1. Risk and Vulnerability (in Southern Africa)
Stuart Gillespie
International Food Policy Research Institute
Regional Network on AIDS, Livelihoods and Food Security
XVII International AIDS Conference, Mexico
4 August 2008

2. Definitions
Risk is the probability or likelihood that a person may become infected with HIV (UNAIDS 2008)
Vulnerability
results from a range of factors outside the control of the individual that reduce the ability of individuals and communities to avoid HIV risk (UNAIDS 2008)
refers to exposure to contingencies and stress, and difficulty in coping (Chambers 1989)

3. Risk in southern Africa
Unprotected sex
Multiple/concurrent sexual partnerships
Coexisting STIs
Non-circumcision
Early sexual debut
……but what underpins and drives these risk factors and behaviors?

4. “The microbe is nothing, the terrain everything”
Louis Pasteur, 1860

5. Loevinsohn and Gillespie 2003

6. Vulnerability and the HIV timeline
Risks HIV AIDS Impacts
Prevention Care & treatment Mitigation
Vulnerability:
upstream (underpins and conditions risk of exposure)
……………….....midstream (susceptibility to disease)
………………………downstream (likelihood/severity of impacts)

7. Upstream vulnerability (exposure to HIV)
Risks HIV AIDS Impacts
Poverty, wealth or inequality?

9. HIV and Poverty in Africa

10. HIV and Income Inequality in Africa

11. Economic status and HIV prevalence
Cross-sectional data from 8 countries (Mishra et al 2007)
The average HIV prevalence across 8 countries is higher for the higher wealth quintiles in the DHS surveys
The difference from lowest to highest is approximately double for women, less pronounced for men
The pattern is more or less compatible in each of the 8 countries
Asset quintiles
Limitations:
Simultaneous causality (Economic status HIV)
Wealthier more likely to live longer ( HIV prev. among wealthy)

12. Factors predisposing wealthier groups to…
Greater risk:
More money
Greater mobility
More leisure time
Earlier sexual debut
More lifetime concurrent partners
More likely to be urban-resident
Greater alcohol consumption
Live longer (healthier, sexual active for longer)
Lower risk
Better nourished
Better access to health care (e.g. STI treatment)
Better communications
Better education
Men more likely to be circumcised
More likely to use a condom

13. Economic status, HIV incidence and adult mortality
3 prospective seroconversion studies
Lowest male HIV incidence among wealthiest asset tertile (Lopman et al 2007, Manicaland)
Lowest incidence in middle tertile (Barnighausen et al, KZN)
No association (Hargreaves et al 2007, Limpopo)
Rural household panel data (MSU and Kadiyala)
In Kenya and Zambia, asset non-poor men more likely to die in prime age
In Ethiopia, poor men more likely to die in prime age

14. Role of other socioeconomic factors
Education increasingly associated with less risky behaviors and lower HIV incidence (Hargreaves et al 2008)
Gender, age and economic asymmetries
Food insecurity (among women)
Low social cohesion (e.g. slums)
Mobility
Positively associated with HIV +ve status

15. Upstream vulnerability (exposure to HIV)
Risks HIV AIDS Impacts
Income inequality
Food insecurity (women)
Gender inequalities
Mobility
Social cohesion
Hope?

16. Midstream vulnerability
Risk HIV AIDS Impacts
Access and quality of health services
- ARVs
- treatment for STIs (especially HSV-2)
Malnutrition
Poverty and food insecurity (time, resources for care)

17. Downstream vulnerability (to impacts of AIDS)
Risk HIV AIDS Impacts
AIDS impoverishes (directly and indirectly)
Depends on quantity, quality and mix of assets at household and community levels, institutional context and processes.
Intra-household effects (women, children)

18. Methodological challenges
Acquiring relevant data (which indicators?)
Unit of analysis (household, cluster, community?)
Assessing counterfactual (valid comparator groups?)
Establishing causality (dealing with endogeneity)
Tracking dynamics
Multiple stresses
Context specificity
Responses
Developing and utilizing panel datasets
Multidisciplinary collaborations
AIDS-sensitive surveillance and M&E
Array of designs, not one single method

19. From vulnerability to resilience
No general approach will work everywhere…..and no single-component intervention will work anywhere (Wellings et al 2006)
Prevention strategies need to take account of:
Who, what, why and where of risk and vulnerability
Many interactions with other stresses and shocks…..but which are most important?
AIDS-sensitive pathways out of poverty
Microfinance plus empowerment generates income and reduces risk
Social protection is relevant across the board
Gender-transformative approaches
Improving school enrolment
Generating hope