Economic Shocks, Risky Sexual Behavior and the HIV/AIDS Epidemic

The relationship between poverty and HIV/AIDS is a tricky one to pin down empirically. Studies have found widely different associations between SES and the likelihood of having been infected, though the positive association between education and HIV risk appears to be stable across time and space (see this excellent paper by Jane Fortson).

Aside from permanent economic status, transitory shocks may have some impact on the HIV/AIDS epidemic, as well. The idea is that bad times may induce people to engage in riskier sex because of market returns to such behaviors. The possibility of transient shocks in driving sexual behavior and, consequently, the HIV/AIDS epidemic is an intriguing one, especially given the potential prominence of "transactional sex" - sex in exchange for gifts, favors, etc (i.e., not necessarily prostitution!) - in African countries.

Two recent papers having examined this issue in the context of commercial sex workers. A study by Pascaline Dupas and Jonathan Robinson looks at the effects of political instability in Kenya circa 2007, which led to civil conflict and adverse economic times, on the behavior of commercial sex workers (CSWs). They find that CSWs were more likely to engage in unprotected sex after the adverse shock. A paper by Robinson and Ethan Yeh tells a similar story: CSWs in Kenya were more likely to have a variety of different types of riskier sex in response to income shocks. Both of these studies are well done from the stand point of data collection (how many people have panel data on CSWs??) and statistics (causality is plausibly inferred from both pieces).

In some African countries, however, CSW is not a common practice while transactional sex, more broadly, is. In such areas, it would be interesting to look at how the sexual behaviors of the general population respond to income shocks. My colleague Brendan Maughan-Brown, from the University of Cape Town, and I are working on this in the context of Khayelitsha, a township of Cape Town, SA, where antenatal clinic data indicates an HIV/AIDS of over 30%. Using longitudinal data from an effectively random sample of the township, we found (from individual fixed effects models) that people responded to income shocks by reducing condom usage. Interestingly, we found the same result when looking at individuals who were on anti-retroviral therapy for HIV/AIDS (draft forthcoming - will keep you posted).

We are currently trying to understand whether our results reflect a price mechanism (individuals cannot afford to pay the cost of obtaining and using condoms during bad times) or a consumption smoothing mechanism (individuals engage in riskier sex to get by during bad times). Either way, we have compelling evidence that economic shocks may play a role in driving the HIV/AIDS epidemic.