Economic Dependency and HIV/AIDS Prevalence in the Developing World: A Comparative, Longitudinal Analysis* Gary Maynard, Ohio State University Corinne Ong, Lee Kwan Yew Center for Innovative Cities The HIV/AIDS pandemic has plagued global society for over three decades. While breakthroughs in antiretroviral treatments (ART) have proven effective in suppressing the virus and HIV/AIDS intervention outreach have widened, epidemic control remains unevenly achieved among countries. At least 95 percent of HIV/AIDS sufferers originate from developing countries. Dependency theory suggests that developing countries’ reli- ance on debt, trade, and foreign investments pose negative effects on their populations’ health. Guided by dependency theory’s propositions, this cross-national study assesses whether increasing dependence on trade, debt, and foreign direct investment potentially increases adult HIV prevalence in developing countries from 1989 to 2012. Using a sample of over 80 nations, we perform a two-way fixed-effects OLS regression to evalu- ate the impact of increasing debt, trade, and foreign investment on adult HIV preva- lence. Total debt, short-term debt, external debt, and GDP were found to increase HIV prevalence. The findings for debt support dependency theory’s predictions concerning the ramifications of global economic inequality on HIV/AIDS prevalence. Introduction In June 2001, the WHO officially declared HIV/AIDS to be a global epi- demic (World Health Organization [WHO] 2015). By the close of 2014, an estimated 36.9 million people have been diagnosed as living with HIV; between 2000 and 2014, 25.3 million deaths have resulted from HIV/AIDS (UNAIDS 2014). Recently, there has been a general decline in HIV/AIDS prevalence rates globally, mostly attributable to advances in antiretroviral ther- apy (ART), as well as intensifying local and international efforts at prevention. For instance, new HIV infections have decreased by about 35 percent between 2000 and 2014, while AIDS-related deaths have fallen by 42 percent between 2004 and 2014 (UNAIDS 2014). Despite the above statistics, millions continue to be afflicted by this debili- tating disease. Further, while rates of new HIV infections have declined on a global scale, countries in certain world regions are experiencing higher number of HIV infections compared to before. Since 2001, HIV/AIDS infection rates Sociological Inquiry, Vol. 86, No. 2, May 2016, 189–215 © 2016 Alpha Kappa Delta: The International Sociology Honor Society DOI: 10.1111/soin.12105 190 GARY MAYNARD AND CORINNE ONG grew by more than 50 percent and 20 percent in Middle-East/North African and East Asian countries, respectively. Because HIV/AIDS is a contagious dis- ease and is affected by social forces, managing its prevalence holds wide-stand- ing implications for present and future global health. The Joint United Countries Program of HIV/AIDS (UNAIDS, 2013) has emphasized the need for “global solidarity” and “shared responsibility” in battling the epidemic. Delays in halting the epidemic have the effect of defeating viral suppression, especially where HIV sufferers are left untreated and undiagnosed in the wider community. Also, commensurate with managing a protracted epidemic like HIV/AIDS is its financial burden. In 2012, $18.9 billion from domestic and international sources have been expended to fund HIV/AIDS initiatives for low- and middle-income countries (UNAIDS 2013). Increased HIV/AIDS prevalence in highly effected regions and corresponding attempts to remediate its effects can only be expected to be increasingly cost-consuming. Specific to the focus of this study, HIV/AIDS has deep socioeconomic impacts for developing countries. Presently, nine out of ten persons with HIV are between 15 and 39 years of age—the age strata at which individuals are expected to possess the greatest (economically) productive potential (Interna- tional Labor Organization [ILO] 2014). At the national level, the loss of skilled workers, such as farmers, bankers, teachers, technology specialists, and health- care workers, to HIV/AIDS translates into major deficits for the capital stock, economic growth, and agricultural productivity of developing countries (Asenso-Okyere et al. 2010; Bell, Devarajan, and Gersbak 2003; Cheru 2002; Haacker 2004; ILO 2014; Poku 2002; Shircliff and Shandra 2011). On the level of households, adult deaths due to HIV/AIDS create single-parent house- holds, or households left with orphaned children (UNAIDS 2013). The loss of a productive household member to the disease also implies the attrition of an income earner. Moreover, in the course of securing medical treatment for a family member afflicted with the disease, households are often compelled to deplete limited savings, borrow money, accumulate major debts, and/or leave the workforce to tend to relatives stricken with HIV/AIDS (Asenso-Okyere et al. 2010; Poku 2002; Whyte et al. 2004). To deal with the impoverishment resulting from income losses and household debts described above, affected families often resort to a range of survival techniques: children are frequently withdrawn from schools to seek work that accrues income; adult women and men may migrate to urban areas to seek waged employment. Last but not least, rural to urban migration renders non-infected populations, especially women, susceptible to the risk of acquiring HIV/AIDS infections. UNAIDS (2012) statistics indicate that up to 50 percent of HIV sufferers worldwide are women; women aged between 15 and 24 also experience twice the propensity to be bearers of HIV infections. These trends indicate how failure to address the HIV ECONOMIC DEPENDENCY AND HIV/AIDS PREVALENCE 191 epidemic could simultaneously perpetuate the condition of gender inequality in gender-stratified societies (Austin and Noble 2014; Burroway 2012; Noble and Austin 2014; UNAIDS, 2012). Objectives of the Study In light of the continued impacts of HIV/AIDS in developing countries that have been explicated above, the objective of this study is to examine the macro-sociological factors that contribute to the HIV epidemic in developing countries. Being aware of the forces that drive this epidemic could create possi- bilities for intervention in the political-economic arena, in a way that supports mainstream epidemiological approaches. The study focuses on the contributions of debt, trade, and foreign investment to HIV/AIDS prevalence, by applying dependency and world-systems theories’ conceptualizations. In recent years, sociologists have sought to test the assumptions of dependency and world-sys- tems theories using cross-national data. Economic dependency has been opera- tionalized by indicators, such as the extent of debt, trade, and foreign direct investments, experienced by developing countries. From this approach, scholars have examined how economic dependency perpetuates underdevelopment, which is indicated by conditions such as environmental quality (Jorgenson 2007; Jorgenson, Dick, and Shandra 2011; Shandra, Shor, and London 2008); infant or under-five child mortality (Shandra, Shandra, and London 2011; Shan- dra et al. 2005; Shen and Williamson 2001; Shircliff and Shandra 2011); and tuberculosis prevalence (Maynard, Shircliff, and Restivo 2012). These studies generally affirm that economic dependency negatively affects social and envi- ronmental well-beings in developing countries. Dependency and world-systems theories thus offer relevant and useful perspective for making sense of the causes and symptoms of underdevelopment, where the latter includes HIV/ AIDS. Our study also serves to extend the methodological approaches conven- tionally used to assess debt, trade, and FDI dependencies, and their effects on HIV/AIDS prevalence. We do so by first, factoring in multiple proxies of eco- nomic dependency, namely a country’s intensity of trade, debt, and foreign investments. We use this approach because of inconsistent findings among studies that have sought to associate population health with economic depen- dency. Some studies have validated the negative outcomes of debt dependency on population health (Shandra, Shandra, and London 2011; Shen and Wil- liamson 2001); others, however, have not obtained similar evidence (McIntosh and Thomas 2004; Shircliff and Shandra 2011). Moreover, no known study has specifically inquired into the effects of trade, debt, and foreign investment dependency, on HIV prevalence in developing countries. Studies accomplished to date primarily examine how world polity institutions (Noble and Austin 192 GARY MAYNARD AND CORINNE ONG 2014; Shircliff and Shandra 2011), or other macro-level factors such as eco- nomic growth, political stability, or religion (McIntosh and Thomas 2004) explain HIV prevalence. We also employ a two-way fixed-effects model to account for the role of change over time in regard to the relationship between debt, FDI, and international trade, on HIV adult prevalence rates. Previous studies, such as that by Shircliff and Shandra (2011), employed a 15-year lag between the independent and dependent variables and did not employ a fixed- effects or first-difference model (see also Noble and Austin 2014). This rather long time lag and lack of difference scores in the model could potentially affect the reliability of findings. We also incorporate a technique similar to Jorgenson (2007 and 2009), using data from every year available instead of at 5-year intervals. The Impacts of Debt, Foreign Investment, and Trade Dependency on HIV/ AIDS Prevalence1 Debt Dependency and its Effects