Is poverty or wealth driving HIV transmission?

Evidence of associations between socioeconomic status and the spread of HIV in different settings and at various stages of the epidemic is still rudimentary. Few existing studies are able to track incidence and to control effectively for potentially confounding factors. This paper reviews the findings of recent studies, including several included in this volume, in an attempt to uncover the degree to which, and the pathways through which, wealth or poverty is driving transmission in sub-Saharan Africa. We investigate the question of whether the epidemic is transitioning from an early phase in which wealth was a primary driver, to one in which poverty is increasingly implicated. The paper concludes by demonstrating the complexity and context-specificity of associations and the critical influence of certain contextual factors such as location, gender and age asymmetries, the mobility of individuals, and the social ecology of HIV transmission. Whereas it is true that poor individuals and households are likely to be hit harder by the downstream impacts of AIDS, their chances of being exposed to HIV in the first place are not necessarily greater than wealthier individuals or households. What is clear is that approaches to HIV prevention need to cut across all socioeconomic strata of society and they need to be tailored to the specific drivers of transmission within different groups, with particular attention to the vulnerabilities faced by youth and women, and to the dynamic and contextual nature of the relationship between socioeconomic status and HIV.