TARGETING FAMILIES AFFECTED BY HIV AND AIDS 33


households in Malawi (Shah et al. 2001). In Mozambique a nationally repre- sentative survey using recall data found that households experiencing deaths had lower levels of cash, cattle, assets, and income (Mather et al. 2004). Several smaller studies in South Africa and Zambia demonstrated large AIDS- related impacts on incomes, including Booysen and Bachmann (2002) in Free State Province, Oni et al. (2002) in Limpopo, and Nampanya-Serpell (2000) in Zambia. As always, the findings are contingent on various economic and social variables at the individual, household, community, and country level. The evidence is thus strong that targeting AIDS-affected families is likely


to reach families that are poor and in need of social protection. There remain the problems, however, that first, many affected by AIDS are not poor, and second, many people are extremely poor due to other causes. Recent work, for example, has highlighted the importance of assets in explaining persistent structural poverty (Carter and Barrett 2006). In a study based on data from six southern African countries, Caldwell (2005) found that household asset ownership was a better predictor of food security than chronic illness, pres- ence of orphans, and gender of the household head. Targeting on multiple criteria capturing poverty and vulnerability, including but not limited to indi- cators associated with AIDS, can capture AIDS-affected families but not exclude others.


Another case for targeting poverty rather than AIDS-affected households


can be made based on evidence that not only does AIDS contribute to impov- erishment but poverty is a driver of HIV infection. Poverty and food insecurity can lead women and older children into transactional sex or prevent eco- nomically dependent women from refusing unsafe sex. A recent review of the evidence (Gillespie, Kadiyala, and Greener 2007) finds a number of qualita- tive and quantitative studies that support this relationship between poverty and risky behavior (Kaufman et al. 2004; Brook et al. 2006; Bryceson and Fonseca 2006; Tladi 2006), although there are also contextual caveats and specificities (Kimuna and Djamba 2005; Nii-Amoo Dodoo, Zulu, and Ezeh 2007; Weiser et al. 2007). Another hypothesized, although less researched, causal pathway is one by which malnourished people are more likely to suffer weak- ened immune systems, which may increase the risk of HIV transmission in an unprotected sexual encounter. Gillespie, Kadiyala, and Greener (2007) review the evidence and conclude that this directional relationship between poverty and AIDS is not straightforward, in part because research on the association between socioeconomic status and the spread of HIV is still in a rudimentary stage and in part because of the complexity and context-specificity of path- ways, including the influence of factors such as location, gender, age, mobil- ity, and the social ecology of HIV transmission. Although the conclusion is that poor people are not necessarily more likely than wealthier people to be


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