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Roadblocks to Development:
The Economic Impact of HIV/AIDS in Developing Countries and the Challenges to Prevention and Treatment
J. Bradon Rothschild
TECON 320
Abstract
Though Sub-Saharan Africa only has 10% of the world’s total population, it holds 69% of all the HIV/AIDS patients. This contributes to the stagnation the entire continent’s economy, making people less overall productive and trapping them in a vicious cycle of poverty. Most individuals living with HIV/AIDS face lack of access to education, medicine, and preventative care. Lack of jobs forces some into informal economic activity which places them at high risk of contracting the disease, continuing the cycle of poverty. Biases against HIV/AIDS infected individuals keep the already infected out of jobs and dependent on family, impoverishing them and their family. Lack of women’s legal rights prevents women from stemming the spread of the disease further. Though some nations have made progress in empowering women and sexual minorities, seeing a concurrent drop in mortality and new infection rates, other nations remain without such legal protections and maintain high rates of infection and mortality. Many good-faith efforts by third party sources fail due to lack of education in many areas, religious biases, and an overwhelming lack of infrastructure.

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HIV/AIDS is perhaps one of the most talked about subjects of the late 20th and early 21st centuries. Infecting millions around the world (UNAIDS, 2012), its impact is both wide and deep with serious personal, social/societal, political, and economic implications. Though for much of the late 20th century the HIV/AIDS pandemic was felt in nearly all corners of the world, the developing world; where medicine and health care of any kind is rare if even available at all; has been hit the hardest. Sub-Saharan Africa remains the most afflicted region of the world with some nations having infection rates over 20% (UNAIDS, 2012). Efforts by third party governments and non-profit organizations such as the Gates Foundation (Bill & Melinda Gates Foundation, 2013) to alleviate the scourge have made little headway, though economic stagnation, lack of capital infrastructure, and political/social impediments prevent many much needed prevention and treatment methods from being implemented. Despite good-faith efforts and political progress in many Sub-Saharan nations crippling poverty, lack of physical infrastructure, and of women and sexual minority rights continues to impede real progress in the fight against HIV/AIDS.
This paper will be organized into five sections. The first section will give a brief history of Sub- Saharan African economics and HIV/AIDS. The second section will cover case studies of poverty and HIV/AIDS in modern Sub-Saharan Africa and how for many it is a vicious cycle. The third section will discuss a few good-faith efforts by NGO’s and foreign aid spending by governments to combat HIV/AIDS through treatment and prevention. The fourth section will discuss the growing effect of sexual rights in some Sub-Saharan nations. And the fifth section will discuss the remaining impediments, primarily physical infrastructure, to access to preventative measures and medicine many Sub-Saharan Africans face. This section will be tailed by a brief conclusion.
1. Brief History of HIV/AIDS in Africa
For many millennia Sub-Saharan Africa thrived. Civilizations of the region supported massive populations and international – as well as intercontinental – trade (Tignor et al., 2008; Diamond, 1997). Gems and jewelry from sprawling African “cities” – though they would not be recognized as such by Europeans – found their way from Central Africa to disparate places such as India or even parts of Europe. Largely thanks to low density urban layouts and sprawling population patters, African civilizations were able to maintain low disease rates and relatively high standards of living for the time (Diamond, 1997).
Through the 19th century, the powerful European nation-states divvied up the militarily far weaker African civilizations into colonies. The primary purpose of these colonies was material extraction in order to fuel the growing European economies. To this end, the European nations re-engineered much of the landscape in order that it would be easier for the governments to administrate; cities, rail lines, mines, and plantations were developed using primarily European models for easier implementation (Tgnor et al., 2008).
After WWII the great empires of the previous century started a several-decades-long process of decolonization. A wide variety of nation-states emerged and gained independence throughout Africa. Sub-Saharan Africa, with its great preponderance of natural resources, had in the previous centuries been divided up into dozens of colonies, each held by different European nation states. While the colonial period dramatically altered the African landscape with plantations, rail, and centralized cities (Diamond, 1997) once the European empires left their colonies, it became readily apparent that the physical and human capital infrastructure was nearly non-existent and out of reach to the newly independent African nation-states. Ethnic lines, often drawn by Europeans during colonialism, added to the inequality and tumult which has impeded economic growth and stability of the region (Bentley and Zeigler, 2006). In the midst of the decolonization period, in 1959, the first cases of HIV/AIDS related deaths were discovered in Central Africa (Zhu et al., 1998). Though the pandemic spread to nearly all continents, Africa, specifically Sub-Saharan Africa, has borne the brunt of the disease with currently over 25million living with HIV/AIDS (UNAIDS, 2012).

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2. HIV/AIDS and Poverty as a Vicious Cycle
The economic impact of HIV/AIDS on Sub-Saharan Africa can be clearly seen in the levels of destitute poverty which afflict infected individuals. Jean Pierre Lachaud, using Burkina Faso, a nation with an HIV/AIDS infection rate of 1.2% – twice that of the United States (CIA Factbook, 2009), asserts that there is a direct, positive relationship between HIV/AIDS infection and poverty to a community and an individual (2006). According to Lachaud, not only are poor individuals more likely to contract HIV, once infected are less socially mobile. Wealthy individuals within the same sample were less likely to contract HIV and more likely to remain socially mobile – with some depreciation of upward mobility – than their poorer national brethren.
In Southeastern Nigeria, with an infection rate of 3.6%, HIV/AIDS infected are likewise more likely to be impoverished. People with HIV/AIDS were significantly more likely to remain in poverty than people without HIV/AIDS. Beyond the individual level, households with HIV/AIDS infected members were significantly more likely to be below the national poverty line and have reduced standards of living. Communities with more HIV/AIDS infected individuals and households with HIV/AIDS infected individuals were predictably more likely to be economically impoverished and stagnant (Ezeokana et. al, 2009).
Predictably, impoverished individuals living with HIV/AIDS have a higher mortality rate, as shown in a study in Kenya. Unfortunately, the same study showed that in Kenya, where infection rates vary between 6.3% and 17.4% depending on the region (Adari et al., 2007; CIA Factbook, 2009), economic growth is more stagnated in higher infection areas. Urban areas, with more economic activity, have lower infection rates by an average of about 7% (2007). The same study concluded that a primary difference between the regions is access to education; female literacy rates in rural areas are significantly lower than urban areas. Adari also points out that the more economically stagnant areas are more likely to have higher infection rates in part because lack of women’s agency as “Kenyan woman have been educationally disadvantaged and, traditionally, are mostly housewives” (p 363, 2007). They are therefore often kept ignorant of dangers of HIV/AIDS, and unable to effectively slow its spread. Compounding this crisis, rural areas often lack the physical infrastructure of hospitals and clinics to treat HIV/AIDS infected individuals.
The one most heavily afflicted nations of the world is South Africa, with a well-known and violent history of segregation. The infection rate of South Africa as of 2009 was 17.8% (CIA Factbook 2009). Due to the size of the nation, the infection rate, and the controversies over apartheid, the nation has been used as a key index country for economics of HIV/AIDS issues. In his 2004 study on income and inequality dynamics of HIV/AIDS patients, F. le R. Booysen described HIV/AIDS and poverty as cyclical and a “vicious cycle” (p523, 2004). He found that poor people afflicted with HIV/AIDS were less socially mobile than un-afflicted poor. Upper income earners afflicted with HIV/AIDS were also more socially mobile than the poor and afflicted. Households headed by women, who in South Africa are less likely to be well educated, are less likely to be economically mobile and likely to have stunted income mobility (p541, 2004).
Even in areas nations with strong state welfare programs, economic stagnation and lack of education often contribute to continued poverty for HIV/AIDS infected individuals. A study performed by Tanusha Ganiga and Barbara Simpson focused on the population of Bhambayi, KwaZulu-Natal, an impoverished community north of Durban on the eastern coast of South Africa. The demographic make- up of the community revealed a high number of young individuals and very few elderly, with 32% of the population being under 15 years of age; over half of the community worked in the informal sector, many of the women, who make up over 70% of the population, as sex workers (p27, 2011). The destitute poverty of the region results in a 20% poverty rate for elderly who are “in dire need of help…” (p81, 2011) often without any form of income, including the Old Age Pension (OAP) which is supposed to cover any South African making under R49k per month (South Africa Government Services, 2013). According to their study nearly half of all elderly South Africans do not have adequate food (Raniga & Simpson, p80, 2011). For many in the region living in poverty, ineligibility in old age is partially caused by activity in the informal economy. As a result, 6.97% of the elderly people in the region had

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HIV/AIDS and no supplemental support, 4.7% have HIV/AIDS and receive some supplemental support but not OAP, and 9.3% have HIV/AIDS and receive OAP support – though they often live below poverty still (p81, 2011). A full 20% of elderly people in the region were HIV/AIDS positive; most of them live below the poverty line.
Households without HIV/AIDS are more likely to have access to or have accessed educational facilities and be headed by someone with an education. A study in South African communities found that 53.3% of rural households and 52.1% of urban households were affected with HIV/AIDS – had one or more members of the household declaring HIV positive status (Murtin, p128, 2013). The same statistics found that while urban households were more likely to be headed by someone with an education, urban households affected by HIV/AIDS were as likely to be headed by someone with an education as rural families without HIV/AIDS. Both urban and rural households affected by HIV/AIDS were significantly less likely to be headed by someone with an education, more likely to experience both chronic and transitory poverty, and less likely to find gainful employment. Rural households affected by HIV/AIDS were 14% more likely to experience chronic poverty – 40.2% of affected households experienced chronic poverty, while only 25.4 of unaffected households reported the same (p128, 2013). Urban affected households reported incomes 20% lower than unaffected households. In rural communities unemployment rates among affected households is 10% higher than unaffected, with a 40% decrease in total income and 50% decrease in labor income – income from labor, excluding pensions and welfare (p129, 2013).
Social stigma and biases not only affects the individual but the community and economy at large. Focusing primarily on women with HIV/AIDS, Teti et al. point to the HIV/AIDS stigma, which averts non-affected individuals from interacting with infected, significantly impedes an individual’s economic opportunities. Members of an index study group called it “the most significant problem” HIV/AIDS afflicted people face when entering a workforce or attempting to end their own cycle of poverty (Michelle Teti et al., p211, 2010). This stigma may also lead infected individuals to conceal their disease from loved ones, employers, and health professionals. Lack of anti-discrimination laws in many Sub-Saharan African nations magnify the stigma by discouraging people from disclosing to their employers that they have the disease for fear of being fired; and for those who do, many then find themselves unemployed and further stigmatized for their efforts, beginning or continuing the vicious cycle (p210-11, 2010). The paper also reports a startling prevalence of psychological distress experienced by HIV/AIDS positive women. Respondents reported fear of rejection, violence in relationships, and a lack of economic resources, some pointing out that they have no or little access to help, and fear accessing what help is available for inciting fear of them and the stigma of HIV/AIDS (p213, 2010).
It is clear through these index studies that HIV/AIDS infection leads to cyclical poverty at the individual level. In some nations, such as in South Africa, governments have attempted to stem the cycle by offering pension programs to augment income of poor. While these programs do help, reducing poverty by a slight margin, they do not fix the problem as in many areas access to jobs and sustainable livelihoods is still lacking.
Infection also disrupts social capital and damages communities and their ability to be collectively constructive and supportive. Winford Masanjala posits that infection stunts individual and communal human capital – illness and inability to work, and lack of education which often follows illness – restricting household incomes, which makes it difficult for affected households to care for the ill (p1035, 2007). Households and families affected by HIV/AIDS not only have the effect of depreciated human capital via loss of health and education opportunities, but have depreciated social capital as “death and sickness erode social networks” making it more difficult for families to create their own support systems– financial and psychological (p1035).
3. Good Faith Humanitarian Efforts
Thus far there have been many concerted, and good faith efforts both by internal organizations based in Africa – governments and NGO’s – as well as external. The Bill and Melinda Gates Foundation is one of many internationally operating NGO’s with one goal of many being the eradication of malaria

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and HIV/AIDS in Africa (Bill & Melinda Gates Foundation, 2013). Washington D.C. based World Bank has consistently placed HIV/AIDS prevention and treatment as a top priority, and it remains one of the organization’s Millennium Development Goals (World Bank, 2011). But the measures and efforts put forward by these organizations and governments have made little headway towards solving the growing HIV/AIDS pandemic. By the end of 2012, the World Health Organization estimated that over 35 million people worldwide suffered from HIV/AIDS, and 69% of all HIV/AIDS patients lived in Sub-Saharan Africa (World Health Organization, 2013). The World Bank estimated that 2.5 million people per year are infected (World Bank, 2011) with an estimated 1.7million AIDS related deaths (UNAIDS, 2011).
The spread of the disease has slowed by an estimated 33% – the rate of new infections dropped by 33% between 2001 and 2013 according to the WHO (World Health Organization, 2013) – while the mortality rate has dropped by 25% since its peak in 2005 (UNAIDS, 2011). While these numbers are good news, relying solely on them to paint the picture distorts the truth. Those same reports point out that infection rates are increasing in some pockets of Sub-Saharan Africa, and stagnant in most of the rest.
4. Gender rights, Agency, and Political Progress
Though not all nations in the region are doing equally well, some have made significant progress in the past decade. The rate of new infections has dropped by over 50% in several nations, including Rwanda (UNAIDS, 2011). Many factors contribute to this decline including the good-faith efforts of NGO’s, however it is impossible to ignore the effect that burgeoning women’s and gender rights have had on many nations with the fastest declining rates. The Parliament of Rwanda, for instance, in the same time period as the new infection rates and mortality rates declined, passed a series of laws significantly strengthening women’s rights in the recently war-torn nation (Boseley, Sarah 2010). Laws against rape and protecting women against physical abuse empower women to make their own health choices, including the use of prophylactics.
South Africa, with new infection rates dropping by 26-49%, has passed similar laws mandating proportional representation of women in parliament (EISA, 2009), as well as the strongest gay rights laws of the entire continent protecting same-sex couples and legalizing same-sex marriage in 2006 (Nullis, 2006). Enhancing and stabilizing sexual minorities, especially the LGBT community which has been so heavily impacted by HIV/AIDS that the disease was originally assumed to be a gay related disease (Self et. al., 1989), has a similar effect as empowering women. This grants them agency and access to economic stability and social capital.
5. Impediments of Access to Prevention and Medicine
One of the most often targeted difficulties in treating HIV/AIDS in Sub-Saharan Africa, or really in any developing region, is the price of treatment. Cost of treatment for HIV/AIDS for an uninsured American citizen is prohibitively high, leading many to rely on charities and government plans to cover treatment. Impoverished people in the United States, like most other developed nations, have far easier access to health care than many in poorer, developing nations (UNAIDS, 2011).
To a large extent, this lack of access is due to prices. Several studies have concluded that the costs of drugs, especially HIV/AIDS treatment drugs, are exorbitant and far beyond the reach of most Africans, especially those caught within the vicious cycle of poverty which is often part-in-parcel with the disease. For many Sub-Saharan Africans living on a few dollars a day, the $7.34/dose treatments are simply prohibitive (McNeil, 2000). Several efforts have been made by a variety of organizations and governments to reduce the price or offer drugs at no cost, but the scale of the need can place the burden of the cost on drug companies, thus shifting the cost to other patients in other countries (Jamieson, 2012).
The second most oft cited and controversial program for fighting HIV/AIDS in Africa is the promotion of contraceptive devices. Several governments and NGO’s have promoted the use of contraceptives such as condoms and diaphragms (UNAIDS, 2011). Use of contraceptive devices significantly reduces transmission rates and has been heavily promoted as a method of slowing the spread of HIV/AIDS with the United States spending as much as $190million on the promotion of contraceptive use in Sub-Saharan Africa along in 2010 (UNAIDS, 2011).

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The primary impediments of condom use include social stigma, lack of education, and the church. For many women, discussing the use of contraception with sexual partners – primarily men – is difficult due to the often violent resistance they encounter; some women in such relationships even sneaking condoms from health clinics without the knowledge of their partners (Teti et. al., p212, 2010). This negative stigma is augmented by a perpetual lack of education which keeps information on prevention rates inaccessible to many at risk. Any organization may release information packets and pamphlets on the benefits of condom use, but high illiteracy rates in many Sub-Saharan nations render these efforts ineffective (UNESCO, 2010).
The stance of the Catholic Church especially has had a significant impact on the availability of contraceptive devices, as well as misinformation about their efficacy. The Catholic Church, which manages and administers millions of dollars in charity and aid work around the world and in Africa, has a long standing firm stance against contraception (Benagiano et al., 2011). Not only has the church wielded a great amount of political power over government lead international aid, but local bishops have perpetuated misinformation about the effectiveness of contraceptive devices with false claims such as that the HIV virus is “small enough to pass through a condom” (Benagiano et al., p702, 2011). For these reasons, the adoption of contraceptive devices has been impeded, potentially allowing a continued increase in infection rates in impoverished nations. That said, with the election of Pope Francis earlier this year, new opinions on these devices have made their way to the forefront of the church. In a series of interviews, Pope Francis signaled that the Catholic Church should allow the use of contraceptive devices for prevention of the spread of sexually transmitted diseases (Goodstein, 2013; Pullella, 2013).
Many efforts to eradicate or alleviate the spread and suffering of HIV/AIDS in Sub-Saharan Africa fail in large part due to the overwhelming poverty and economic stagnation of the continent. Many programs sponsored by NGO’s and governments alike fail to reach their intended audience due to lack of access, funding, or transportation to affected communities (Salon, 2011). Even with drug prices reduced via price controls and subsidies, transportation via highway, train, or air is not always possible with the lack of infrastructure in many Sub-Saharan African nations. Not only does this lack of infrastructure impede distribution of medication, but it increases the cost of international business transactions and discourages physical capital investments (Mukoko, 1996; Salon, 2011; Stietchiping et al., 2011). In rural areas and urban areas, especially in land-locked nations the lack of transportation options impedes individuals’ access to job opportunities as well as health resources. Without economic growth, supporting any effort to eradicate such a wide-spread epidemic may be ultimately unsustainable. Ironically, economic growth will be difficult to achieve without higher quality transportation, which may require massive investment which will be difficult to fund without a strong economy.
Recent years, though, have yielded reasons for hope in parts of Africa. Women, often subjugated and relegated to entirely domestic positions, have begun to gain greater amounts of political power. Ellen Johnson Sirleaf has been re-elected as president of Liberia (Mkandawire-Valhmu et al., 2013). Her administration has lead the nation to some of its greatest years of economic growth and a significant reduction of poverty (African Development Bank Group, 2013). In Malawi, one of the nations most heavily affected by HIV/AIDS, Interim President Joyce Banda, who as Vice President succeeded President Bingu wa Mutharika after his death, has successfully continued national strategies for poverty reduction and a significant growth of health care access (Mkandawaire-Valhmu et al., 2013; Wachira and Ruger, 2011). Rwanda also has made leaps and bounds with gender equality as well as economic growth with gender quotas, leading to innovating solutions to economic issues, HIV/AIDS treatment and prevention, women’s rights (Mkandawire-Valhmu et al., 2013; Quota Project, 2013). With these efforts, and cooperation from world financial organizations, fixes to some of the greatest underlying problems may be on their way.

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