4. Underlying causes of HIV/AIDS

According to the Southern African Migration Project (SAMP), the reasons why the highest rates of infection in the world occur in Southern Africa and other African regions are unclear. Although the countries of the SADC region have much in common, their histories over the last twenty years have been very different (Williams et al, 2002). ‘Botswana, with the highest rate of infection, has experienced stable, democratic government and a strong economy since independence in 1966. Mozambique, with the lowest rate of infection, experienced sixteen years of devastating civil war from which it only emerged in 1992. While South Africa and Botswana are the two richest countries in Sub-Saharan Africa (as measured in per capita gross domestic product), Mozambique is the poorest’ (Williams et al, 2002). A number of different factors have been advanced to explain the rapid spread, high prevalence and uneven distribution of HIV/AIDS in Sub-Saharan Africa. They include poverty and economic marginalisation, poor nutrition, opportunistic infection, migration, sexual networking and patterns of sexual contact, armed conflict, and gender inequality. Some of these will be discussed in more detail below.

4.1 HIV/AIDS and Poverty

HIV/AIDS, like all communicable diseases, is linked to poverty. The complex relationship between poverty and HIV/AIDS is central to an understanding of the impact of the epidemic on rural livelihoods. The relationship is bi-directional in that poverty is a key factor in transmission and HIV/AIDS can impoverish people in such a way as to intensify the epidemic itself.

4.1.1 Poverty as a key transmission factor

Thus the relationship between poverty and HIV transmission is not simplistic (Collins and Rau, 2001). The debate on the role of poverty in driving the sexual transmission of HIV in Sub-Saharan Africa is widely acknowledged and accepted in the literature around HIV/AIDS (HSRC, 2001a: 41). Although there are some powerful critiques of the poverty-AIDS argument, which claim that many of the worst affected African countries such as Botswana, Zimbabwe and South Africa are among the most economically developed in the region, poverty does seem to be a crucial factor in the spread of HIV/AIDS. It should be emphasised that poor people infected with HIV are considerably more likely to become sick and die faster than the non-poor since they are likely to be malnourished, in poor health, and lacking in health attention and medications.

In effect, all factors, which predispose people to HIV infection, are aggravated by poverty, which “creates an environment of risk”. According to Balyamujura et al, poverty relates to the spread of HIV in three interrelated ways (2000: 8):

1. Deep-rooted structural poverty, arising from such things as gender imbalance, land ownership inequality, ethnic and geographical isolation, and lack of access to services.

2. Developmental poverty, created by unregulated socio-economic and demographic changes such as rapid population growth, environmental degradation, rural-urban migration, community dislocation, slums and marginal agriculture.

3. Poverty created by war, civil unrest, social disruption and refugees^[2]. High levels of rape and the breakdown of traditional sexual mores are associated with military destabilisation, refugee crisis and civil war (Walker, 2002: 7).

All three have severe effects on individuals’ and communities’ vulnerability to the spread of HIV, their ability to handle risks, and opportunity to participate in prevention and care activities^[3]. The experience of HIV/AIDS by poor individuals, households and communities is likely to lead to an intensification of poverty, push some non-poor into poverty and some of the very poor into destitution. In turn, poverty can accelerate the onset of HIV/AIDS and tends to exacerbate the impact of the epidemic.

4.1.2 The impact of HIV/AIDS on poverty

Thus, as a result of the effect on mortality, morbidity, life expectancy and population growth, HIV/AIDS is having a direct negative impact on poverty, especially as experienced by poor rural households. In the 2001 report on the Special Session of the General Assembly on HIV/AIDS, the United Nations Secretary-General warned that HIV/AIDS was reversing decades of development in the hardest-hit regions of the world:

“It [HIV/AIDS] changes family composition and the way communities operate, affecting food security and destabilising traditional support systems. By eroding the knowledge base of society and weakening production sectors, it destroys social capital. By inhibiting public and private sector development and cutting across all sectors of society, it weakens national institutions. By eventually impairing economic growth, the epidemic has an impact on investment, trade and national security, leading to still more widespread and extreme poverty” (cited in Fourie and Schonteich, 2002: 32).

The most devastating consequences of HIV infection arise not simply because many people will die but because the deaths will occur mainly among adults between the ages of 25 and 45 years, the very people who work to support families and should be most productive economically (SAMP, 2002: 9). Therefore HIV/AIDS is changing the contours and dynamics of poverty through its demographic and socio-economic impacts, which may^[4]:

• Create inter-generational poverty by impoverishing surviving orphans (often forcing them out of school, thus limiting their livelihood options), by fragmenting or dissolving households and by decimating the fragile asset base of the poor;

• Alter the age structure and composition of the poor, by decimating the young adult population while impoverishing an increasing number of children and elderly people;

• Result in irreversible survival mechanisms for the poorest as what is to some extent unique about HIV/AIDS is that the shock it inflicts is one from which many households are unable to recover. In particular, the erosion of the household asset base tends to be permanent;

• Intensify discrimination and marginalisation of poor people living with HIV/AIDS as well as their families. This is especially the case with women who are often perceived to be responsible for transmitting the HIV virus;

• Increase the prevalence of poor female-headed households (young widows with small children as well as elderly grandmothers looking after grandchildren) and thus the feminisation of poverty and agriculture;

• Exacerbate unequal asset distribution (land, livestock, labour) leading to landlessness and destocking. Once land and livestock are sold, the recovery potential of these households is severely diminished. Destitution is the culmination of this process of asset depletion; and

• Intensify poverty-driven labour migration as a coping strategy, thereby increasing the risk of HIV infection among the survivors.

As indicated by the last point, many of these strategies involve people migrating from their homes to other places, usually urban or rural centres, where they hope to find employment. For some women, the pressures of poverty may lead them to engage in sexual transactions in order to support themselves (Collins and Rau, 2001: 8). Therefore migration and commercial sex work are two activities closely associated with risk for HIV infection, two issues that require closer elaboration as they often form central options in the multiple livelihood strategies developed by rural households.

4.2. Regional Migration

Research in Africa has long demonstrated that the prevalence and patterns of spread of infectious disease are closely associated with patterns of human mobility (SAMP, 2002: 15). Thus the continuous movement of people is an underlying factor in the spread of HIV/AIDS. Numerous studies have established a clear link between elevated HIV seroprevalence and short duration of residence in a locality, settlement or travel along major transportation routes, immigrant status, and international travel to the region (Brockerhoff and Biddlecom, 1999). Large-scale economic migration has been a feature particularly of the southern African region (HSRC, 2001a: 4). Historically, men migrated from Lesotho, Botswana, Swaziland, Mozambique, Malawi, Zimbabwe and Zambia to South African gold, platinum and diamond mines to seek work. The close proximity of these countries, in particular that of South Africa’s “enclosure” of Lesotho is indicated on the map of Africa presented earlier in this paper. The ease of movement of people has brought with it infections from other parts of the region to “destination” countries such as South Africa and conversely back to other countries. It is important to reiterate that these regional countries are some of the worst affected in the world.

Massive migration of young, unmarried adults from presumably “conservative” rural environments to more sexually permissive African cities in recent years has been regarded as partly responsible for the much higher infection levels observed in urban than in rural areas (Brockerhoff and Biddlecom, 1999). For example, in South Africa, many male migrants have been forced to separate from their families for long periods and live in overcrowded singe sex hostels. These hostels became sources of clients for sex workers seeking respite from poverty. This resulted in high-risk behaviour which increased the rates of sexually transmitted infections, including HIV, which spread rapidly back to the homes of the migrant workers.

Topouzis and du Guerney have noted that in a number of countries, the HIV/AIDS epidemic has resulted in a return to rural areas of community members who have been living and working in towns and cities (1999). Much documented evidence indicates that rural communities carry the cost of their migrants contracting HIV/AIDS both through the loss of income remitted by a worker who has fallen ill, and through the cost of supporting the family member if they return home once they are ill.

Economic integration in the region, particularly in SADC, has been facilitated by the transport of goods between countries. The vulnerability of truck drivers who frequent sex workers while transporting goods between countries has been well documented (SAMP, 2002: 29; Burayo, 1991). Truck drivers become major conduits of sexually transmitted infections and HIV (Marcus, 2001: 110).

4.3. Poverty-driven Commercial Sex Work

In the absence of alternative opportunities to earn a livelihood for themselves and their households, millions of people sell sex (Collins and Rau, 2001: 13). In discussing the poverty-driven selling of sex, some authors emphasise the importance of recognising that whilst millions engage in commercial sex work on a regular basis, even more people not commonly thought of as “commercial sex workers” find themselves needing to exchange sex for money or goods on an occasional basis (Collins and Rau, 2001: 14, Cohen, 1998: 6). Many mothers have been forced to turn to sexual transactions in order to obtain desperately needed money and in communities characterised by social inequalities, some older men with money procure sex from young females in exchange for gifts or spending money.

Sex work or sexual transactions that are poverty driven are likely to foster behaviours that are risk-taking, which encourages unprotected sex to be more prevalent. People whose livelihood strategies expose them to a high risk of infection are, precisely because they are impoverished, less likely to take seriously, or able to take seriously, the threat of an infection that is fatal in years from the present (Collins and Rau, 2001: 15). They are after all facing the reality of day-to-day survival for themselves and their households in the present.

The conceptualisation of the factors contributing to the spread of the epidemic and linking it to issues such as poverty, migrant labour, income inequalities, and gender relations are crucial to an understanding of HIV/AIDS and its impact on society and the household in particular. From this discussion it is clear that poverty increases vulnerability to HIV infection and poverty is compounded by HIV/AIDS. The latter is a result of the shocks, which result from HIV/AIDS-related deaths and infection that intensify the usual problems associated with severe poverty. This discussion has also indicated some of the options, such as commercial sex work, that affected households may be forced to adopt in the face of the epidemic and increasing levels of poverty. This indicates the need for a more focused discussion around the household and the multiple livelihood strategies that are constituted for survival in an increasingly difficult economic context.