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

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)

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?

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

Loevinsohn and Gillespie 2003

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)

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

HIV and Poverty in Africa

HIV and Income Inequality in Africa

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)

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

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

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

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

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)

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)

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

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