1. Investigating the empirical evidence for
understanding vulnerability and the associations
between poverty, HIV infection and AIDS impact
Stuart Gillespiea, Robert Greenerb, Alan Whitesidec and
James Whitworthd
AIDS 2007, 21 (suppl 7):S1–S4
It is just over 25 years since the first cases of AIDS were were dead, killed in the First World War. It is only in the
reported. Over this quarter-century, AIDS has become past decade that the last of these spinsters has died. The
one of most highly studied diseases in history. There impacts of AIDS will take even longer to work through
have been significant medical advances in understanding the population.
the consequences of HIV infection and treating AIDS, as
is well documented in many journals, including AIDS. Second, HIV is diverse in its spread. Early fears that the
The complex and place-specific social, economic, virus would spread rapidly outside Africa have not
behavioural and psychological drivers of the spread of materialized. For example, the UNAIDS 2006 ‘Report
HIV remain less well delineated. The consequences of on the global AIDS epidemic’ estimated that there were
increased illness and death in poor countries and commu- 5.7 million people living with HIV in India. In July 2007,
nities are still unfolding. this was revised downward to 2.5 million, reflecting much
less spread of the infection than had been feared [2].
In 2000, HIV was placed firmly on the global development Similar downward revisions of estimates have been made
agenda by UN Security Council Resolution 1308, which in China. In a recent book, James Chin [3] argued that
stated: ‘the spread of HIV can have a uniquely devastating there are many populations in which heterosexual
impact on all sectors and levels of society’. A year later, in epidemics will not occur in the general population and
July 2001, there was a UN General Assembly Special the epidemic will remain confined to specific risk groups.
Session on HIV/AIDS. Since then our understanding of Chin’s examples of where the potential for HIVepidemics
the epidemic and its potential impacts has deepened. This has been overstated are primarily from Asia, and in
supplement, written by social scientists, looks at how particular China and the Philippines. This is not to
socioeconomic determinants drive HIV spread and how understate the individual tragedy of each infection, but
AIDS illness and mortality is impacting on communities. rather to recognize that there are countries where AIDS
will have a considerable impact and others where its
It is helpful to locate the contents of this supplement in importance can be downgraded.
the context of the history of the epidemic. There are three
overarching points to be made in introduction. First, the It is not just globally that there is wide variation. In
epidemic is complex both in terms of what is driving it mainland sub-Saharan Africa HIV prevalence in adults
and the effects it has. It has been described as a ‘long wave ranges from 0.7% in Mauritania to 33.4 % in Swaziland.
event’. It takes years for the epidemic to spread through The hardest-hit countries are all in southern Africa; these
society and generations for the full impact to be felt. A are shown in Fig. 1, the so-called ‘red’ countries. Adult
recent book highlights the nature of such long wave HIV prevalence exceeds 20% in four of these countries:
events [1]. ‘Singled out: how two million women Swaziland, Lesotho, Botswana and Zimbabwe. South
survived without men after the First World War’ describes Africa, Namibia, Zambia, Mozambique, and Malawi all
how in the United Kingdom a generation of women were have adult prevalence rates in the range of 10–20% [2].
unable to marry, as the men they would have partnered These countries are the focus of this supplement.
From the aInternational Food Policy Research Institute, Geneva, Switzerland, the bJoint United Nations Programme on HIV/AIDS,
Geneva, Switzerland, the cHealth Economics and HIV/AIDS Research Division, University of KwaZulu-Natal, South Africa, and
the dWellcome Trust, London, United Kingdom
Correspondence to Alan Whiteside, Health Economics and HIV/AIDS Research Division, University of KwaZulu-Natal, Block
J418 Westville, University Road Westville, Private Bag XS4001, Durban, 4000, South Africa.
Fax: +27 (31) 260 25 87; e-mail: whitesid@ukzn.ac.za
ISSN 0269-9370 Q 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins S1
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

2. S2 AIDS 2007, Vol 21 (suppl 7)
deficiency virus (HIV) was identified as the cause. The
number of cases rose rapidly across the United States and
was quickly identified in Europe, Australia, New Zealand
and Latin America. In central Africa, health workers were
observing new illnesses such as Kaposi’s sarcoma (a cancer)
in Zambia, cryptococcosis (an unusual fungal infection) in
Kinshasa, and there were reports of ‘slim disease’ and
unexpectedly high rates of death in Lake Victoria fishing
villages in Uganda [6–8]. These illnesses were occurring in
heterosexual adults, not just gay men, individuals with
haemophilia, blood transfusion recipients, and intravenous
drug users, who formed the main groups at risk in
developed countries. By 1982, cases were being seen in the
partners and infants of those infected [8,9].
The initial response of public health specialists, epide-
miologists and scientists was to try to identify what was
causing the disease and to understand how it was
spreading. This would inform prevention strategies and
Fig. 1. Map of adult HIV prevalence in Africa. 20–34%; medical interventions. Early responses were therefore
10–< 20%; 5–< 10%; 1–< 5%; < 1%. predominantly scientific and technical in nature.
Third, social science faces problems in addressing the It soon became apparent, however, that this was not
phenomenon of HIVand its consequences. The epidemic enough, and attention shifted to understanding why
is only 25 years old, which means that it, and its effects, are people were being exposed. This led to early knowledge
still unfolding. Social science relies on assessing what has attitude and practice surveys, which sought to understand
happened. This is done through surveys and panel data, high-risk behaviours [3] p.73. This emphasis on
and sometimes the picture is at odds with what we expect. prevention gained momentum because medical scientists
For example in the 1980s it was suggested, on the basis of had not yet discovered drugs that could cure, or even slow,
models, that AIDS would cause economies to grow more the progress of the disease. Initial optimism for developing
slowly than otherwise would be the case. In 2007, at the an effective vaccine soon faded and is now seen to be
individual country level, this does not seem to have many years, if not decades, away.
occurred. Uganda had the worst epidemic in the world
during the early 1990s yet managed consistent economic Internationally, the World Health Organization (WHO)
growth estimated at 6.5% per annum from 1991 to 2002. took the lead in response to HIV in 1986; teams visited
Botswana’s growth rate over the same period was 5.6%. most developing countries to establish short and
South Africa has seen steady growth since 1999. Yet it is medium-term AIDS programmes, which then evolved
only through longitudinal and cross-sectional studies that into national AIDS programmes [10]. International
we can hope to understand the impact of the disease. responses to HIV were, however, limited and character-
Longitudinal panel data give a picture of what has ized by denial, underestimation, and oversimplification.
happened in a population over the period for which the HIV was not placed high on the agenda of any other
data are collected. An alternative is to gather cross- United Nations agency. Although life expectancy was
sectional data: if we can understand what has happened in plummeting in certain African countries, for example,
Uganda will it help predict what might happen in the United Nations Development Programme waited
Lesotho? The one thing we have not been good at is until 1997 to take this into account in calculating its
predicting the future, although UNAIDS made a brave human development index [11].
attempt at this through its ‘AIDS in Africa: three scenarios
to 2025’ report launched in March 2005 [4]. By the 1990s there was a new perspective developing, as
interest in the individual, social, and economic milieux
that lead to vulnerability to HIV infection began to grow.
Academics and programme officers increasingly recog-
A brief history of 25 years of response nized that social justice, poverty and equity issues were
driving the uneven spread of the virus within and
1981–1996 between communities and societies [12–15].
The AIDS epidemic was recognized in 1981, initally
among gay men in New York and San Francisco [5]. It was 1996–2007
officially named ‘acquired immune deficiency syndrome’ In 1996, there were major changes in response to HIV,
(AIDS) in July 1982, and in 1983 the human immuno- reflecting and reflected in the scholarship of the time. In
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3. Editorial Whiteside et al. S3
the 1994 book ‘AIDS in Africa’ of 33 chapters only three inequity, long-term concurrent partnerships, the lack of
were on preventive strategies and four on socioeconomic male circumcision, and the prevalence of co-infections
impact, the rest were scientific or epidemiological [16]. are factors that have been identified and need further
By 1996, when the second edition of ‘AIDS in the world’ examination. There are no easy solutions to curbing the
was published, of 41 chapters only approximately 18 were spread of the epidemic. There are countries, outside
pure science [17]. southern Africa, where the epidemic appears to be under
control: Uganda brought early hope to Africa by showing
In 1996, the new UN agency charged with coordinating how high levels of political commitment and com-
the response to the epidemic, UNAIDS, began operations munity-led responses can work to stabilize HIV
in Geneva. This was significant as it acknowledged that prevalence. In other locations, such as Tanzania, infection
the international health body the WHO was not able to rates peaked at a lower level than those currently seen in
respond to the epidemic in all its facets, and there needed most of southern Africa.
to be international coordination for an exceptional
disease. At the XIth International AIDS Conference in The focus of this supplement is on bringing together and
Vancouver, the arrival of new drugs in developed understanding the data on the socioeconomic dimensions
countries to treat AIDS was announced, and mortality of the epidemic. It came out of a meeting sponsored by
among those being treated plummeted. UNAIDS and hosted by the Health Economics and
HIV/AIDS Research Division of the University of
At the XIIIth International AIDS Conference in KwaZulu-Natal held in Durban from 16 to 18 October
Durban, South Africa, in July 2000, Nelson Mandela, 2006. The aim of the symposium was to bring together
closed the conference with a call for drugs to be made people, especially those involved in field research, to share
accessible to all. Since then, the response to AIDS has knowledge and experience and to address gaps in our
been dominated by new initiatives for making treatment understanding of the spread of HIV and impact of AIDS.
accessible, especially in developing countries. The price In particular, we were looking for community-
of drugs has fallen dramatically with the manufacture of based longitudinal studies currently being carried out
generic drugs.1 In 2001, United Nation’s Secretary in Africa.
General, Kofi Annan, called for spending on AIDS to be
increased 10-fold in developing countries, and the The outputs of this meeting were to be a review of the
Global Fund for AIDS, TB and Malaria was established. main longitudinal socioeconomic data collections in
The same year, President George W. Bush announced Africa with a bearing on HIV, the publication of the
the Presidential Emergency Plan for AIDS Relief participants’ best papers, and an opportunity to network
(PEPFAR) targeting 15 developing countries. In 2003, and share ideas.
the WHO and UNAIDS proclaimed the ‘3 by 5’ plan, to
treat 3 million people in poor countries by the end The meeting was a qualified success in that papers were
of 2005. presented and we have this interesting and thought-
provoking supplement. There are, however, a number
Over the decade from 1996 to 2006, more financial of caveats, and these cut to the heart of the issues we
resources than ever before were made available for the are dealing with. South African research and papers
response to AIDS, with emphasis increasingly on making dominate. Of the 10 papers we publish, seven are from
treatment available in developing countries. In 1996, South Africa, two compare data from across the continent
there was approximately US$300 million for HIV/AIDS and one is from Zimbabwe. This is also true of the
in low and middle-income countries; by 2006, this authors, the vast majority are either South African or
increased to US$8.3 billion. It is noteworthy that this based in the developed world. Clearly, there are real issues
response, largely a result of treatment becoming with developing capacity in African countries. The global
available and affordable, led to a ‘remedicalization’ of emphasis is on delivery not research, but, as this
HIV/AIDS. supplement shows, quality data and good science are
essential.
It is not clear why southern Africa has been so hard hit by
HIV. Socioeconomic variables, cultural factors and sexual Of the ten papers, there is a good thematic spread with
behaviour all play a role. Poverty, income inequality, sex four papers focusing on drivers, four on impacts and two
on both. What do the papers tell us? Put simply, the causes
and consequences of the epidemic are complex and policy
1
Presentation by Peter Graaf of the HIV/AIDS Department of the needs to take this into account.
WHO to an ‘Informal technical consultation on the relevance and
modalities of implementation of an observatory for HIV commodities Although poor individuals and households are likely to be
in Africa’ organized by Health Economics and HIV/AIDS Research
Division (HEARD), University of KwaZulu Natal, the World Health hit harder by the downstream impacts of AIDS than their
Organization, and Swedish/Norwegian HIV/AIDS Team on 25 June less poor counterparts, their chances of being exposed to
2007. HIV in the first place are not necessarily greater than
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

4. S4 AIDS 2007, Vol 21 (suppl 7)
wealthier individuals or households. It is too simplistic to References
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Conflicts of interest: None. Oxford University; 1996.
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