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AIDS, Poverty and Malnutrition: A Review of the Household Survey Literature

30 June 2001

Robert van Niekerk (Principal Researcher, Oxford University and Economic Policy Research Institute)
Michael Samson (Director of Research, Economic Policy Research Institute and Williams College)
Carrie Green (Researcher, Williams College and Economic Policy Research Institute)

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The discussion of HIV/AIDS on the African continent no longer revolves simply around issues of health. It has evolved, rather, into a deliberation of economics, national development and poverty relief. The study of how this particular disease affects individuals, households and the national economy reveals a complex but important relationship between HIV and poverty. In Sub-Saharan Africa, the rates of infection are actually higher among the wealthy than among the poor, but because the poor population is so much larger, infection among the poor is considerably higher in absolute terms. Economic growth, moreover, typically leads to higher rates of HIV in the poor population with large project investments resulting in labour migrations and family disruptions.1 According to R. Bonnel, the growth affects on the greater economy are more pronounced the longer HIV has been around while HIV is most advanced in the weakest economies least able to adjust expenditures and revenues. School attendance rates decline, medical costs rise, economic opportunities for women become more limited, and infrastructural investment declines.2

Sound fiscal policies are eroding while gains in employment and economic growth are reversing in what Bonnel terms a "vicious cycle of underdevelopment."3 Martha Ainsworth of the World Bank, in her study of the impact of household death on the health of children in Kagera, Tanzania, notes that AIDS is slowly reversing a thirty year trend (1960-90) of improvement in the health and education of poor children, severely compromising their prospects for future productivity. Maternal infection rates for newborns in Southern Africa are as high a 30-40% without intervention. Children born with HIV suffer stunting, nutritional wasting, acute, chronic and persistent diarrhoea, failure to thrive, pneumonia, thrush, and neurological abnormalities.4 In addition to this grim clinical picture, children infected with AIDS, if cared for by their family, are typically raised in household economically compromised by previous HIV infection.

According to UNAIDS and the World Health Organization, 90% of the 600,000 children under the age of fourteen who became HIV-infected in the year 2000 were born to HIV-infected mothers. Nearly 90% of these new infections were in Sub-Saharan Africa, while 70% of the global total of HIV-infected persons reside in Sub-Saharan Africa. The number of AIDS orphans (a child under fifteen years of age who lost one or both parents to AIDS) in South Africa alone is estimated to reach one million by the year 2005. By the year 2010, the estimate is closer to 2.5 million with the majority of these being under four years of age. Despite this, very little research has been devoted to the impact of AIDS at the household level in South Africa. Reflecting this lack of research, the authors of the Kaiser Foundation Lovelife publication, a report specifically devoted to the HIV/AIDS epidemic in South Africa, cited the need to rely on anecdotal evidence and research from other countries.5

The consequences of AIDS deaths, though similar throughout the African countries, are unlike those from other diseases. By striking adults in their prime, at the peak of their productivity and earning capacity, this disease disables and kills those people on whom families rely for their very survival.6 AIDS is also characterized by the likelihood of multiple deaths in a given household.7 The high cost of transportation to medical facilities and funeral expenses at a time when household income is diminishing due to reduction in labour time puts the household at serious financial risk.8 With multiple deaths, the family's ability to cope is additionally compromised by the potential for stigmatization and the inability or refusal of extended family to lend support due to either this same stigmatization or the financial burden of deaths within the family.

Given the many factors characteristic of HIV/AIDS death-- what Gladys Bindura Mutangadura labels a "major form of idiosyncratic shock affecting households"9 -- the financial cost to a household is considered to be as much as 30% higher than deaths from other causes.10 The role of public sector intervention at the household level is the subject of much debate. There is evidence that public assistance "crowds out" private support and reduces the incentives for family and other donors to contribute to the welfare of those in need. On the other hand, it is possible that public assistance stimulates private transfers. Most importantly, however, is the evidence that family support systems are weakening. The burden of multiple deaths from a highly stigmatized disease has either lessened the degree to which families and communities are willing to assist or, in some cases, brought such assistance to a halt. Public sector intervention may be required to meet the basic needs of household's whose ability to self-insure has been compromised by HIV/AIDS.11

The purpose of this literature review is to assess household studies performed in Zimbabwe, Zambia , Thailand, and Tanzania, as well as an array medical literature on the relationship between AIDS, poverty and malnutrition. Section One, therefore, comprises a discussion of household surveys and the methods used by different researchers. Section Two involves an analysis of the economic impact of AIDS deaths on the household and a discussion of vulnerability within the household. Section Three will focus on coping mechanisms and strategies used by households in the event of adult death. Section Four relies heavily on the medical literature to explore the link between HIV/AIDS, poverty and malnutrition, while Section Five assesses the recommendations for targeting, mitigation, and government intervention.

  1. R. Bonnel,"HIV/AIDS and Economic Growth: A Global Perspective," South African Journal of Economics, Vol. 68:5 (Dec 2000), p. 848.
  2. HIV/AIDS and Economic Growth: A Global Perspective," pages 824, 825, 848.
  3. HIV/AIDS and Economic Growth: A Global Perspective," p. 848.
  4. Martha Ainsworth, Innocent Semali, "The Impact of Adult Deaths on Children's Health in Northwestern Tanzania," World Bank Policy Research Working Paper (2000), p. 5.
  5. "Impending Catastrophe Revisited: An update on the HIV/AIDS Epidemic in South Africa," Henry J. Kaiser Foundatation, LoveLife (2001), p. 4, 8, 10.
  6. M. Lundberg, M. Over, P. Mujinja, "Sources of Financial Assistance for Households Suffering an Adult Death in Kagera, Tanzania," South African Journal of Economics, vol. 68, no. 5 (Dec 2000), p. 948.
  7. Gladys Bindura Mutangadura, "Household Welfare Impacts of Mortality of Adult Females in Zimbabwe: Implications for Policy and Program Development," Paper presented at the AIDS and Economics Symposium (2000), p.13.
  8. "Sources of Financial Assistance for Households Suffering an Adult Death in Kagera, Tanzania," p. 948.
  9. "Household Welfare Impacts of Mortality of Adult Females in Zimbabwe: Implications for Policy and Program Development," p.30.
  10. "Impending Catastrophe Revisited: An update on the HIV/AIDS Epidemic in South Africa," p. 9.
  11. "Sources of Financial Assistance for Households Suffering an Adult Death in Kagera, Tanzania," pages 950-951.

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