Address for correspondence: Mark F. Cotton, FCPaed (SA), DTM&H, PhD, KID-CRU/J8, Tygerberg Children's Hospital, Francie van Zyl Ave, Tygerberg 7505, South Africa. Voice: +27-21-938-4298; fax: +27-21-938-4157. email@example.com
Sub-Saharan Africa is the region affected worst by human immunodeficiency virus (HIV), with the most southern countries, including Botswana, Zimbabwe, Swaziland, and South Africa, carrying the highest disease burden. This geographic distribution represents a complex interaction among virological, political, social, cultural, and economic forces. In South Africa the HIV epidemic is seemingly unchecked, with 18% of the adult population infected. Although South Africa is a middeveloped country, there is a large chasm between the wealthy and the poor, with many living in moderate to extreme poverty. Poverty creates conditions that fuel the HIV epidemic while HIV exacerbates the multiple interlinking causes of poverty. Children are the most vulnerable members of society, severely affected by all components of the poverty cycle. Although improved health education and access to care will alleviate many problems, sustainable poverty alleviation should form an essential component of the response to AIDS. The formulation of the United Nations Millennium Developmental Goals is an important step in the right direction, but global and local political commitment is essential for success.
Extreme poverty, the world's biggest killer and the greatest cause of suffering and ill health, is coded Z59.5 in the International Classification of Diseases (ICD 10) and is listed only in the penultimate of 22 chapters.1 In this review we discuss the interaction of poverty and human immunodeficiency virus (HIV) infection—how it affects households and children, including a specific focus on our experiences dealing with HIV-infected children in the Western Cape Province of South Africa. We describe our experience with the debilitating effects of unequal wealth distribution and persistent poverty among those outside the mainstream economy.
There are various definitions of poverty (Table 1); the World Health Organization categorizes poverty by the ability of the household to meet its basic needs. In the most severe forms of poverty, where households cannot meet their basic needs, there is chronic hunger and poor access to safe water and sanitation. The World Bank, on the other hand, attaches a monetary value, defining severe poverty as a household income of ≤$1 per person per day. There is no accurate information on the exact number of poor people on the planet, where they live, and how their numbers and economic conditions are changing over time. Although relative and moderate poverty occurs in pockets within the developed countries, extreme poverty occurs almost exclusively in the developing world.2
Table 1. Definitions of poverty
World Health Organization
Not meeting basic needs
Barely meeting basic needs
Household income level below a given proportion of average national income
Unable to access health care
No safe drinking water
Unable to afford education
≤$1 per day per person
$1–$2 per day per person
Poverty in South Africa
South Africa is a mid-developed country with a relatively well-developed public health sector and (since 1994) a democratic political system. The main reasons for child poverty in South Africa include the legacy of apartheid, high unemployment, and HIV.3 During and preceding 46 years of apartheid, resource allocation and educational opportunities were based on skin color, with the black population suffering the greatest deprivation. The inequalities in wealth distribution fostered high levels of illiteracy and poor education. The psychological effects of apartheid include lack of self-esteem and empowerment (personal communication, Nocawe Frans, Department of Social Services, Tygerberg Academic Hospital, June 2007). Therefore, standard definitions for poverty do not adequately capture the wide disparities in South Africa.
Noble et al. assessed measures of childhood poverty in 2006 and found that 12% of children lived in shacks, 40% of children had no access to clean water in or within 200 m of their homes, 49% had no access to a refrigerator, and 60% did not have a flush toilet in their homes.4 They constructed a multidimensional model of childhood poverty in South Africa with both absolute and relative measures (Fig. 1). In this model, child is at the core, surrounded by eight domains of potential deprivation influencing the child's ability to develop to his or her full potential. These domains include deprivation in physical safety, abuse, health, mothering, human capital, social capital, living environment, and adequate care. Absolute indicators include family income and food security, whereas relative indicators focused on the child's ability to participate fully in South African society, including factors, such as exclusion from school because of distance or lack of transport or inability to perform schoolwork at home because of the allocation of many household tasks.
Surrounding the core is a concentric ring, representing access to good-quality services designed to protect the child.4 According to the South African Constitution, access to basic care and protection is a constitutional right and includes the right to basic nutrition and health care. In a study measuring access to care, both in an urban site in the Western Cape and a rural site in the Eastern Cape, 40% of children in need were unable to access health care. Barriers include distance to the facility, cost of transport, unavailability of medications, and long waiting times in clinics because of insufficient or overburdened personnel.5
HIV/AIDS was identified as a major factor contributing to affected communities remaining poor; it had multiple effects on children, including stigmatization at school, increased economic instability, and higher risk of contracting opportunistic infections from unwell family members.5
The South African National Government uses a household monthly income of ≤ R800 (US$133) per month to indicate “indigent” families. Subsistence below this level is thought to be extremely difficult. In September 2006, only 42.7% of working-age South Africans were employed.6
In settings with high unemployment, caretakers rely on support from their extended family and on social support grants. Unemployed parents and/or legal guardians can access a basic income grant of $28 per month per child younger than 11 years. Children with severe disability, who are unable to attend school and require full-time parental care, can receive $114 per month. Children with HIV do not qualify for a disability grant unless they meet criteria for severe disability. Establishing guardianship for orphaned and abandoned children is often extremely challenging, and these children add a significant financial burden to the homes of their caregivers. Adults with HIV can temporarily receive $114 per month, as long as their CD4 count remains below 200 cells/mL. This ruling may encourage nonadherence and be highly deleterious if the patient and his or her extended family depend on the grant for their subsistence.
Many obstacles impede access to social services. Nocawe Frans, social worker at the family clinic for HIV, Tygerberg Academic Hospital, made the following observations (personal communication, June 2007): Many parents are unskilled and low-income earners, especially those migrating from rural areas. They cannot cope with the relatively simple paperwork needed to process a grant application. Lack of parental information leads to children not even being registered at birth, hence delaying access to grants. She described “countless” mothers who have waited in line from 4 am at the Social Welfare office, only to be turned away later without success. Allocations to foster children end at 18 years of age, probably excluding the possibility of further education and self-improvement.
HIV in South Africa
Fifteen percent to 18% of the adult population (5.5 million people) and approximately 360,000 (2.1%) children younger than 18 years are HIV infected.7 The prevalence of HIV infection in public antenatal attendees in 2005 was 30.2%.8 The disease is the most important cause of death in women in their reproductive years and in children younger than 5 years.9
Implementation of nevirapine-based prevention of mother to child transmission (PMTCT) programs and access to highly active antiretroviral therapy (HAART) are highly variable within the different provinces. The national average is only 14.6%.10 Within the various provinces, between 27% and 61% of children who require HAART are currently on treatment.11 HIV is the leading cause of infant mortality in South Africa, together with respiratory infection, malnutrition, and diarrhea.
Poverty and HIV: The Link
Figure 2 illustrates the cycle that poverty and HIV may induce. Children are trapped in the middle, where they are affected by a spiral of events beyond their control. To delineate the specific influence of poverty on HIV in childhood, we identified two main areas: (1) the influence of poverty on HIV transmission to children and (2) the influence of poverty on the provision of optimal care to HIV-infected children.
Table 2 summarizes the various levels at which poverty influences the risk of vertical HIV transmission to children. That pediatric HIV is essentially a preventable disease is often underemphasized; therefore, it is a moral imperative that every possible effort be made to optimize the effectiveness of the national PMTCT program. PMTCT is also the most cost-effective pediatric HIV intervention. Children from poor areas are also at increased risk of horizontal HIV transmission: The presence of HIV-infected blood products; unhygienic medical, dental, or cultural practices; and indecent assault are all increased compared with conditions in developed countries, where the necessary protective systems are in place.12,13
Table 2. Levels at which poverty influences risk of vertical HIV transmission to children
Prevalence of HIV infection
No. of pregnancies
Effectiveness of PMTCT
Access to safe feeding
among potential mothers
Poor health education
Poor health education
Absence of routine HIV testing in pregnancy
Poor access to infant formula
Unequal gender relationships
Poor empowerment of women
Late antenatal booking
Stigma associated with formula feeding
Young sexual debut
Poor access to family planning
Increased home deliveries
Poor access to clean water
Forced sexual intercourse
Poor access to optimal interventions, including HAART and elective cesarean delivery
Exclusive breastfeeding often the best option available under the circumstances
High-risk sexual behavior
Poor access to alternative options, such as dual therapy
Poor access to preventive options (male or female condoms)
Poverty also influences the ability to optimally manage HIV-infected children. Children in underserved (rural or periurban) areas have poor access to early diagnosis and accurate disease staging. Diagnostic options are often severely restricted. For example, only one diagnostic DNA PCR (polymerase chain reaction) test at 6 weeks of age is affordable. A strategy of an early and later PCR testing would facilitate earlier diagnosis, identify children infected later, and help to eliminate laboratory errors.
HIV and the Household
HIV has multiple effects on the household, many of which feed the poverty cycle (Fig. 2). Illness and death of adult caretakers significantly add to morbidity and mortality of children. Chronically ill adults cannot work. Ill household members need to be cared for, limiting options for the carer to seek outside employment. Care of orphaned children has a similar effect.14 As an extreme example: In Chad the household cost because of AIDS up to death of the individual was $836 per case and included productivity losses (28%), health care (56%), and funeral (16%).15 With maternal death, a 2.5-fold increase in childhood mortality, extending to HIV-uninfected infants and children, was documented in Lusaka.16 Limiting the spread of the epidemic and securing adequate treatment access for HIV-infected adults are therefore imperative.
Effects on children in the household include stigma within the community and at school, increased emotional and economic instability due to parental illness or death, and higher risk of contracting opportunistic infections, such as tuberculosis.17 The cost that HIV imposes on the extended family is not well documented. Our data suggest that extended family members who act as caretakers of orphaned or abandoned children spend a significant percentage of their income to care for these children. HIV-infected children are often chronically ill and require multiple hospital visits or admissions, thereby adding to the transport cost and keeping caretakers out of work.
Barriers to treatment adherence include the following:
• Lack of access to a refrigerator limits the use of some child-friendly drug formulations.
• Regular clinic follow-up is difficult because of the relatively high traveling costs.
• Drugs must often be given on an empty stomach, and it is difficult to motivate children to take their medication if they are hungry.
• Treatment supervision is difficult because parents or caregivers may be ill themselves or may have to leave the home for work.
HIV and Poverty: Our Experience
Even though the prevalence of HIV in antenatal clinic attendees is lowest in the Western Cape (15.7%) and well below the national figure (30.2%), two poor areas within the Cape Town Metropole, Khayelitsha and Gugulethu/Nyanga, reported rates of 33% and 29%, respectively.
In our clinic, 25% of HIV-infected children do not live with a parent but rather live with extended families or are in foster care.18
In a survey of 217 infants enrolled in a prospective study at Tygerberg and Red Cross Children's hospitals between 2003 and 2004, preceding the availability of HAART in the public sector, 176 (81%) had been previously hospitalized, most (71%) having had two or more episodes. The median age of children was 1.8 (interquartile range, 0.7–4) years. The median household income was $126 per month, with on average five persons per household, which translates into $0.84/person/day. Half the households had a monthly income below $133/month (the subsistence line as defined by the South African government), and 75% had an income of less than $200/month.
Yet only a third of mothers or caretakers accessed the basic income grant of $28 per month per child; 21% were employed, most of whom failed to complete secondary school education, thereby limiting their options to secure permanent employment. Nearly half (44%) of children lived in informal settlements; 97% had access to clean water, 47% using outside taps. Surprisingly, 75% had access to electricity and only 5% had no access to flush toilets.
Food insecurity is a daily reality for many South Africans. Data from 1999 indicate that two-thirds of households experience food insecurity. The survey indicated that those most at risk lived in informal dwellings, mainly in rural and periurban areas, where the level of education in homes was low.19
The risk of HIV transmission through breastfeeding has increased the nutritional vulnerability of young infants, as well as the financial burden on households. In the Western Cape Province, replacement feeding is given for the first 6 months of life, thereafter parents must self-fund infant nutrition. Children with HIV often have higher caloric needs. For example, those with chronic lung disease expend additional energy breathing, and it is important that parents and caretakers understand the need for appropriate supplemental foods. In the symptomatic HIV-infected child with failure to thrive, energy intakes of 50%–100% above the normal requirements may be needed for catchup growth.20
In South Africa, there is a steady increase in the cost of basic foodstuffs that disproportionately affects the poor—particularly in rural settings, where annual food inflation is 12% compared with the 6.9% annual wage increase paid by high-income earners who, themselves, spend less than a fifth of their own salaries on food. Poor families often spend 50% or more of their income on food.21
The dramatic effect of HAART on reducing the morbidity and mortality in HIV-infected children has been well documented. Nevertheless, less than 10% of African children in need of HAART currently can access treatment programs. In the Western Cape, most pediatric HIV clinics are situated in urban settings, often at secondary and tertiary hospitals. By February 2007, 3 years after the introduction of HAART in the public sector, 45% of the children on HAART received treatment at the three tertiary hospitals. Ninety percent of children in the province receive HAART in larger urban hospitals.
Transport adds a substantial financial burden; the cost incurred by families to reach the Tygerberg Family HIV Clinic ranges from $1 to $6 per trip. For families farther away, the cost is considerably more. Because of limited capacity, HIV-infected children and their parents are often treated at different clinics or on different days, compounding the financial strain. Fortunately, there is an increased understanding of the urgency to facilitate community-based family-centered care, and several family-oriented clinics have been established recently. Although lack of access to refrigeration and complex dose calculations are perceived barriers to care, using simplified weight-based charts has largely overcome these obstacles. At the Tygerberg Family HIV Clinic, 70% of caretakers report access to refrigeration; however, electricity supply is often inconsistent and refrigerators are often not repaired if they break down. The development of child-friendly, heat-stable formulations remains a priority.
Despite all the constraints discussed, children on HAART generally do well. Data from our clinic show that only 3% of children require a second-line regimen within 3 years. Viral suppression below 400 copies/mL is achieved in 61% of children at 12 months, with the median CD4 percentage increasing from a base line of 15% to 27% at 18 months, remaining at that level after 30 months.22
A View from HOPE Community Workers
HOPE (HIV Outreach Program and Education), a nonprofit organization, provides HIV support in several clinics served by Tygerberg Hospital. One author of this report (S.G.) conducted a semistructured interview with 22 HOPE community health workers (CHWs), all previously unemployed and from the poor communities where they now provide HIV support.
They noted that because of marginal income, clients cannot miss a day of work to travel to the health care center for a doctor's appointment. A CHW mentioned the refusal of some patients to travel to distant hospitals because of funeral expenses and cost of transporting the body home. HIV awareness and life skills programs in the schools seem inadequate, and the CHWs note poor insight in their communities and even in the media.
For schooling, there is a lack of textbooks and school supplies. Parents struggle to pay school fees. The children and youth are attracted to ubiquitous criminal gangs where they can make money or receive food, clothes, and accessories. The gangs provide emotional and structural support for parental absence due to work commitments, illness, or neglect. Their communities lack recreation facilities, organized after-school programs, and adult supervision. Crime is perpetuated by a need for money. Many with HIV elect to go to distant health care facilities because of fear of being recognized. Even local antiretroviral (ARV) therapy sites are often far away and may require patients to use transportation. Grants are unavailable or inaccessible. Both public transport and the taxis are unsafe. There is a lack of affordable housing with good sanitation. Informal settlements rely on communal toilets. Unemployment breeds depression, leading to alcohol abuse and domestic violence. The CHWs describe mothers on ARV regimens who are adherent during the week but too inebriated to take their medicine on the weekends; the mothers also know that they cannot take their ARV medications with alcohol.
CHWs also note that crime is a major negative factor contributing to the poverty cycle.
HIV and poverty exacerbate each other. Improved health education and access to care will alleviate many problems, but sustainable poverty alleviation should form an essential component of the response to AIDS. The United Nations Millennium Developmental Goals23 presents an important step in the right direction but depends on global and local political will.
Millions of people in the world's poorest countries remain imprisoned, enslaved, and in chains. They are trapped in the prison of poverty. It is time to set them free. Like slavery and apartheid, poverty is not natural. It is manmade and it can be overcome and eradicated by the actions of human beings. And overcoming poverty is not a gesture of charity. It is an act of justice. It is the protection of a fundamental human right, the right to dignity and a decent life. While poverty persists, there is no true freedom.
—Nelson Mandela (MakePovertyHistory [British] campaign speech/Global Campaign for Action Against Poverty, Feb. 3, 2005, London)
We thank the following for their contributions: Madrie Carstens, HOPE community doctor; Nocawe Frans, Department of Social Services, Tygerberg Academic Hospital; Morne Louw, data manager, Children's Infectious Diseases Clinical Research Unit (KID-CRU); Lise Chartrand, HOPE project manager; Pauline Jooste, HOPE trainer; HOPE CHWs. Prof. Heather Zar, from Red Cross Children's Hospital, gave permission to use demographic data from a shared database (funding through the Rockefeller Foundation). Sarah Godwin was an elective student attached to HOPE and KID-CRU and now is studying medicine at Emory University, Atlanta, GA. Funding source: Employed by the various institutions listed above.