Understanding HIV and AIDS in the context of poverty and inequality

Understanding HIV and AIDS in the context of poverty and inequality Date: 29 January 2009 Jerker Edstrom, KNOTS, IDS

Topics to Cover in the Session

Key concepts in HIV and how the epidemic works, in terms of transmission dynamics

The virus itself, modes of transmission and what it does

Prevalence, incidence and peaks of infectivity

Vulnerability; individual/embodied and contextual/structural

Limitations on vulnerability and the relevance of individuals as ‘threats’

Linking poverty and inequality to HIV transmission and impacts

Macro-level relationships in poverty – HIV prevalence

Some myths around the unhelpful ‘gender-binary’

Impacts of HIV on poverty and on Children

Long-term effects and adolescents affected becoming vulnerable

Contemporary debates about HIV, AIDS, aid and development

What is meant by AIDS revisionism and exceptionalism?

Social protection for poor as a response to the needs of Children affected?

Poverty reduction interventions or better policy processes?

HIV is the virus which attacks the human immune system and causes AIDS, which can lead to death within 7-10 years unless treated

There is no vaccine nor any cure available, though drugs (ARVs) can keep people healthy for many years

HIV has been known and with us for 25 years, but the problem keeps growing. About 33 Mn are now living with HIV, (a majority in Africa)

It is transmitted through (i) penetrative sexual contact, (ii) shared injection equipment and (iii) from mother to child

Globally, women and men are equally infected, and, sex ratios have remained stable for over a decade (i.e. no “Feminisation of HIV”)

In Africa, more women are infected than men (2 women per 1 man in Southern Africa), whist in other continents men are still more affected

Epidemics are stabilising in some countries (Kenya, Zimbabwe) but increasing in others (Southern Africa and the former soviet block)

Key concepts: Basic facts on HIV and AIDS

As an infectious agent, HIV is highly inefficient and often requires several 100s of inter-personal ‘risk contacts’ to infect a new person

A person is most infective immediately (in the weeks) after infection and then again if and when HIV related disease sets on (often several years later)

This means epidemic spread requires not only frequent ‘risk contacts’ (unprotected penetrative sex, sharing needles etc.) but also overlapping networks of concurrent partners

Social stigma and taboos associated with these issues have led to a lot of fear and denial

Stigma inhibits both HIV testing and disclosure of HIV status which increases risks of passing on infections

Campaigns characterising ‘risk groups’ (e.g. sex workers, IDU or gay men) ‘by proxy’ can lead to further stigma, making them ‘hard to reach’ and/or leading to unrealistic perceptions of risk

Key concepts: How transmission works

Incidence of HIV = new infections (t) /numbers infected (t-1)

It describes the rate of spread and is key to understanding what the epidemic is doing

(‘epidemic’ means an unusual increase in the incidence of cases)

HIV prevalence refers to the proportion of HIV sero-positive people in a population – i.e. HIV +ve/population

Prevalence is defined by:

[new infections (t) + pre-existing numbers infected (t-1) – deaths of HIV +ve (t) ] / [Population (t-1) + Births (t) + immigration (t) – deaths (other causes) (t) – emigration (t) ]

Therefore, prevalence is a very crude indicator of what the epidemic is currently ‘doing’

It has a lot of built-in (slow) momentum and it tells some story about what has been happening with HIV in a population over a period of time

Key concepts: HIV incidence & prevalence

Key concepts: Vulnerability as a bridging concept

Most use vulnerability as the ‘connecting concept’ between HIV and Development (poverty, inequality etc.)

Focused on risk, health perspectives increasingly recognise vulnerability as relevant to prevention and care -(but with limited analysis of impacts of AIDS)

Development also identified upstream structural causes as well as downstream impacts of HIV -(but with limited analysis of care, and with contradictory views of vulnerability)

Although simplified, this highlights difficulties in finding common languages for making linkages across health and development.

Key concepts: dichotomies in Vulnerability

We need to embrace three dichotomies inherent in the concept of vulnerability

Vulnerability has two senses – anticipative of risk of exposure and of potential impacts

It is a product of someone’s/something’s internal susceptibility and sensitivity in relation to contextual factors

Vulnerability, susceptibility and sensitivity have flip-sides, or ‘altered states’ – i.e. resilience, resistance and responsiveness

A reconciled view of vulnerability is needed which integrates these dichotomies

This is important because links with poverty and development go both ways (Development  HIV/AIDS), involve dynamics at both individual and collective/aggregate levels and are mitigated by ‘agency’

Vulnerability and resilience, embodied and in context, before and after crises Suscepti- bility Resist- ance Resilience Vulnerability Respon- siveness Sensi- tivity “ Before ” Hazards & risk factors “ After ”, or “If” Outcomes & impacts Internal Embodied/ Embedded External Interaction with context Potential shock/stress

Limitations of vulnerability and resilience

As HIV and AIDS are also highly inter-personal , vulnerability does not sufficiently capture the dynamics of epidemic spread

That requires attention to its opposite – likelihood (or ‘threat’) of passing on the virus

Vulnerability and resilience exists in the face of a real or potential external threat, which generates risks and in vulnerability to HIV and AIDS, that is a threat brought by some body else:

Risk = threat + Vulnerability

Hence, the concept of “key populations”, who are a) most vulnerable, b) most likely to pass on the virus and c) who are key to the response

The force of threats as relative to vulnerability

There is a greater effectiveness of transmission from men to women steming from a greater biological susceptibility of women

there is also the fact that ‘rough sex’ can involve tearing of vaginal memberanes (all of this applies even more in anal sex – for both men and women)

However, the fact that women are in biologically more susceptible to HIV (in vaginal sex), does not always mean they are more vulnerable, nor necessarily the most important to engage

Force, virulence and susceptibility all do matter, as does the differential transmission along different pathways in social networks (even in a high-prevalence setting)

Linking poverty and inequality to HIV transmission and impacts

HIV sero-prevalence in Africa (2006)

Linking poverty and inequality to HIV

Poor regions may be more affected by HIV, but the correlation is weak for countries and it does not imply that economic development generally would ‘take care’ of HIV transmission

HIV prevalence and Poverty in Africa Source: Stuart Gilespie, IFPRI, presentation at Irish Aid, Dublin, 29 November 2007

Inequality and lack of social cohesion is more closely correlated with higher HIV prevalence rates and addressing this is important to be able to reduce transmission

HIV Prevalence and Income Inequality in Africa Source: Stuart Gilespie, IFPRI, presentation at Irish Aid, Dublin, 29 November 2007

Inequality and lack of social cohesion is more closely correlated with higher HIV prevalence rates and addressing this is important to be able to reduce transmission

Higher income groups often reach higher HIV prevalence rates at first, but as the epidemic generalises poorer groups also experience increasing rates, and are harder hit by the impacts

So, You don’t have to be poor to be vulnerable to contracting HIV, but if there are deep inequalities the risks increase…

Why is HIV a development issue?

HIV creates new categories of vulnerable people, less resilient to various livelihood crises

The epidemic reproduces or reinforces livelihood vulnerabilities and impacts on development in varied and sometimes synergistic ways at several levels

Food and nutrition insecurity in southern Africa cannot be properly understood if HIV/AIDS is not factored into the analysis

Why is HIV a development issue?

HIV creates new categories of vulnerable people, less resilient to various livelihood crises

The epidemic reproduces or reinforces livelihood vulnerabilities and impacts on development in varied and sometimes synergistic ways at several levels

Food and nutrition insecurity in southern Africa cannot be properly understood if HIV/AIDS is not factored into the analysis

Why is development an HIV issue?

Development strategies have variable impacts on different peoples’ role in the dynamics of the epidemic itself

Effective care and treatment requires livelihood security, freedom from hunger, good sanitation, and support for adherence

Development strategies and social protection play a crucial role in mitigating, or exacerbating, the impacts of HIV and AIDS

Livelihoods – downstream impacts of AIDS

Declining personal assets and stores of physical strength, with reducing ability to fall back on ones labour

Morbidity and mortality linked household labour shortages, lower incomes and demand, loss of skills (school drop out and deaths), falling savings & investment etc.

Clustering of impacts in pockets of most vulnerable groups can increase inequality

The most marginalised and vulnerable are likely to be most affected by livelihood shocks and stresses resulting from HIV

You don’t have to be poor to be vulnerable to contracting HIV, but if you do, you are vulnerable to becoming poorer as a result..

And, if you are already poor when you do, then even more so…

The gendered physical reproduction of HIV vulnerability

A much larger percentage of orphans than non-orphans live in households that are food insecure with child hunger

The nutrition of young girls is important to reducing future susceptibility to HIV infection, particularly where girls have sex at a young age

Orphans appear to be less likely to attend school than non-orphans

When there is economic hardship for vulnerable children, educational investments tend to suffer first – more so for girls

Orphans from AIDS often do suffer greater stigma and greater negative impacts on mental health, self-esteem and delinquency

Studies show links between orphaning and riskier and earlier sexual behaviours amongst adolescent children and youth

Contemporary debates on AIDS, aid and development

‘ AIDS revisionism ’ is a recent trend of critical reassessments of the evidence on AIDS, vulnerability and its linkages with poverty and gender

One strand of it (e.g. J. Chin, E. Pizani etc.) argues for a stronger epidemiological rigour in the analysis of trends, dynamics and issues – e.g. “poor women aren’t the key to solving the epidemic”

Another strand argues that HIV has simply received too much attention relative to its actual burden of disease and other health priorities (e.g. L. Garrett and R. England) or that poverty and gender are more fundamentally important (e.g. Stilwaggon etc.)

Contemporary debates on AIDS and development

‘ AIDS revisionism ’ is a recent trend of critical reassessments of the evidence on AIDS, vulnerability and its linkages with poverty and gender

One strand of it (e.g. J. Chin, E. Pizani etc.) argues for a stronger epidemiological rigour in the analysis of trends, dynamics and issues – e.g. “poor women aren’t the key to solving the epidemic”

Another strand argues that HIV has simply received too much attention relative to its actual burden of disease and other health priorities (e.g. L. Garrett and R. England) or that poverty and gender are more fundamentally important (e.g. Stilwaggon etc.)

‘ AIDS exceptionalism ’ is the opposition and target for the second strand of revisionists. It is perfectly compatible with the first.

It argues that AIDS (the leading cause of adult mortality in Africa) requires exceptional exceptional efforts at all levels (e.g. P. Piot) and/or that successful AIDS mobilisation and policies are actually strengthening health systems and improving health in many areas (P. Farmer) – i.e. its’ not a ‘zero-sum game’

Contemporary debates on AIDS, aid and development – Social Protection?

Social protection for the poor is held up by DFID or UNICEF as critical to responding to the impacts of HIV on families and children

There is evidence that SP can improve child welfare, but also disagreement about if and how it should link to AIDS or other crises

Debates continue over whether e.g. targeting of HIV positive or orphans and other vulnerable children for SP is effective or valid

Some consensus that ‘poverty reduction’ should be universally applied for poor, but also that it needs to link and connect with specific programs and services to contribute to goals in HIV and AIDS, or education etc.

Although unpopular, conditionality can work, as in programmes that also provide take-home food rations for disadvantaged kids

Food for education (FFE) has been shown to have a positive impact on absolute school enrolment

HIV treatment for sick adults is likely to have the greatest protective effect on the welfare of children and families affected by HIV

Contemporary debates on AIDS and development – Micro Credit or IGAs?

Microfinance can help HIV vulnerable youth become more resilient generally and innovation should be encouraged, paying close scrutiny to discrimination against those affected by HIV

Whilst it has been shown to be helpful in increasing women’s abilities to negotiate with partners and reduce gender-based violence, no specific impact on HIV transmission has been shown

IGAs and Microfinance are often held up as recommended in ‘guidance’ in for example prevention and reduction of sex work policies, but there is no strong evidence that such programmes working

(likely because they patronisingly assume women want ‘out’ and can actually find better options)

Structural approaches to reducing vulnerability to infection are

- Difficult to test in randomised controlled trials and

- Often assume that ‘vulnerability’ is what matters most

This does not mean livelihoods strengthening does not have a role, merely that it needs to be guided and developed by those concerned

- those men and women at the margins most central in transmission

Linking poverty and inequality to HIV - Recap

HIV is not fuelled by poverty, so much as by inequality – i.e. scarcity in the presence of wealth, along with mobility, disruption and change

It is more a disease of development than of ‘underdevelopment’

HIV affects people’s wealth and welfare negatively, and poor people’s more so

- It may contribute to income differentiation

Effective prevention and HIV treatment pre-empts welfare shocks

If the structural determinants of ‘vulnerability’ to HIV (and/or to the impacts of AIDS) matter, the structural drivers of people’s likelihood of infecting others matters more to the evolution of the epidemic

- E.g. what drives multiple concurrent partnership, risky practices etc.?

Links between AIDS, gender and poverty have been over-simplified in rhetoric and policies, with ‘revisionism’ challenging past approaches

AIDS exceptionalism remains important and can involve revisionism

Social protection, micro-credit etc. can contribute to the response, but the ‘how’ is complex and context-specific

Suspect myths to dispel

The supposed feminisation of HIV was a historical trend (and hasn’t been active for the past decade globally, nor in Africa)

Women are biologically more susceptible to infection during vaginal sex, and sometimes socially more vulnerable to sexual risk, but not generally the most important to HIV prevention