The HIV poverty thesis re-examined: Poverty or inequality as an underlying cause of HIV in sub -Saharan Africa

Contrary to theories that poverty acts as an underlying driver of HIV infection in sub-Saharan Africa, an increasing body of evidence at the national and individual levels indicates that wealthier countries and wealthier individuals within countries, are at heightened risk for HIV. This study poses the hypothesis that HIV infection rates increase as a result of conditions associated with socio-economic inequality rather than poverty. Examining demographic and health survey data from sixteen African countries, this study utilizes a multi-level model to assess the relationship between HIV infection, economic inequality and individual wealth. All multivariate models were run as two-level, hierarchical random intercept and slope models in Stata 10 adjusted for clustering at the sub-national (regional) and national levels. Results from the two-level random intercept model with country fixed effects demonstrated that individual wealth status and regional Gini coefficient on average positively predict HIV infection, with inequality producing a contextual effect even once the individual wealth composition of a region is taken into account. As hypothesized, wealthier individuals are at higher risk for HIV infection and the probability of infection increases with rising economic inequality within countries. However, the results also reveal an ecologic paradox in most countries: In rich regions, the poor are at higher risk of HIV infection, whereas in poor regions the rich are most at risk. Further analysis demonstrates that participation in concurrent sexual network structures partially explain these patterns. Implications of these findings for HIV prevention strategies in developing countries are discussed.