Skip to main content Accessibility help


  • ASHLEY M. FOX (a1)


Although health is generally believed to improve with higher wealth, research on HIV in sub-Saharan Africa has shown otherwise. Whereas researchers and advocates have frequently advanced poverty as a social determinant that can help to explain sub-Saharan Africa's disproportionate burden of HIV infection, recent evidence from population surveys suggests that HIV infection is higher among wealthier individuals. Furthermore, wealthier countries in Africa have experienced the fastest growing epidemics. Some researchers have theorized that inequality in wealth may be more important than absolute wealth in explaining why some countries have higher rates of infection and rapidly increasing epidemics. Studies taking a longitudinal approach have further suggested a dynamic process whereby wealth initially increases risk for HIV acquisition and later becomes protective. Prior studies, conducted exclusively at either the individual or the country level, have neither attempted to disentangle the effects of absolute and relative wealth on HIV infection nor to look simultaneously at different levels of analysis within countries at different stages in their epidemics. The current study used micro-, meso- and macro-level data from Demographic and Health Surveys (DHS) across 170 regions within sixteen countries in sub-Saharan Africa to test the hypothesis that socioeconomic inequality, adjusted for absolute wealth, is associated with greater risk of HIV infection. These analyses reveal that inequality trumps wealth: living in a region with greater inequality in wealth was significantly associated with increased individual risk of HIV infection, net of absolute wealth. The findings also reveal a paradox that supports a dynamic interpretation of epidemic trends: in wealthier regions/countries, individuals with less wealth were more likely to be infected with HIV, whereas in poorer regions/countries, individuals with more wealth were more likely to be infected with HIV. These findings add additional nuance to existing literature on the relationship between HIV and socioeconomic status.



Hide All
Barham, B. & Boucher, S. (1998) Migration, remittances, and inequality: estimating the net effects of migration on income distribution. Journal of Development Economics 55, 307331.
Barnett, T., Whiteside, A. & Decosas, J. (2000) The Jaipur paradigm: a conceptual framework for understanding social susceptibility and vulnerability to HIV. South African Medical Journal 90, 10981101.
Bärnighausen, T., Bor, J., Wandira-Kazibwe, S. & Canning, D. (2011) Correcting HIV prevalence estimates for survey nonparticipation using Heckman-type selection models. Epidemiology 22(1), 2735.
Bärnighausen, T., Hosegood, V., Timaeus, I. M. & Newell, M-L. (2007) The socioeconomic determinants of HIV incidence: evidence from a longitudinal, population-based study in rural South Africa. AIDS 21(S7), S2938.
Bärnighausen, T. & Tanser, F. (2009) Rethinking the role of local community in HIV epidemic spread in sub-Saharan Africa: a proximate-determinants approach. HIV Therapy 3(5), 435445.
Buve, A. M., Hayes, R. J., Auvert, B., Ferry, B., Robinson, N. J. & Anagonou, et al. (2001) The multicentre study on factors determining the differential spread of HIV in four African cities: summary and conclusions. AIDS 15(S4), S127131.
Coovadia, H. M. & Hadingham, J. (2005) HIV/AIDS: global trends, global funds and delivery bottlenecks. Globalization and Health 1, 13.
Drain, P. K., Smith, J. S., Hughes, J. P., Halperin, D. T. & Holmes, K. K. (2004) Correlates of national HIV seroprevalence: an ecologic analysis of 122 developing countries. Journal of Acquired Immune Deficiency Syndrome 35(4), 407420.
Epstein, H. (2007) The Invisible Cure: Africa, the West, and the Fight Against AIDS. Farrar, Strauss, Giroux, New York.
Fenton, L. (2004) Preventing HIV/AIDS through poverty reduction: the only sustainable solution? Lancet 364, 11861187.
Filmer, D. & Pritchett, L. (2001) Estimating wealth effects without expenditure data- or tears: an application to educational enrollments in states of India. Demography 38(1), 115132.
Filmer, D. & Scott, K. (2008) Assessing Asset Indices: Policy Research Working Paper No. 4605. World Bank. URL:
Forston, J. G. (2008) The gradient in sub-Saharan Africa: socioeconomic status and HIV/AIDS. Demography 45(2), 303322.
Fox, A. M. (2010) The social determinants of serostatus in sub-Saharan Africa: an inverse relationship between poverty and HIV? Public Health Reports 125(S4), 1624.
Fisher, A. A. & Way, A. A. (1988) The Demographic and Health Surveys program: an overview. International Family Planning Perspectives 14(2), 1519.
Gelman, A. & Hill, J. (2007) Data Analysis using Regression and Multilevel/Hierarchical Models. Cambridge University Press.
Gilbert, L. & Walker, L. (2002) Treading the path of least resistance: HIV/AIDS and social inequalities – a South African case study. Social Science & Medicine 54, 10931110.
Goldstein, H. (1999) Multi-Level Statistical Models. London Institute of Education.
Hargreaves, J. (2011) Investigating the inverse equity hypothesis: the changing social epidemiology of HIV in Tanzania. Presented at the Structural Drivers of HIV Conference, 9th September 2011, Norwich, UK.
Hargreaves, J. R., Bonell, C. P., Boler, T., Boccia, D., Birdthistle, I., Fletcher, A. et al. (2008) Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS 22(3), 403414.
Harling, G., Ehrlich, R. & Myer, L. (2007) The social epidemiology of tuberculosis in South Africa: a multilevel analysis. Social Science & Medicine 66(2), 492505.
Heise, L. L. & Elias, C. (1995) Transforming AIDS prevention to meet women's needs: a focus on developing countries. Social Science & Medicine 40(7), 931943.
Hirsch, J. S. & Wardlow, H. (2006) Modern Loves: The Anthropology of Romantic Courtship & Companionate Marriage. Tor/Forge.
Human Science Research Council. (2005) South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey. HSRC Press, Cape Town.
Hunter, M. (2002) The materiality of everyday sex: thinking beyond ‘prostitution’. African Studies 61, 99120.
Hunter, M. (2007) The changing political economy of sex in South Africa: the significance of unemployment and inequalities to the scale of the AIDS pandemic. Social Science & Medicine 64, 689700.
Hunter, M. (2010) Love in the Time of AIDS: Inequality, Gender, and Rights in South Africa. Indiana University Press, Bloomington, IN.
Kennedy, B., Kawachi, I., Prothow-Stith, D., Lochner, K. & Gupta, V. (1998) Social capital, income inequality and firearm violent crime. Social Science & Medicine 47(1), 717.
Kuznets, S. (1955) Economic growth and income inequality. American Economic Review 45, 128.
LaChaud, J.-P. (2007) HIV prevalence and poverty in Africa: micro- and macro-econometric evidences applied to Burkina Faso. Journal of Health Economics 26, 483504.
LeClerc-Madlala, S. (2004) Transactional sex and the pursuit of modernity. Social Dynamics 29(2), 121.
Link, B. G. & Phelan, J. (1995) Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 35 (Extra) Issue, 8094.
Luke, N. (2005) Confronting the ‘sugar daddy’ stereotype in urban Kenya. International Family Planning Perspectives 31(1), 614.
Lurie, M. N., Williams, B. G., Zuma, K., Mkaya-Mwamburi, D., Garnett, G. P., Sweat, M. D. et al. (2003) Who infects whom? HIV-1 concordance and discordance among migrant and non-migrant couples in South Africa. AIDS 17(15), 22452252.
Lynch, J. W., Davey-Smith, G., Kaplan, G. A. & House, J. S. (2000) Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions. British Medical Journal 320, 12001204.
Marmot, M. G. (2004) Status Syndrome: How your Social Standing Affects your Health and Life Expectancy. Bloomsbury Publishing, London.
McKenzie, D. J. (2005) Measuring inequality with asset indicators. Journal of Population and Economics 18, 229260.
Mishra, V. K., Assche, S. B., Greener, R., Vaessen, M., Hong, R., Ghys, P. D. et al. (2007a) HIV infection does not disproportionately affect the poorer in sub-Saharan Africa. AIDS 21 (Supplement 7), S1728.
Mishra, V. K., Bignami, S., Greener, R., Vaessen, M. & Hong, R. (2007b) A Study of the Association of HIV Infection with Wealth in Sub-Saharan Africa. DHS Working Paper No. 31. URL:
Mishra, V. K., Vaessen, M., Boerma, T., Arnold, F., Way, A., Barrere, B. et al. (2006) HIV testing in national population based surveys: experience from the demographic and health surveys. Bulletin of the World Health Organization 84(7), 537545.
Moran, T. P. (2005) Kuznets's inverted u-curve hypothesis: the rise, demise, and continued relevance of a socioeconomic law. Sociological Forum 20(2), 209244.
Morris, M. (1997) Sexual networks and HIV. AIDS 11 (Supplement A), S209216.
Msisha, W. M., Kapiga, S. H., Earls, F. & Subramanian, S. V. (2008a) Socioeconomic status and HIV seroprevalence in Tanzania: a counterintuitive relationship. International Journal of Epidemiology 37, 12971303.
Msisha, W. M., Kapiga, S. H., Earls, F. & Subramanian, S. V. (2008b) Place matters: multilevel investigation of HIV distribution in Tanzania. AIDS 22, 741748.
Opuni-Akuamoa, M. (2009) Issues in assessing the relationship between economic status and HIV infection in sub-Saharan Africa. Doctoral dissertation, Johns Hopkins Bloomberg School of Public Health.
Over, M. (1999) The effects of societal variables on urban rates of HIV infection in developing countries: an exploratory analysis. In Ainsworth, M., Fransen, L. & Over, M. (eds) Confronting AIDS: Evidence from the Developing World. The World Bank, Washington, DC.
Parikh, S. A. (2007) The political economy of marriage and HIV: the ABC approach, “safe” infidelity, and managing moral risk in Uganda. American Journal of Public Health 97(7), 11981208.
Parkhurst, J. O. (2008) “What Worked?”: the evidence challenges in determining the causes of HIV prevalence decline. AIDS Education and Prevention 20(3), 275283.
Parkhurst, J. O. (2010) Understanding the correlations between wealth, poverty and human immunodeficiency virus infection in African countries. Bulletin of the World Health Organization 88(7), 519526.
Poku, N. (2002) Poverty, debt and Africa's HIV/AIDS crisis. International Affairs 78, 531546.
Potts, M., Halperin, D., Kirby, D., Swidler, A., Marseille, E., Klausner, J. D. et al. (2008) Reassessing HIV prevention. Science 320, 749750.
Preston, S. H. (1975) The changing relation between mortality and level of economic development. Population Studies 29, 231248. Reprinted in International Journal of Epidemiology (2007) 36, 484–490.
Pronyk, P. M., Kim, J. C., Hargreaves, J. R., Makhubele, M. B., Morison, L. A., Watts, C. et al. (2005) Microfinance and HIV prevention – emerging lessons from rural South Africa. Small Enterprise Development 16, 2638.
Rapoport, H. (2002) Migration, credit constraints, and self-employment: a simple model of occupational choice, inequality, and growth. Economics Bulletin 15(7), 15.
Rutstein, S. O. & Johnson, K. (2004) The DHS Wealth Index. DHS Comparative Reports No. 6. ORC Macro, Calverton, MD.
Sahn, D. E. & Stifel, D. C. (2003) Urban–rural inequality in living standards in Africa. Journal of African Economies 12(4), 564597.
Schoepf, B., Schoepf, C. & Millen, J. (2000) Theoretical therapies, remote remedies: SAPs and the political ecology of poverty and health in Africa. In Kim, J. Y., Millen, J. V., Irwin, A. & Gershman, J. (eds) Dying for Growth: Global Inequality and the Health of the Poor. Common Courage Press, Monroe, Maine, pp. 91125.
Shelton, J. D., Cassell, M. M. & Adetunji, J. (2005) Is poverty or wealth at the root of HIV? Lancet 366(9491), 157.
Smith, D. J. (2007) Modern marriage, men's extramarital sex, and HIV risk in Southeastern Nigeria. American Journal of Public Health 97(6), 9971005.
Stillwaggon, E. (2006) AIDS and the Ecology of Poverty. Oxford University Press.
Talbott, J. R. (2007) Size matters: the number of prostitutes and the global HIV/AIDS pandemic. PLoS ONE 2(6), e543.
Wai-Poi, M., Spilerman, S. & Torche, F. (2008) Economic Well-Being: Concepts and Measurement using Asset Indices. Working Paper No. 27. Center for Wealth and Inequality, Columbia University.
Wilkinson, R. G. & Pickett, K. E. (2006) Income inequality and population health: a review and explanation of the evidence. Social Science & Medicine 62, 17681784.
Wojcicki, J. M. (2005) Socioeconomic status as a risk factor for HIV infection in women in East, Central and Southern Africa: a systematic review. Journal of Biosocial Science 37(1), 136.


  • ASHLEY M. FOX (a1)


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed