HIV hits Africa's rich hardest, study says

DURBAN, South Africa -- The richest people in Africa have higher HIV prevalence rates than the poorest, disputing commonly held beliefs that AIDS is a disease driven by poverty, according to an analysis released yesterday of recent data from eight African countries.

The study, which was presented and debated in South Africa at the third annual US President's Emergency Plan for AIDS Relief meeting, found that the poorest 20 percent of the population almost always had a lower HIV prevalence rate than the richest 20 percent. The study's author said the findings should be used to make sure AIDS prevention messages are reaching those who earn the most money.

``Poverty-driven programs are likely to have limited impact on prevention efforts when the majority of HIV-infected people are the wealthiest, not the poorest," said Vinod Mishra , director of research at ORC Macro , a Maryland-based research company that conducts detailed demographic surveys around the world.

Mishra gave several possible reasons why those with more money have higher HIV prevalence rates. One is that studies show that the richest people have more partners, ``more opportunities to travel, more opportunities for casual sex," and rich men can afford to buy sex, Mishra said in an interview. He also said wealthier men in Africa start having sex at an earlier age than poorer men, though wealthier women start to have sex later than poorer women.

Several delegates to the conference later took issue with Mishra's conclusions. ``Ninety percent of the people in Africa are poor," John Lambert , a British development official, told Mishra after his talk. ``The danger is that people could say that AIDS affects the wealthy more than the poor people. We worry about that."

Mishra said HIV infections still have a much harsher impact on the poorest because they generally lack access to good healthcare as well as proper nutrition. But he said many donors and African countries remain dismissive of data that show the richest men and women in Africa have higher infection rates.

``It may be that they see other diseases related to poverty, and they don't expect it to be the case with HIV," Mishra said.

He said Lambert was partly correct in saying that in many African countries the richest 20 percent included people who were poor by most standards. Still, he said, there was a great divide in African countries between the richest and poorest, and HIV prevention efforts would be better targeted toward those with more wealth.

Standing next to him, Dr. Alex Opio , assistant commissioner in Uganda's national disease-control department, said he was met with disbelief recently when he briefed foreign donors on the HIV prevalence data. In Uganda, the rate of HIV infection among the poorest 20 percent of women was 5 percent, compared with an 11 percent infection rate for the richest 20 percent; for men, 4 percent of the poorest were infected, compared with 6 percent of the richest.

``People wanted to stone me," Opio said of the reaction from donors. He said they didn't want to admit their programs were focused on the wrong population group. ``It's in their mind-set that the poorest have the highest prevalence. They don't want to hear anything different."

The data were debated in several corners around the conference, which has attracted more than 1,100 delegates. While several raised questions about whether the findings could be extrapolated to the rest of Africa, many said the data could cause a reevaluation of whether prevention efforts were adequately reaching the relatively well-off group.

``The strategy should be geared to all population groups," said Pamela Bridgewater, the US ambassador to Ghana. If the data prove to be accurate, she said, ``we would find additional strategies to reach this group."

The surveys, the most complete of their kind in Africa, included interviews with 6,000 to 18,000 people in each country and the taking of blood samples for HIV tests. Researchers did not ask people their income level, but instead registered a number of details about their residence and possessions to rank their wealth.

``The reality is that HIV prevalence is higher among the better-offs," Mishra said. ``That is a fact. All those ideas that absolute poverty is at the core of AIDS are misplaced."

John Donnelly can be reached at donnelly@globe.com.