University of California, San Francisco Logo

University of California, San Francisco | About UCSF | Search UCSF | UCSF Medical Center

transparent gif
transparent gif
Home > Topics > Emerging Issues > Socioeconomic Status and HIV Prevention
transparent gif

Socioeconomic Status and HIV: Does Increasing Women's Income Decrease Risk of HIV Acquisition?

Transparent Image
transparent gif

Introduction

transparent gif

Few would argue the relationship between socioeconomic status (SES) and health. The literature contains much evidence that individuals with higher SES are healthier, using a number of measurements of health such as morbidity, malnutrition, health care utilization, and mortality. In fact, there is specific evidence that the risk of sexually transmitted infections (STIs) such as herpes, chlamydiosis, gonorrhea, and syphilis is increased in individuals of lower SES.( 1 , 2 , 3 , 4 ) One would expect that lower SES also correlates with increased risk of HIV infection. But does it?

If there is a relationship between lower SES and risk of HIV acquisition, interventions designed to increase socioeconomic power, particularly for women, would be well advised. Some research suggests that women who have higher incomes, a secure place to live, and control over economic assets can more effectively negotiate abstinence, fidelity, and safer sex, and can more easily avoid exchanging sex for money, food, or shelter.( 9 , 10 ) However, little is understood about how these dynamics affect a women's ability to avert HIV infection. In fact, there are conflicting findings about the relationship between SES and HIV infection. In some studies, men and women of higher SES have a higher prevalence of HIV than poorer ones--suggesting that education, negotiating skills, and other determinants, not SES itself, may correlate with HIV infection. This discussion explores microfinance as a means of increasing women's economic power and examines what is known about the association of SES with HIV infection.

Although the relationship between economic status and HIV infection has not been clearly demonstrated, there is a widespread assumption that increasing the economic assets of women and girls is an effective HIV prevention tool. Research, such as a study from KwaZulu-Natal Province in South Africa, has demonstrated that poorer women are more likely to have early sexual debut, a nonconsensual first sexual encounter, and higher rates of physically forced sex. They are also more likely to have exchanged sex for money, goods, or favors, and more likely to have had a higher number of sexual partners. They are less likely to use condoms.( 5 ) All of these are significant risk factors for HIV. But as this discussion will explore, it has not been proven that SES affects the ultimate outcome, HIV infection, even though increased SES may minimize some HIV risk factors.

transparent gif

Background on Microfinance

transparent gif

Microfinance (or microcredit) refers to the provision of small loans to clients who are typically excluded from traditional finance and lending systems. These loans are used to start small business operations and are one of the very few options available for initiating income-generating activities.( 6 ) These activities, in turn, help women develop marketable skills, secure some economic independence, and, to some extent, increase their SES. Some microfinance efforts have begun to integrate the provision of HIV information and referrals into their programs.

Ongoing microfinance programs with built-in HIV interventions include one in Malawi, where the microfinance lender FINCA, in partnership with the U.S.-based Bill and Melinda Gates Foundation and Johns Hopkins University, integrates HIV prevention into its village banking program for women. That program is training 400 village bank members as peer educators to deliver HIV prevention and behavior-change messages.

World Vision, a Christian relief and development agency, has successfully combined HIV education with microfinancing to groups of 20-30 women though its community banking programs. The women in these programs pay back 97% of their loans, and show higher levels of HIV awareness and prevention behaviors, improved educational attainment among their children, greater economic resilience, and better nutrition within their families.( 7 )

The conventional wisdom behind the use of microfinancing as an HIV prevention intervention is that, because of the interconnectedness of poverty and HIV, increasing economic assets for women and girls lowers their vulnerability to becoming infected with HIV. Some research suggests that women who own property or have economic assets have greater bargaining power within their households and can better protect themselves against domestic violence. A study in India found that 49% of women with no property reported physical violence, compared with only 7% of women who did own property reporting physical violence.( 8 )

Whereas women in India who owned property may have fared better than those who did not, owning property and running a small business funded by a microfinance loan are worlds apart in terms of their socioeconomic implications. Microfinance loans typically fund small enterprises (such as soap making, honey harvesting, and jewelry making), and these endeavors can increase women's spending power to some extent. But it is unclear to what extent they transform a woman's economic power and social standing within a particular culture. As mentioned, there is some evidence of decreased risk of HIV associated with property ownership and increased economic assets, but there is no conclusive evidence that microfinance helps decrease HIV incidence.

transparent gif

SES and HIV: What Is Known

transparent gif

Although little is known about the relationship between microfinance and HIV, there is a considerable amount of research examining the relationship between SES and HIV infection in women. A systematic review by Wojcicki examined 36 studies of SES and HIV infection, including 30 cross-sectional studies, 1 case-control study, and 5 prospective cohort or nested case-control studies. Of these, 35 used at least one measurement of women's SES, and 14 also included at least one measurement of partner's SES.( 11 ) The studies used variables measuring educational level, household income, and occupation or employment status at the individual and neighborhood level to ascertain SES.

Of the 36 studies reviewed, 15 found no association between SES and HIV infection; 12 found an association between high SES and HIV infection; 8 found an association between low SES and HIV infection; and 1 study yielded mixed results. The author concluded that, in low-income sub-Saharan African countries, increasing access to resources for women may initially increase risk of HIV infection or have no effect on risk-taking behaviors. In parts of sub-Saharan Africa where per capita income is higher and within-country inequalities in wealth are greater, increasing SES may decrease risk. The author concluded that increased SES may have differential effects on married and unmarried women and that future studies should use multiple measures of SES. The author also suggested that the primary partner's SES (measured by education or income/employment) may be a stronger predictor of female HIV status than measures of female SES.

The author of another study found that positive HIV status was associated with lower SES among women aged 15-24, whereas there was some indication that HIV infection was associated with higher SES among women aged 25-49.( 12 ) This study used a cross-sectional population survey that included 1,000 women from the city of Kisumu, Kenya, aged 15-49 years. SES was determined using a composite variable of educational status, occupation, and availability of household utilities. Higher SES was associated with a more mobile lifestyle, later sexual debut, marriage, and condom use among the women aged 25-49. The author concluded that women of lower SES may be at greater risk of newly acquired HIV infection and that new infections may now be occurring most frequently among young women of the lowest SES.

A study by the U.S. Agency for International Development (USAID) of 8 recent population-based, nationally represented surveys involving HIV testing in sub-Saharan Africa found that HIV prevalence is not higher among adults with lower SES.( 13 ) These results echo those of Wojcicki's systematic review of studies pertaining to sub-Saharan Africa. The USAID research found that any positive association between SES and HIV is diminished considerably in most cases when adjusted for underlying factors (eg, education, urban/rural residence, and community wealth) and mediating factors (eg, sexual risk taking, condom use, and male circumcision).

transparent gif

Mediating Factors

transparent gif

Which factors are responsible for the higher HIV prevalence seen among individuals with higher SES in these countries? A number of factors may explain this phenomenon. Wealthier individuals are more likely to live in wealthier communities and in urban areas, where HIV is more prevalent.( 13 ) Those with higher SES also tend to be more mobile, more likely to have multiple partners, and more likely to engage in sex with nonregular partners.( 13 )

Conversely, a number of factors would contribute to a decreased HIV prevalence among those with higher SES. Wealthier individuals are more likely to have a higher level of education and a greater knowledge of HIV prevention strategies. They also may be more likely to receive health care and to use condoms consistently, and less likely to use alcohol when having sex.( 13 )

transparent gif

Conclusion

transparent gif

There are no studies comparing prevalence of HIV infection among women who have received microfinance loans and those who have not. Research into the correlation between SES and HIV prevalence or incidence in a given population has yielded mixed results. In fact, at least in sub-Saharan African countries, higher SES may actually increase vulnerability to HIV. Factors other than SES, including education, condom use, community wealth, and number of sexual partners, are more directly associated with HIV. Microfinance efforts that incorporate specific HIV education and referral to prevention and care may be more effective than those that do not.

transparent gif

References

transparent gif
  1. Ellen JM, Kohn RP, Bolan GA, et al. Socioeconomic differences in sexually transmitted disease rates among black and white adolescents, San Francisco, 1990 to 1992. Socioeconomic differences in sexually transmitted disease rates among black and white adolescents, San Francisco, 1990 to 1992 . Am J Public Health 1995;85:1546-8.
  2. Fleming DT, McQuillan GM, Johnson RE, et al. Herpes simplex virus type 2 in the United States, 1976 to 1994. Herpes simplex virus type 2 in the United States, 1976 to 1994 . N Engl J Med. 1997 Oct 16;337(16):1105-11.
  3. Lancey CJ, Merrick DW, Bensley DC, et al. Analysis of the sociodemography of gonorrhoea in Leeds, 1989-93. Analysis of the sociodemography of gonorrhoea in Leeds, 1989-93 . BMJ. 1997 Jun 14;314(7096):1715-8.
  4. Holtgrave DR, Crosby RA. Social capital, poverty, and income inequality as predictors of gonorrhoea, syphilis, chlamydia and AIDS case rates in the United States. Sex Transm Infect. Social capital, poverty, and income inequality as predictors of gonorrhoea, syphilis, chlamydia and AIDS case rates in the United States . 2003 Feb;79(1):62-4.
  5. Hallman K. Gendered socioeconomic conditions and HIV risk behaviors among young people in South Africa. Afr J AIDS Res. 2005;4(1):37-50.
  6. United Nations Capital Development Fund. Microfinance and the Millennium Development Goals: A Reader's Guide to the Millennium Project Reports and Other UN Documents. Available at: Microfinance and the Millennium Development Goals . New York: UNDCF; October 2005.
  7. World Vision. Protecting Women from HIV/AIDS via Micoenterprise Development. Available at: Protecting Women from HIV/AIDS via Microenterprise Development (MED) . Accessed April 17, 2007.
  8. Panda P. Rights-based strategies in the prevention of domestic violence. Working paper 344. Trivendrum, India: Centre for Development Studies; March 2003. Available at: Rights-based strategies in the prevention of domestic violence .
  9. Schuler S, Hashemi S, Riley A. The influence of women's changing roles and status in Bangladesh's fertility transition: evidence from a study of credit programmes and contraceptive use. World Development 1997;25: 563-75.
  10. UNAIDS. Gender and HIV/AIDS: Taking Stock of Research and Programmes. Geneva: UNAIDS; 1999.
  11. Wojcicki JM. Socioeconomic status as a risk factor for HIV infection in women in East, Central and Southern Africa: a systematic review. J Biosoc Sci. 2005 Jan;37(1):1-36. Socioeconomic status as a risk factor for HIV infection in women in East, Central and Southern Africa: a systematic review .
  12. Hargreaves JR. Socioeconomic status and risk of HIV infection in an urban population in Kenya. Trop Med Int Health. 2002 Sep;7(9):793-802. Socioeconomic status and risk of HIV infection in an urban population in Kenya .
  13. Mishra V, Bignami S, Greener R, et al. A study of the association of HIV infection with wealth in sub-Saharan Africa. DHS Working Papers. Washington: United States Agency for International Development; January 2007.
transparent gif
transparent gif