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Socio-economic Status and HIV/AIDS in Sub-Saharan Africa

By Amy Potts

My plane to the coast of Kenya made its slow ascent above the capital city of Nairobi. It was a cool clear morning in May 2001. From my vantage point, I could survey the bustling city center, the nearby game park, the surrounding slums, and the local cemetery with newly dug graves in the iron rich red soil. While much of Kenya is economically depressed, coffin makers and grave diggers are making off well these days due to the spreading HIV/AIDS crisis.

Reflecting on the newly dug graves that seemed to pepper the countryside in Kenya, I could not help but wonder about the individuals that soon would fill the void in the freshly turned earth and the gaps they were leaving in their communities. When I arrived on the coast, I found out very quickly who the many faces of HIV/AIDS were. They came from many walks of life. The graves were filled with a mother of seven children who was laid next to her husband, who had died a year earlier of AIDS, leaving behind two co-wives and their children. Another grave was filled with a young woman who had found school fees and support from a head-master for a deadly price. And yet another was filled with a local village elder who conducted church services every Sunday.

It seems the AIDS virus knows no boundaries. The loss of life and the loss of human potential moved me greatly. To contextualize the devastation I had witnessed, I began reading and researching everything I could get my hands on about the epidemic in sub-Saharan Africa. As I began to read, I soon realized the devastation of HIV/AIDS was far worse than I initially thought.

It is estimated that over 700 people a day die in Kenya due to AIDS related complications. Nearly 15 percent of Kenya= s 29 million people are infected with the deadly virus (UNAID 2002). Many of sub-Saharan Africa’s nations are much worse off. Botswana, Zimbabwe, and Swaziland have HIV infection rates of 30 percent or higher (UNAID 2002). There are over 11 million AIDS orphans in the region and this number is expected to rise to more than 20 million by the year 2010 (UNAID 2002). As would be anticipated with this number of infected individuals, life expectancies have dropped from 62 years to 47 years (UNAID 2002). Botswana= s has dropped to 39 years (UNAID 2002). Unfortunately, many of those who are dying are of working age. This devastates local and national economies, reduces military forces and national security, impedes the educational process as many teachers are infected, and leaves millions of children without parents. Questions about the "at risk" populations and economic consequences were always forefront in my mind as a mulled over these grim statistics.

Determining risk factors for this deadly disease are not without complications. It was initially hypothesized that long haul truck drivers spread the disease as they traveled from town to town visiting sex workers. They would contract the disease and then take it home to their wives or other female companions (Whiteside 2002). It is a long standing joke that you don't need a map in sub-Saharan Africa, you need only follow the HIV/AIDS trail and you will be able to get around just fine. Now that we have moved into a new century, the pattern of distribution is somewhat different. Truck drivers and sex workers are still at high risk of contracting the disease, but so are school children, teachers, government workers, faithful partners, newborn babies, and the social elite.

While poverty and lack of resources exacerbates the HIV/AIDS problem in Africa, HIV is now being associated with urban living, having a good education, and having a higher income (Gisselquist 2003). Economic figures for sub-Saharan Africa show that those countries with the highest HIV/AIDS burden are also among the wealthiest in the region (Whiteside 2002). Alan Whiteside, an economist who has studied HIV/AIDS in Southern Africa, argues that the answer to this paradox may lie in the success of economic growth (Whiteside 2002). Rapid economic growth brings its own problems - disruption, deprivation, disease and death. (Whiteside 2002). Growth in and of itself does not translate into better health for all. Growth and wealth, in the absence of redistributive policies, pro-poor policies, and government regulations, can mean greater disparities of equity within a given population (Gershman et al 2000).

In many developing countries it is not uncommon for the social elite to benefit financially under growth policies while the poor become poorer with fewer resources at their disposal (Gershman et al 2000). Some women who are left with very few alternatives for income, exchange sex for subsistence as the following story about a young mother of two children whose father and husband left them illustrates (Schoepf et al 2000). "…Desperate for cash, and without money to start a business exchanging sex for subsistence appeared to be Nsanga’s only recourse. In the first year of this new strategy Nsanga thought she was lucky. She became the second (unrecognized) wife of a government official, who paid her rent and provided regular support. She also had occasional "spare tires" to buy medicine when one of her children became sick. But then she got pregnant. Shortly thereafter, this "husband" told her his salary could not stretch farther, and he, too, left" (Schoepf et al 2000). In 1989, Nsanga became very thin. Many in the community speculated that she must be infected with the AIDS virus. In 1991 she died of AIDS. Many thought she contracted through her work, but given the long incubation period of HIV/AIDS, the likely source was her husband who left her several years before (Schoepf et al 2000).

This is an all too familiar story in many regions in Africa today. While some women may be forced into the sex industry for economic reasons, there is another side to the equation. There are men with resources and extra money that can purchase these services. Socio-economic status, therefore, can reinforce behaviors that can put one at risk as I will discuss further in this paper.

Educational attainment, one of the components of SES, has often been associated with positive health outcomes. In 1998, UNAID surveyed 161 countries in the world for which there was data for both HIV and literacy. The data showed a positive association between literacy levels and a reduction in HIV cases. However, in 44 countries in sub-Saharan Africa, the analysis revealed a relationship between HIV and literacy, but the direction was now reversed. The countries with the highest levels of HIV infection are also those whose men and women are most literate. (UNAID 1998). Education may actually be a risk factor contributing to the spread of the virus in this region for various cultural reasons.

Educated people have higher earning power and use their disposable income to support behaviors or lifestyles that put them at risk of infection (UNAID 1998). Men with higher incomes have the opportunity to engage in more leisure activities, which include drinking and sexual relationships. They have the income necessary to be more mobile - moving from an urban work environment to a rural traditional family life. Men with more income are also able to support more than one wife and may choose to support mistresses as well. HIV spreads very quickly in this environment, devastating those who lay in its path. President Kibaki, the current leader of Kenya, summed up these points in a recent address saying the virus did not discriminate between the rich and poor. He continued by saying, some of the rich were responsible for the spread since they had the means to move around. And he caused prolong laughter when he said: Stay faithful, don't think God made all these [women] for you (men). (Mugonyi 2003).

For many, Kibaki's plea may come too late. In my own field work, I found that it was not uncommon for female students to engage in sexual relations with a teacher or headmaster. These relationships often involved an exchange of some type, typically school fees and support for the female student. Further research shows this is not an isolated incident. Many South African teachers believe it is acceptable for them to have sexual relationships with pupils for whom they are responsible. Some of the relationships were approved by parents because teachers were able to provide money to impoverished households. (iafrica.com 2002). Recent reports from the World Bank show that as many as 30% of school teachers in sub-Saharan Africa are infected with the HIV virus (World Bank 2002). Teacher shortages have cropped up all over the region. This will certainly impact development in this region further compounding the HIV/AIDS crisis.

Wealth, education, and occupation, typical factors to measure socio-economic status (SES) and health outcomes (Adler 2002), have become blurred in the face of HIV/AIDS. Nsanga’s story illustrates that the social elite, as well as the impoverished mother can play a role in the spread of the virus. Undoubtedly, SES is only one component of the HIV/AIDS crisis. There are several factors that contribute to the rising pandemic. The reuse of dirty needles and immunization programs has recently come under scrutiny. Lack of acknowledgement about HIV causing AIDS by political leaders has impeded prevention programs. Lack of gender equity and traditional beliefs often puts women in a higher "at risk" category for contracting the virus. Rethinking current paradigms about SES, cultural and traditional beliefs, and gender roles may be the key in reducing the numbers of new HIV cases throughout the world, not just in Africa.

The future of many lives hangs in the balance. I can only hope that on my next trip to Kenya as I fly over the countryside, there will be fewer graves and fewer voids in the communities I have grown to love and call my second home.

Works Cited

Adler, N., and K. Newman. 2002. "Socioeconomic Disparities in Health: Pathways and Policies." Health Affairs. 21(2): 60-76.

Gershman, J. and A Irwin. 2000. "Getting a Grip on the Global Economy." eds. Kim, JY, Millen, J, Irwin A., Gersham, J. Dying for Growth: Global inequality and the health of the poor. Monroe: Common Courage Press.

Gisselquist, D., J.J. Potterat, S. Brody, and F. Vachon, 2003. "Let It be Sexual: How Health Care Transmission of AIDS in Africa was Ignored." International Journal of STD & AIDS. 14:144-47,148-61,162-73.

Iafrica.com editor. 2002. "SA schools sex shock." Cape Town. 20 Feb 2002.www.africaonline.com. 12 Apr 2003.

Mugonyi, David. 2003. "Seek Treatment, Kibaki Urges AIDS Patients." The Daily Nation. 14 July 2003. www.nationaudio.com .

Schoepf, BG, Schoepf C., and Millen, JV. 2000. "Theoretical Therapies, Remote Remedies: SAP’s and the Political Ecology of Poverty and Health in Africa." eds. Kim, JY, Millen, J, Irwin A., Gersham, J Dying for Growth: Global inequality and the health of the poor. Monroe: Common Courage Press.

UNAID. 1998. Report on the global HIV/AIDS epidemic. UNAIDS, Geneva, Switzerland.

UNAID. 2002. Report on the global HIV/AIDS epidemic. UNAIDS, Geneva, Switzerland.

Whiteside, A. 2002. AIDS: Challenges for South Africa: Human and Rousseau.

Whiteside, A. 2002. "Poverty and HIV/AIDS in Africa." Third World Quarterly. 23(2): 313-332.

World Bank Study. 2002. "Education and HIV/AIDS: A Window of Hope." May 2002.