Elsevier

Social Science & Medicine

Volume 64, Issue 5, March 2007, Pages 1032-1041
Social Science & Medicine

The poverty-HIV/AIDS nexus in Africa: A livelihood approach

https://doi.org/10.1016/j.socscimed.2006.10.009Get rights and content

Abstract

This paper reviews the nexus between poverty and HIV/AIDS in Africa using a sustainable livelihood framework. Much of the literature on HIV and AIDS has generated an almost universal consensus that the AIDS epidemic is having an immense impact on the economies of hard-hit countries, hurting not only individuals, families and firms, but also significantly slowing economic growth and worsening poverty. International evidence has concentrated on the pathways through which HIV/AIDS undermines livelihoods and raises vulnerability to future collapse of livelihoods. Yet, little attention has been paid to the role that social relations and livelihood strategies can play in bringing about risky social interaction that raises the chance of contracting HIV. Using the sustainable livelihood and social relation approaches, this article demonstrates that although AIDS is not simply a disease of the poor, determinants of the epidemic go far beyond individual volition and that some dimensions of being poor increase risk and vulnerability to HIV.

Introduction

Two strands of orthodoxy have held sway over most writings on the relationship between the AIDS epidemic and poverty in Africa. The conventional view of the poverty–AIDS nexus is that debilitating HIV or full-blown AIDS undermine livelihoods by eroding affected households’ resource base, thereby raising vulnerability to future collapse of livelihoods. The central argument is that the experience of AIDS by individuals, households and even communities can readily lead to an increase in numbers of impoverished households and intensification of poverty among those that are already deprived (see Loewenson & Whiteside, 2001; UNAIDS, 2002). The second school of thought argues that poverty encourages the spread of HIV and quicker progression from HIV seropositivity to full blown AIDS. While acknowledging that AIDS is not simply a disease of the poor, this school of thought argues that the shape and form of the AIDS epidemic reflects the economic, political and cultural characteristics of the society (Barnett & Whiteside (2000), Barnett & Whiteside (2002)) and that some dimensions of poverty and inequality can drive those on the margin of destitution into risky livelihood and coping strategies that raise their likelihood of contracting HIV.

This article seeks to review the literature and contextualize the interaction between poverty and AIDS in Africa using the livelihoods framework (e.g. Carney, 1998; DFID/FAO, 2000). To this end, we build upon a number of studies that have attempted to systematically apply the livelihood framework to study the impact of the AIDS epidemic on livelihoods (e.g. Loevinsohn & Gillespie, 2003; Seeley, 2002; Stokes, 2003) and then extend the analysis to consider the role that unequal social relations and livelihoods may play in the transmission of HIV.

The utility of the livelihood framework lies in its ability to generate analysis that has both positive and normative policy implications. At the positive level, the livelihoods framework allows us to show that AIDS can and does affect every part of a livelihood—some livelihoods more so than others. We also demonstrate how certain dimensions of being poor not only increase the likelihood of engaging in risky social interaction and raise the probability of contracting the HIV but also how they limit access to, and efficacy of, life-prolonging anti-retroviral treatment (ART). At the normative level, the livelihood framework demonstrates that just as the impact of AIDS can be seen at every point of a livelihood, in Africa and similarly impoverished populations efforts to address either poverty or the AIDS epidemic should attend to factors that affect a household's livelihood outcomes.

The preceding notwithstanding, the livelihoods framework, whether in its basic form or the myriad variants, is still a limited instrument for analyzing the complex dynamics between livelihoods and the spread of HIV. First, like much of the social science, the livelihoods framework has depended on the household as the basic building block for research and analysis. Implicit in this approach is the image of a household, comprising individuals who behave as if they share common preferences and aim at maximizing a common utility function. In turn, this requires an assumption of impact homogeneity, where individuals within a household are portrayed as being equally wealthy or poor, to have equal access to goods and services and suffer equally when a shock hits the household. However, we know that intra-household decision making and resource allocation are affected by different culturally, temporally and spatially specific dimensions of social differences (Bolt & Bird, 2003). These social differences result in differential levels of wealth and poverty, consumption, leisure and work, and differential access to and control over resources and benefits.

To account for the role of these social differences on the risk of transmission of HIV, in the second part of the paper, we compliment the livelihoods framework with social relations framework. We recognize that within the household, a socially constructed gender division of labor exists which places differential demands on time and energy of males and females (Bolt & Bird, 2003; Moser, 1994) and there is limited substitutability between male and female labor on specific tasks (Kabeer, 1994). While we concede that there are other social differences beyond gender, e.g. age differences, child birth-order, wife order in polygamous marriages (Bolt & Bird, 2003), we demonstrate that social factors associated with gender differences shape the HIV risk environment more than the other dimensions through asymmetric sexual relations, economic inequalities and population movement.

Section snippets

The sustainable livelihoods framework

Livelihood is defined as a means of living, and the capabilities, assets and activities required for it (Carney, 1998; Chambers & Conway, 1992). A livelihood encompasses income, as well as social institutions, gender relations and property rights required to support and sustain a certain standard of living (Ellis, 1998). It also includes access to and benefits derived from social and public services provided by the state such as education, health services and other infrastructure. Following

Impact of HIV/AIDS on livelihoods

The effect of the AIDS epidemic on livelihood outcomes is profound and varied. International evidence reveals that household impacts of the AIDS epidemic are being felt at different levels (see Koestle, 2002 for cases from Malawi and Tanzania; Serpell, 1999 for Zambia and Bollinger, Stover, Kerkhoven, Mutangadura & Mukurazita, 1999 for cases from Zimbabwe). In this section we demonstrate how HIV/AIDS impact the four components of a livelihood.

Impact of social relations and livelihoods on HIV

Whereas the link from HIV/AIDS to livelihoods is direct and clear-cut, much controversy surrounds the debate regarding the existence of reverse causality. This is because although some dimensions of being poor can increase risk and vulnerability to transmission of HIV, empirical evidence also clearly shows that AIDS is not simply a disease of the poor since AIDS is killing the poor and the rich alike. Yet, in many countries the spread of the AIDS epidemic has followed a definite pattern where

Conclusion

This paper draws upon two existing frameworks to suggest a methodology that provides an analytical starting point for analyzing the nexus between HIV/AIDS and livelihoods. The livelihoods framework demonstrates that the AIDS epidemic affects every part of a livelihood. The AIDS epidemic depletes livelihood assets, undermines normal livelihood strategies, renders households more vulnerable to collapse of livelihoods and thus creates a cycle of poverty and HIV and AIDS. By complimenting the

Acknowledgement

I thank the two anonymous referees for useful comments.

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