By Paul Brodish
An Association between Neighbourhood Wealth Inequality and HIV Prevalence in Sub-Saharan Africa, published recently in the Journal of Biosocial Science, investigates whether community-level wealth inequality in the region predicts HIV serostatus. The study analyzed data from country-specific Demographic and Health Surveys and HIV biomarker data.
When assessing ‘diseases of poverty,’ it is important to look upstream at social, economic, and political factors and try to turn off the faucet there, particularly if you want sustainable solutions. The three goals of sound public policy — efficacy, efficiency, and equity — are all better served in this way, provided you can trace a reasonable, putative causal chain to the outcome.
Nearly 30 years ago, the World Health Organization’s Ottawa Charter stated, “The fundamental conditions and resources for health are: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity. Improvement in health requires a secure foundation in these basic prerequisites.”
We have known this for 30 years (and in truth since the time of Hippocrates) but often forget it. Health care interventions, which are nevertheless important, are often prioritized over these more fundamental bases for health itself.
This study examined at least two of these nine interrelated fundamental conditions for health as they relate to HIV prevalence. Commenting in The Lancet, Shelton et al. (2005, p. 1058) suggested that both wealth and economic disadvantage may play pivotal roles in HIV transmission through sexual concurrency networks, with wealth being “associated with the mobility, time, and resources to maintain concurrent partnerships” and where women “might improve their economic situation by having more than one concurrent partner.”
Although causality cannot be inferred from the study results, taken as a whole, they could be interpreted as suggesting a situation in which neighborhood wealth inequalities in sub-Saharan Africa, particularly in urbanized areas, lead to greater risk of HIV. Such inequalities are associated with, and possibly promote, increased extramarital sexual relationships by women of childbearing age, who are able to trade sex for money or resources provided by men in households with greater wealth, thus escalating HIV risk within sexual networks. The positive relationship for women with a primary education could reflect increased contact in urbanized areas, through the educational system, with men seeking extramarital partnerships, with women increasingly engaging in such relationships in contexts of high wealth inequalities but less so as they achieve higher levels of education and a trajectory leading to greater autonomy and financial independence. These results point to the importance of disaggregating by sex in such analyses and exploring potential mechanisms of action/causal pathways through modelling behavioral mediators.
Paul Brodish, applications analyst with the MEASURE Evaluation project and doctoral candidate in the Department of Public Policy at the University of North Carolina at Chapel Hill, authored An Association between Neighbourhood Wealth Inequality and HIV Prevalence in Sub-Saharan Africa. For more information on MEASURE Evaluation’s work on HIV and AIDS, see http://www.measureevaluation.org/our-work/hiv-aids.