural town, of the 40 However, some of the countries is significantly and strongly correlated adults taking antiretroviral drugs, only with the highest inequality and HIV to positive HIV status (K. Beegle, three were women. Moreover, even if prevalence, such as Botswana, South unpublished data). drugs are free, poor families may have Africa, and Namibia, have low levels of Gender inequality is one of many insufficient resources to meet basic domestic corruption as measured by injustices fuelling the epidemic. The nutrition needs or the costs of travel to the regional corruption perceptions spread of HIV is disproportionately health clinics for care [11]. index published by Transparency high among many groups that We can thus expect AIDS to impede International (http://www. experience discrimination and suffer efforts to reduce poverty. In high- transparency.org/policy_research/ from a lack of human rights protection. prevalence countries such as Botswana, surveys_indices/cpi), and are regarded This includes groups that have been estimates have projected that the as having reasonably good governance. marginalized socially, culturally, and number of households living in poverty Meanwhile, some countries that have often economically, such as injection will increase at a rate that is 0.5% high levels of corruption according drug users, sex workers, migrants, and higher per year than if there were no to this index, such as Kenya and men who have sex with men. Women’s AIDS [12]. A smaller effect can be Côte D’Ivoire, have lower—but still susceptibility to HIV is further expected in lower-prevalence countries, very significant—HIV prevalence, enhanced in members of marginalized but the number of households living in suggesting that inequality is a stronger or migrant populations: research in poverty is likely to increase by at least predictor of HIV prevalence than poor Viet Nam, for example, revealed that 0.1%–0.5% per year. governance. One possible consequence women migrant workers were twice as The epidemic is dramatically of this apparent association between likely as other women to become HIV increasing the numbers of orphans, inequality and HIV is that economic positive [8]. particularly in high-prevalence growth that is not pro-poor and that countries. More than 15 million leads to greater income inequality may The “Downstream Effects”: The children worldwide have been even fuel the HIV epidemic. Impact of AIDS on Poverty and orphaned by AIDS—over 12 million This result also appears to be Development of them in sub-Saharan Africa, applicable to gender income The economic impacts of AIDS are overwhelming the capacity of social inequality—at household level and proportionately greater for poor networks and traditional patterns of more generally. Where women’s households, and AIDS can be expected intergenerational dependency, and economic and social safety is largely to increase both poverty and income creating an uneducated, unsocialized, dependent on their partners’ inequality. At the same time, AIDS has and often uncared-for generation [4]. occupations and status, they have a significant impact on the aggregate Companies in high-prevalence little choice in determining their own economy of high-prevalence countries. countries can also expect AIDS to

PLoS Medicine | www.plosmedicine.org 1572 October 2007 | Volume 4 | Issue 10 | e314 meetings and regional summits in Table 1. HIV Prevalence by Wealth Quintile in Eight African Countries (Percentage of Africa, the Caribbean, and elsewhere. Adult Population) In more than 40 countries, National Country Gender 1 2345 AIDS Programmes are led by the (Poorest) (Wealthiest) President, Vice-President, or Prime Burkina Men 1.4 2.9 1.3 0.4 2.7 Minister. Faso Women 0.9 1.1 1.5 1.7 3.4 Political action has fuelled financial Ghana Men 1.4 1.5 2.0 1.4 1.1 investment. Global expenditure on Women 1.4 2.7 4.0 3.0 2.4 AIDS in low- and middle-income Cameroon Men 1.4 2.2 4.7 5.3 5.3 countries increased from $250 million Women 3.1 4.1 8.1 9.4 8.0 in 1996 to an expected $10 billion in Uganda Men 4.0 4.2 5.1 5.9 5.5 Women 4.8 6.6 6.7 7.0 11.0 2007. Kenya Men 3.4 4.2 2.2 4.3 7.3 We are now beginning to see a Women 3.9 8.5 7.1 9.7 12.2 return on this investment. Fewer Tanzania Men 4.1 4.3 4.3 7.7 9.5 people are becoming infected with HIV Women 2.8 4.7 6.8 10.9 11.4 in almost all East African countries, Men 4.4 4.6 12.1 11.7 14.9 Malawi in the Caribbean, in Cambodia, and Women 10.9 10.3 12.7 14.6 18.0 Lesotho Men 18.3 16.8 23.7 21.6 14.8 in southern India. Almost 2.5 million Women 19.6 27.9 25.5 27.3 28.9 people are now on antiretroviral therapy in developing countries—up doi:10.1371/journal.pmed.0040314.t001 from 100,000 five years ago. To build on this progress and ensure that it is decrease productivity and increase costs $2.8 billion per annum, slightly less sustainable, however, six elements are for recruitment and training, with the than half of the AIDS estimates [14], key. magnitude of these effects depending while the impact of malaria has been First, AIDS money has the most on the employment conditions and estimated to be in the same range as impact when strategies are based benefits offered by the company, the AIDS—as much as 1.3% of GDP growth on the concept of “know and act on HIV prevalence in the workforce, in highly affected countries [15]. This your epidemic”. UNAIDS’ Practical and the skill levels of the employees level of impact is significant, therefore, Guidelines for Intensifying HIV Prevention most affected. A study in Africa has but not catastrophic. Impact in lower- [16] provide practical guidance found widely varying HIV-related costs prevalence countries can be expected to tailor national HIV prevention from 0.5%–10% of the total labour to be correspondingly lower. responses so that they respond to the costs—which in some sectors would Some researchers have drawn epidemic dynamics and social context constitute a very significant proportion attention to the longer term potential of the country and reach populations of company profit (see the examples in for progressive weakening of human who remain most vulnerable to HIV Table 2 [J. Simon et al., unpublished capital, and the lost transmission infection. For example, economic data]) of knowledge and skills between growth and the growth of trade Government and the public sector generations. This is of particular between neighbouring countries can be are similarly affected by increases in concern given the increasing expected to lead to increased mobility, employment costs, but also experience recognition that AIDS is a long-term particularly of transport workers, which the results of a falling revenue base phenomenon for which long-term is known to increase vulnerability (to the extent that economic growth is strategies are required. to HIV in the absence of tailored affected), and increased demands for prevention efforts. In parts of Asia, health and other public services related Responding to the Interactions mobile men who have unprotected to the epidemic. between AIDS and Poverty sex with sex workers are a key factor in At a national level, the Understanding both upstream and spreading HIV [17]. macroeconomic impact is expected downstream interactions between AIDS Second, a growing number of small- to be relatively small when compared and poverty is critical to understanding scale activities indicate the value of to that of other factors related to the local and global epidemiological trends combining HIV programmes with global economic environment and and patterns. Such an understanding poverty reduction initiatives. In Malawi, the quality of economic management is, in turn, vital to the development and non-governmental organizations in affected countries. Most estimates implementation of effective strategies integrate HIV prevention into village making use of standard economic to prevent and treat HIV. banking programmes for women, and models in high-prevalence countries Growing awareness of the economic combine AIDS education with the indicate a reduction of about 0.5%– aspects of the epidemic has helped provision of microfinance to groups of 1.5% in the gross domestic product catalyze greater political action on women through community banking (GDP) growth rate over a 10 to 20-year AIDS in recent years. For example, programmes [18]. In Northern time frame compared to the situation AIDS is the only health issue ever to Thailand, the Population and without AIDS (for a useful summary, become the subject of a United Nations Community Development Association’s see [13]). The impact of tuberculosis— Security Council debate or a Special Positive Partnership Project offers many cases of which are linked to Session of the UN General Assembly. loans to partnerships consisting of a HIV—has been estimated to be $1.4– It has been featured regularly at G8 person living with HIV and a “buddy”

PLoS Medicine | www.plosmedicine.org 1573 October 2007 | Volume 4 | Issue 10 | e314 Table 2. HIV-Related Labor Costs Sector Country Number of Estimated HIV Cost per AIDS Death or Aggregate Annual Costs Workers in Sector Prevalence (% of Retirement (Multiple of (% of Labor Cost) Adult Population) Annual Compensation)

Retail South Africa 500 10.50 0.7 0.50 Agribusiness South Africa 700 23.70 1.1 0.70 Uganda 500 5.60 1.9 1.20 Kenya 22,000 10.00 1.1 1.00 Zambia 1,200 28.50 0.9 1.30 Manufacturing South Africa 1,300 14.00 1.2 1.10 Uganda 300 14.40 1.2 1.90 Ethiopia 1,500 5.30 0.9 0.60 Ethiopia 1,300 6.20 0.8 0.60 Media South Africa 3,600 10.20 1.3 1.30 Utility South Africa 25,000 11.70 4.7 2.20 Mining South Africa 600 23.60 1.4 2.40 Botswana 500 29.00 4.4 8.40 Tourism Zambia 350 36.80 3.6 10.80 doi:10.1371/journal.pmed.0040314.t002

(often a friend or family member who the economic and social needs of the effectiveness of current and future is not living with HIV) to set up small households that are directly affected by efforts, and could also lead to the business ventures [19]. The challenge AIDS. unravelling of progress already made. now, however, is to make the shift Fifth, both poverty reduction from small-scale projects to large-scale programmes and AIDS strategies Conclusion programmes. must reduce vulnerability to HIV— AIDS, it has been said, is exceptional Third, the provision of HIV particularly for women and young [23] in terms of its threat to humanity, treatment can help prevent poverty— people. Doing so involves protecting and its complexity. The relationship and indirectly contribute to HIV human rights and tackling issues between AIDS and poverty is just one prevention as well—by helping to around social marginalization and example of that complexity, having break down stigma. A study in Kenya stigma. The link between poverty, more to do with inequality than poverty observed a rapid improvement gender inequality, and HIV has per se. in labour productivity among tea prompted many institutions to Another example of complexity pickers in 12 months after starting talk about integrating gender is that the relationship between antiretroviral treatment [20]. Such and AIDS into development and socioeconomic status and HIV varies findings highlight the economic poverty reduction strategies, but considerably from country to country, importance of ensuring that the far more action is required [22]. reflecting differences in culture and poor have access to HIV treatment One obvious step is to ensure that traditions. Effective actions to tackle and prevention services. This access domestic legislation is consistent with AIDS must directly address these requires action in four key areas: international human rights norms, specific factors—the inequalities—that increased investment in antiretroviral and that it is effective in protecting drive HIV transmission in different treatment—by both national and women’s rights within marriage, contexts, and must overcome the international funders; a reduction securing their right to own and inherit obstacles to accessing treatment in in the cost of antiretroviral drugs; property, ensuring equality in the different groups. [6]. improved HIV service delivery systems; workplace, and strengthening laws Complex problems famously require and better services for the poor. against domestic violence. complex solutions. In this case, it Fourth, development plans (whether Sixth, addressing AIDS in the world’s is crucial to place AIDS squarely they concern the development of poorest countries and communities at the centre of all socio-economic productive sectors or the provision depends on increased and sustained development, and provide long-term, of social safety nets) must “pass the international support, driven by high-level domestic and international AIDS test”. Development initiatives high-level political will. Although investment in HIV prevention and must contribute to AIDS prevention it is ultimately the responsibility of treatment in the world’s poorest and treatment in the communities they all states to provide HIV prevention countries. work in. The World Bank–supported and treatment for all citizens, and References Chad/Cameroon Pipeline Project, to mitigate the impact of AIDS on 1. afrol News (2002 October 4) WHO calls HIV/ for example, supports HIV workplace the poor, many countries require AIDS ‘Disease of Poverty.’ Available: http:// interventions along the pipeline international support to live up to www.afrol.com/Categories/Health/health026_ aids_poverty.htm. Accessed 19 September 2007. route—both for workers and for these responsibilities, and are likely to 2. Mishra V, Bignami-Van Assche S, Greener R, affected communities [21].Social do so for some time to come. Failure Vaessen M, Hong R, et al. (2007) HIV infection does not disproportionately affect the poorer protection programmes must also by donors to prioritise the provision in sub-Saharan Africa. AIDS (supplement). In include specific measures to address of such support is likely to undermine press.

PLoS Medicine | www.plosmedicine.org 1574 October 2007 | Volume 4 | Issue 10 | e314 3. Kalichman SC, Simbayi LC, Kagee A, Toefy Y, 11. UNAIDS, United Nations Population Fund, http://www.unaids.org/en/MediaCentre/ Cain D, et al. (2006) Association of poverty, United Nations Development Fund for Women PressMaterials/FeatureStory/20070820_ substance use, and HIV transmission risk (2004) Women and HIV/AIDS: Confronting ICAAP2007.asp. Accessed 19 September 2007. behaviors in three South African communities. the crisis. Available: http://www.unfpa.org/ 18. Global Coalition on Women and AIDS (2006) Soc Sci Med 62: 1641–1649. hiv/women/. Accessed 19 September 2007. Economic security for women fights AIDS. 4. Barnett T, Whiteside A (2006) AIDS in the 12. Greener R (2004) Chapter 5: The Available: http://data.unaids.org/pub/ twenty-first century: Disease and globalization. macroeconomics of HIV/AIDS. In: Haacker BriefingNote/2006/20060308_BN_GCWA_ 2nd edition. New York: Palgrave Macmillan. M, editor. The impact of HIV/AIDS on poverty en.pdf. Accessed 19 September 2007. 416 p. and inequality. International Monetary Fund. 19. Population and Community Development 5. Sen A (2000) Development as freedom. New Available: http://www.imf.org/external/ Association (2007) Available: http://www.pda. York: Oxford University Press. pubs/ft/AIDS/eng/index.htm. Accessed 19 or.th/eng/. Accessed 19 September 2007. 6. Gillespie S, Kadiyala S, Greener R (2007) Is September 2007. 20. Simon J, Larson B, Fox M, Rosen S, Bii M,et al. poverty or wealth driving HIV transmission? 13. Haacker M (2004) Chapter 2: HIV/AIDS: The (2007) Early effects of antiretroviral therapy on AIDS (supplement). In press. impact on the social fabric and the economy. work performance: Results from a cohort study 7. Go VF, Sethulakshmi CJ, Bentley ME, Sivaram In: Haacker M, editor. The impact of HIV/ of Kenyan agricultural workers. Center for S, Srikrishnan AK, et al. (2003) When HIV- AIDS on poverty and inequality. International International Health and Development, Boston prevention messages and gender norms clash: Monetary Fund. Available: http://www.imf. University School of Public Health. Available: The impact of domestic violence on women’s org/external/pubs/ft/AIDS/eng/index.htm. http://www.hivimplementers.org/agenda/ HIV risk in slums of Chennai, India. AIDS Accessed 19 September 2007. pdf/E1/E1%20Simon%20abstract%20811.ppt. Behav 7: 263–272. 14. Grimard F, Harling G (2004) The impact of pdf. Accessed 26 September 2007. 8. Asian Development Bank (2005) Gender tuberculosis on economic growth. Department 21. Zewdie D (2000) The World Bank perspective Network News. Special issue: Perspectives on of Economics, McGill University. Available: on AIDS. 13th International AIDS Conference; gender and HIV/AIDS. Available: http://www. http://neumann.hec.ca/neudc2004/fp/ 11 July 2000; Durban, South Africa. Available: adb.org/Documents/Periodicals/GNN/ grimard_franque_aout_27.pdf. Accessed 19 http://lnweb18.worldbank.org/AFR/afr.nsf/ newsletter-13.pdf. Accessed 19 September 2007. September 2007. General/F0986E1B4CD360608525691A004B69C 9. Gillespie S, Kadiyala S (2005) HIV/AIDS and 15. Gallup JL, Sachs JD (2001) The economic C?OpenDocument. Accessed 19 September 2007. food and nutrition security: From evidence burden of malaria. Am J Trop Med Hyg 64S: 22. Smith MK (2002) Gender, poverty and to action. International Food Policy Research 85–96. intergenerational vulnerability to HIV/AIDS. Institute. Available: http://www.ifpri.org/ 16. UNAIDS (2006) Practical guidelines for Available: http://www.oxfam.org.nz/imgs/ pubs/fpreview/pv07/pv07.pdf. Accessed 19 intensifying HIV prevention: Towards universal whatwedo/hivaids/gendervuln.pdf. Accessed September 2007. access. Available: http://data.unaids.org/ 19 September 2007. 10. Asian Development Bank, UNAIDS (2004) The pub/Manual/2007/20070306_Prevention_ 23. Piot P (2005) Why AIDS is exceptional. impact of HIV/AIDS on poverty in Cambodia, Guidelines_Towards_Universal_Access_en.pdf. Speech at the London School of Economics. India, Thailand, and Vietnam. Available: Accessed 19 September 2007. Available: http://www.lse.ac.uk/collections/ http://www.adb.org/Documents/Reports/ 17. Rao P (2007) Plenary speech at VIII pressAndInformationOffice/newsAndEvents/ Asia-Pacific/APO-HIV.pdf. Accessed 19 International Congress on AIDS in Asia and archives/2005/Peter_Piot.htm. Accessed 19 September 2007. the Pacific (ICAAP), Colombo. Available: September 2007.

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