Former US Ambassador to the United Nations Richard Holbrooke made a striking statement in a speech for World AIDS day at the United Nations last year. "I have come to the conclusion over the last few years...that the most important issue in the world dealing with the spread of HIV and AIDS." He continued, "No one in this room can say that we are winning the war against HIV and AIDS, [though] there are some positive signs that the world leadership is beginning to address it, finally and belatedly." Indeed, the UN Security Council has discussed the HIV epidemic twice within the past year, largely due to pressure from the United States, and against the opposition of some members of the Council.

Still, the question remains: why has the international community largely ignored the social, economic, and political development issues raised by the epidemic, and why has it allocated such scarce resources to an effective global response? These are questions more easily posed than answered, although many nations harbor the suspicion that developed countries perceive the epidemic as being "out there," not their concern, something that can be relegated to the public-health community through the use of their dwindling quantity of overseas development assistance. But because of this neglect, it will prove much more costly to address the impact of AIDS today than it would have been in the 1980s, or even in the 1990s, before the epidemic intensified and expanded.

Poverty Trends in Africa

Although the epidemic is truly global in its scope, it is most pervasive in sub-Saharan Africa. Not surprisingly, it is concentrated in developing countries, which suggests that poverty is a significant causal factor for infection: poor people are more likely to become infected with HIV, and the disease in turn intensifies their poverty. In the case of sub-Saharan Africa, the World Bank estimates that in 1998 some 291 million people lived on less than US$1 a day, and that between 1987 and 1998 the percentage of the total sub-Saharan African population living at this level remained constant at 46 percent, implying a significantly increased absolute number of poor people.

While in 1987 sub-Saharan Africa accounted for 18 percent of those living in poverty worldwide, by 1998 this figure had risen to more than 24 percent. Between 1990 and 1999, real GDP per capita in sub-Saharan Africa increased at an annual rate of 0.1 percent, compared to 2.8 percent in the years 1965 to 1980. Not only has there been roughly zero growth in real income in Africa over the past decade, but incomes have substantially declined in countries such as Zambia, and the already large disparities between urban and rural incomes have only grown. This devastatingly poor economic performance has been accompanied by further worsening in the quality of and access to basic social services in many countries, leading to deteriorating school enrollment, nutrition, and health, as well as to an increasingly impoverished population.

In spite of the fact that poverty has a clear causal role in the dynamics of the HIV epidemic, development agencies who trumpet their role as institutions engaged in poverty eradication have done little to integrate HIV into their poverty programs. Thus, the September 2000 World Bank Development Report, Attacking World Poverty, allocated about two pages to HIV and AIDS in its comprehensive study of global poverty. The report displayed little or no understanding of the relationship between poverty and HIV and made no attempt to integrate HIV into its analysis of poverty and its policy recommendations. This is an appalling omission in a world where, according to the World Bank's own data, poverty is increasingly concentrated in Africa and where HIV and AIDS are undermining development performance.

Current Evidence

Of the 36 million persons worldwide infected with HIV in 2000, almost 70 percent, or 25.3 million, are in sub-Saharan Africa. Infection is concentrated in the socially and economically productive groups aged 15 to 45, with slightly more women infected than men. It is estimated that of the 21.8 million persons who have died from HIV-related illnesses since the start of the epidemic worldwide, 17 million were Africans.

The cumulative affected population in Africa, taking into account spouses, children, and elderly dependents, is on the order of 210 million: 25 million currently living with HIV plus 17 million who have died, multiplied by a factor of five to represent those directly affected. This is a staggering proportion of the total sub-Saharan African population: according to these figures, close to one-third of Africans are directly affected by the HIV epidemic. In Botswana, for example, the overall HIV prevalence rate for the adult population in 1999 was 36 percent, the highest rate of any country, and it is projected that over the next 10 years Botswana will lose about one quarter of its population to AIDS. These startling figures come from a country where there has been sustained social and economic development, but where about half the population still lives in poverty.

HIV infection is not confined to the poorest persons, even though the poor account for the largest absolute number of infections in Africa. There is limited evidence of a socioeconomic gradient to HIV infection, although the correlation between infection rates and educational and socioeconomic structure is not readily apparent. Relationships between poverty and HIV are far from simple and direct, and more complex forces are at work than simply the effects of poverty. Indeed, many of the non-poor in Africa have adopted and pursued lifestyles that expose them to HIV infection, with all its social and economic consequences. It follows that the capacity of individuals and households to cope with HIV and AIDS will depend on their initial endowment of assets--both human and financial. The poorest are, by definition, least able to cope with the effects of HIV and AIDS, but even the non-poor find their resources diminished by the disease. Urban communities display increasing evidence of an emerging class of those recently impoverished by the epidemic.

The effects of HIV and AIDS are reflected in the changes in life expectancy, which is the best summary indicator of the effect of HIV and AIDS on countries with high levels of HIV prevalence. In many countries, adult mortality has doubled or tripled over the past decade, leaving these populations with levels of life expectancy that were typical of the 1950s.

Complicit Poverty

The characteristics of the poor are well known, as are some of the causal factors that contribute to a culture of poverty: children of the poor often become the poor of succeeding generations. Poverty is associated with weak endowments of human and financial resources, such as low levels of education, low literacy rates, few marketable skills, poor health status, and, consequently, low labor productivity. One aspect of the health status of the poor is the prevalence of undiagnosed and untreated sexually transmitted diseases (STDs). STDs are now recognized as a very significant co-factor in the transmission of HIV. Poor households typically have few, if any, financial or other assets and are often politically and socially marginalized. This social exclusion increases the problems of reaching these populations through programs aimed at changing sexual habits and other behaviors.

It is not at all surprising under these circumstances that the poor adopt behaviors that expose them to HIV infection. Not only are prevention activities unlikely to reach the poor, but such messages are often irrelevant and inoperable given the realities of their lives. Even if the poor understood what they were being urged to do, they would rarely have either the incentive or the resources to adopt the recommended behavior.

An even more fundamental part of poverty is social and political exclusion. HIV-specific programs are often oblivious to the interests of the poor and are rarely, if ever, related to their needs, as are other non-HIV-related program activities--for example, those relating to agriculture and credit. More generally, the absence of effective programs aimed at sustainable livelihoods limits the possibilities of changing the socioeconomic opportunities for the poor. Unless the reality of the lives of the poor is changed, they will persist in behavior that exposes them to HIV infection.

Two examples will perhaps suffice to indicate how poverty exposes the poor to HIM. First, poverty and the absence of access to sustainable livelihoods cause higher degrees of labor migration, which itself contributes to the conditions in which HIV transmission occurs. Mobile populations, often consisting of large numbers of young people, are isolated from traditional cultural and social networks and are thus prone to engaging in risky sexual behavior, with obvious consequences in terms of HIV infection. Second, many of the poorest persons are women who often head the poorest of households. Such women will often turn to prostitution, sometimes as regular sex workers, but more often as occasional ones who work when they or their dependents need money. The effect of this behavior is much higher infection rates among young women who are increasingly unable to sustain themselves by other work in either the formal or informal sectors.

Increasing numbers of children are infected with HIV through mother-to-child, or perinatal, transmission. This trend reflects the large numbers of pregnant women who are HIV-positive. Perinatal transmission is largely preventable through access to drugs such as azidothymidine (AZT), but these drugs and the necessary infrastructure for their delivery are out of reach for most African women. A related problem is the transmission of HIV through breast milk. This route is also avoidable, but it continues to be an avenue for HIV transmission due to the inability of the poor to buy baby formula, the lack of access to clean water, and the limited knowledge among the poor of why changes in feeding practice are required if HIV transmission is to be reduced.

Coping with HIV and AIDS

Individuals, families, and communities are impoverished by their experience with HIV and AIDS in ways that are typical of protracted, terminal illnesses. HIV infections cluster in families in which both parents are often HIV-positive. Thus enormous strain is placed on the capacity of families to cope with the psychosocial and economic consequences of the illness, such that many families disintegrate as they become ineffective social and economic units. This trend is manifested in the disappearance of traditional support processes for the elderly, who can no longer anticipate being supported by their children. Instead, the old are taking on the burdens of child care under conditions of increasing personal impoverishment and other associated living problems for both generations.

Poor families have less capacity to deal with the effects of morbidity and mortality than do rich ones. The most obvious reason is the absence of savings and other assets that can cushion the impact of illness and death. The poor are already on the margins of survival and thus are often unable to deal with the costs that result from infection. These costs include those of drugs to treat opportunistic infections, transport costs to health centers, reduced household productivity due to illness and diversion of labor to care-giving, loss of employment through illness and job discrimination, funeral costs, and so on. In the longer term, poor households never recover even their initial standard of living as their capacity is reduced by the losses of productive family members through death, migration, and the sale of any productive assets they once possessed.

The inability to treat and manage infection is reflected in the statistics of survival times from initial HIV infection to death. HIV-infected persons in Africa live for a shorter time after initial infection than do their counterparts in developed countries. This is not simply a result of different levels of access to new anti-retroviral treatments, although this is now an important factor in the differential experience of rich and poor countries. Even prior to the availability of anti-retroviral drugs in rich countries, evidence showed that HIV-infected persons in Africa had a survival time from infection to death of approximately five to seven years, about half that of developed countries. The explanation is complex, but it is to a significant degree related to the poverty of most of those infected with HIV in Africa.

Elements in the survival-time differential of Africans include the inability to purchase relatively inexpensive drugs to deal with HIV-related opportunistic infections such as tuberculosis and diarrhea, poor basic health and nutrition, limited psychosocial support, and generally poor-quality care in hospital and home settings. All these factors are exacerbated by the lack of access to clean water, sanitation, and basic hygiene. However, these factors could be ameliorated through programs that the state or nongovernmental organizations could provide at relatively low cost.

The plight of the poor is made even worse due to the isolation and discrimination that AIDS victims often face, making inoperable the traditional forms of social support for the poor and the sick. Societies characterized by random events such as illness and death often develop mechanisms of social support--traditional safety nets for those impoverished by disease and crop failure. These systems of support are now themselves in decline for structural reasons, and they are not being replaced by state mechanisms. At the same time, the clustering of poverty caused by HIV, which is concentrated in only certain communities, places great demands on disintegrating social-support systems that cannot respond properly to such strains. Furthermore, because HIV and AIDS are viewed in many communities as the outcome of reprehensible behavior, there is often both an unwillingness to seek care on the part of those affected and negative responses by those able to provide assistance.

Intergenerational Impacts

The intergenerational effects of HIV and AIDS are the longest lasting of all. These effects stem from the mechanisms whereby the epidemic intensifies and perpetuates poverty. These processes generate a culture of poverty over time--not immediately created by the HIV epidemic, but undoubtedly strengthened by the direct and indirect effects of the epidemic on social and economic development. They arise in part from the effects of the epidemic on human and institutional capacity, where losses occur because of the erosion of human resources. Poverty-reduction strategies will thus be increasingly ineffective in the face of an intensifying HIV epidemic that undermines sustainable development. Reducing poverty through sustainable development has become an even greater challenge than before for African countries.

The effects of the epidemic can be disaggregated to perceive its effect at the levels of families and communities. Some 12 million children in Africa have lost one or both parents to an HIV-related illness, and by 2010 this number is projected to reach around 40 million. By losing most forms of social support, these children are left isolated, and the mechanisms for their socialization disappear. Where systems for acculturation are inoperative and children are isolated from their communities, a process of alienation and anomie begins that has socially destructive outcomes for children, their communities, and, ultimately, for society at large.

The direct effects of such childhood experiences are material and damaging to these children's futures. Poor nutrition leads to poor health, which is an important cause of low labor productivity and thus the persistence of low incomes for the poor. Poor and damp housing is a major factor in causing illnesses such as tuberculosis, which is itself exacerbated by the HIV epidemic; a dual epidemic is in fact underway in Africa. These children will continue to experience poor health over their lifetimes, with many social and economic consequences for them and their families.

A child's chances of escaping from poverty depend on having access to resources like education, which is the primary mechanism that the poor have for social mobility. However, education is one thing to which these children do not have access in accordance with their abilities. A study in Zambia found that 32 percent of orphans in cities and 68 percent in the rural areas were not enrolled in school. A generation of children will grow up with poor health, insufficient skills even for rural development, low levels of literacy and numeracy, little or no access to financial and other real assets, and a lack of normal processes for socialization and social inclusion. Indeed, many children will face additional social exclusion because they come from families who have experienced AIDS.

These children display all those characteristics typical of the poor and the disadvantaged. They are the next generation of the poor, the products of ongoing structural processes that are being intensified by the HIV epidemic currently affecting Africans of all social classes and all ages. If their educational, health, housing, and other psychosocial needs are not addressed through specific policies and programs, national development objectives cannot be achieved. Just as important, large numbers of children growing up in poverty without any hope of escape will adopt precisely those behaviors that lead to HIV infection. They will in effect become the next cohort of the HIV-infected, a state of affairs that will permit the epidemic to continue and intensify.

The Ways Forward

The African HIV epidemic has its origins in African poverty. Unless and until poverty is reduced, little progress will be made either in reducing transmission of the virus or in building the capacity to cope with its socioeconomic consequences. Sustained human development is essential for any effective response to the epidemic in Africa. This realization has yet to permeate approaches to the epidemic, not only in Africa, but almost everywhere. While the HIV epidemic makes sustained human development more and more unattainable and actually adds to poverty, it also destroys the human resources essential for an effective response.

Central to this response are programs that will immediately alleviate the poverty of increasingly large numbers of Africans. Programs that expand employment are needed, especially for young men and women, as is a vast expansion of access to basic social services, with health and education as key priorities. Also integral are nutrition and other support programs for children in need, not just for the increasing numbers of AIDS orphans, but for all children who are being deprived of the basic necessities of life and social support.

Herein lies the problem: how to achieve the sustainable development essential for an effective response to the epidemic when the epidemic itself is destroying the capacities essential for that response. Simple answers to this problem do not exist, but the recognition of its existence is a step towards its resolution.