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Contents lists available at ScienceDirect

HIV & AIDS Review

journal homepage: www.elsevier.com/locate/hivar

Review Article

The history and impact of HIV&AIDS. A decade of INDEPTH research

Osman Sankoh a,d,e,∗ , Samuelina S. Arthur a , Bongiwe Nyide b,a , Mark Weston c
a
INDEPTH Network, Accra, Ghana
b
Africa Centre, Kwa-Zulu Natal, South Africa
c
Independent Consultant and Writer, Mwanza, Tanzania
d
School of Public Health, University of Witwatersrand, Johannesburg, South Africa
e
Hanoi Medical School, Hanoi, Viet Nam

a r t i c l e i n f o a b s t r a c t

Article history: Aim: To evaluate the contributions of the member health research centres of the INDEPTH Network
Received 17 February 2014 which operate health and demographic surveillance system (HDSS) field sites to research efforts on
Received in revised form 7 April 2014 the epidemiology and impacts of HIV/AIDS in low- and middle-income countries, via a review of peer-
Accepted 5 May 2014
reviewed published papers on HIV/AIDS that use the HDSS framework.
Available online xxx
Methods: Publication titles were sent to INDEPTH by member centres. These were uploaded onto the
Zotero research tool from different databases (most from PubMed). We searched for publications using
Keywords:
the keyword “HIV” and the publication date. The 540 relevant papers were all published in peer-reviewed
HIV/AIDS
Health and demographic surveillance
English language journals between 1999 and 2012. 71 papers were finally selected which met the key
systems criterion for inclusion: papers must deal with the spread and impact of HIV.
Sexually transmitted diseases Results: The study found that alcohol consumption, socioeconomic status, educational attainment and
age are factors that put certain groups at higher risk of HIV infection. The study found strong effects of
AIDS on household dissolution. Women with HIV whose husbands were uninfected faced a higher risk of
separation and divorce than women in uninfected households or in households where both female and
male partners were infected. Elderly women also face social stigma and isolation as a result of either living
with HIV/AIDS themselves or caring for an individual who has the virus as well as financial difficulties on
household welfare. Children with mothers who are infected with HIV appear to face threats to survival
even while the mother remains alive.
Conclusion: INDEPTH member centres have tracked the course of the HIV/AIDS epidemic in sub-Saharan
Africa. They have analysed how the virus is transmitted, how and where it emerged, which groups are
most affected, and how the virus impacts families, communities and economies. The robust and extensive
data they have generated provide critical insights to policy-makers as the epidemic moves into its fourth
decade.
© 2014 Polish AIDS Research Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

1. Introduction area, to address the critical gaps in information on population

INDEPTH – the International Network for the Demographic Eval-
uation of Populations and their Health – is a growing network of
42 member centres running 49 health and demographic surveil-
lance system (HDSS) field sites across Africa, Asia and the Pacific
region. Its member centres use robust longitudinal data, collected
through regular visits to all households in a geographically defined
∗ Corresponding author at: P.O. Box KD213, Kanda, Accra, Ghana.
Tel.: +233 244201563.
E-mail addresses: osman.sankoh@indepth-network.org,
oasankoh@gmail.com (O. Sankoh).
health in low- and middle-income countries (LMICs). By monitoring
new health threats, tracking population changes through fertil-
ity rates, death rates and migration, and measuring the effect of
policy interventions on communities, HDSSs provide information
that enables policy-makers to make informed decisions that adapt
to changing conditions. Many health interventions that are now
used routinely across the world were trialled on HDSS research
platforms. There are no other sustainable sources of longitudinal
data that can provide the knowledge and policy-relevant evidence
needed to serve health and development in the Global South.
For the past three decades, HIV/AIDS has been one of the Global
South’s most pressing health problems. The epidemic has so far
taken the lives of 36 million people, and 35 million are currently

http://dx.doi.org/10.1016/j.hivar.2014.05.002
1730-1270/© 2014 Polish AIDS Research Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

Please cite this article in press as: O. Sankoh, et al., The history and impact of HIV&AIDS. A decade of INDEPTH research, HIV & AIDS
Review (2014), http://dx.doi.org/10.1016/j.hivar.2014.05.002
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Studies by Country
3 South Africa
2 1
5 3 1 Uganda
Tanzania
7
15
19 Guinea-Bissau
24 Kenya
Malawi
194
53 Mozambique
Ethiopia
Senegal
29
Burkina Faso
Gambia
Vietnam
India
150
Papua New Guinea
*NB remaining studies were conducted by 2 or more centres.
Fig. 1. Distribution of studies by countries. *NB remaining studies were conducted
by 2 or more centres.
living with the virus. In 2012 alone, 1.6 million people died of AIDS-
related causes, and 2.3 million were newly infected with the virus.1
The United Nations recognised the importance of the epidemic by
including combating HIV/AIDS, malaria and other diseases among
its eight Millennium Development Goals. Reversing the spread of
HIV/AIDS by 2015 and providing universal access to AIDS treatment
by 2010 were key UN development targets.
HDSSs have been at the forefront of global efforts to under-
stand and help halt the virus. Centres in Africa, Asia and the Pacific
have analysed how the virus emerged, how it is transmitted, and
how it can be prevented and treated. They have also assessed its
effects on individuals, communities and economies, and endeav-
oured thereby to strengthen the case for action by policy-makers.
The uniquely robust data gathered by HDSSs over long periods
of time have enabled them to track the progress of the epidemic
and to test rigorously the effectiveness of policies and technologies
designed to stop it.
In this paper, we review only studies conducted by HDSSs
between 1999 and 2012. Drawing on 540 papers published in peer-
reviewed English language journals, we outline the key findings
unearthed by INDEPTH member centres and discuss their impli-
cations for future HIV/AIDS policies. Of INDEPTH’s 42 member
centres, 23 published papers on HIV between 1999 and 2012, cov-
ering 14 countries in 3 continents (see Fig. 1). All except four of the
papers were produced in Africa, where the HIV epidemic is most
widespread. Two centres – the Africa Centre Demographic Infor-
mation System (ACDIS) in South Africa and Rakai HDSS in Uganda
– were responsible for over 140 papers each.
Studies included cross-sectional surveys, cohort studies, nested
surveys, qualitative focus group discussions, key informant inter-
views, literature reviews, clinical trials, testing of diagnostic tools,
and multi-site studies (the latter accounting for 8% of total studies).
In this paper we discuss the main themes of the studies in terms
of the history and impacts of HIV/AIDS. In part 1 we trace the epi-
demiology of HIV/AIDS as reported by HDSSs. In part 2 we discuss
the social and economic impacts of the virus.
1
UNAIDS (2013): 2013 Fact Sheet. UNAIDS Report on the Global AIDS Epidemic
2013. Geneva.
Please cite this article in press as: O. Sankoh, et al., The history and impact of HIV&AIDS. A decade of INDEPTH research, HIV & AIDS
Review (2014), http://dx.doi.org/10.1016/j.hivar.2014.05.002
2. One: HIV/AIDS epidemiology
2.1. History of HIV/AIDS in Africa
Human immunodeficiency virus (HIV), the virus that causes
acquired immunodeficiency syndrome (AIDS), emerged in central
Africa in the first half of the 20th century. In a paper published in
AIDS in 2009, researchers from the Rakai HDSS in Uganda exam-
ined molecular epidemiology and geographical and historical data
to trace the spread across Africa of subtypes HIV-1A and D of the
HIV-1 strain of the virus [1].
Cities in what is now the Democratic Republic of Congo (DRC)
were among the first areas to be affected by HIV-1. HIV prevalence
rates in that country have remained low, in part because the isola-
tion and inaccessibility of its urban centres meant that there were
few channels along which the virus could spread. Although isolated
from each other, however, Kinshasa, Lubumbashi and Kisangani
have historically had a small degree of connectivity with other parts
of Africa. Kinshasa is connected to Angola in south-western Africa,
Lubumbashi to Zambia in southern Africa, and Kisangani to east
Africa. HIV appears to have travelled along these routes. Gray and
co-authors found that ‘Distribution of subtypes in west, south, and
east Africa is similar to the distribution of the DRC city with which
they share a network: high diversity is found in Kinshasa and west-
ern Africa, subtype C is highest in Lubumbashi and southern Africa,
and subtype A is highest in Kisangani and east Africa.’
DRC’s eastern and southern neighbours lacked the protection
afforded to Congolese cities by their isolation, and once the virus
spilled out from central Africa in the 1970s its expansion was rapid.
Population centres in eastern and southern Africa were well con-
nected by major highways, and trade and migration along these
routes was prolific. As the Rakai paper suggests, ‘The major high-
ways likely served as a transit route with groups such as mobile
prostitutes and their clients, soldiers and truck drivers introducing
the virus into new networks and villages.’ In Ethiopia, on the other
hand, which is cut off from the main East African trade routes, sub-
types A and D are almost absent, with subtype C accounting for 99%
of infections. ‘The unequal spread of subtypes in Africa does appear
to reflect founder effect as well as the distribution in the DRC urban
centre from which a particular wave of infection originated,’ the
authors conclude.
West Africa has been less hard hit by HIV/AIDS. This is largely
because the more infective and more pathogenic HIV-1 strain of
the virus has been less prevalent there than the HIV-2 strain.
Researchers at the Bandim HDSS in Guinea-Bissau traced the early
history of HIV-2 infection in the former Portuguese colony [2]. HIV-
2 prevalence is high among people in older age groups, and a 1989
survey in two districts of Bissau found that among older women,
variables including having had sex with a white man and having
lived in neighbouring Senegal were associated with a higher risk of
infection. The authors surmise that these risk factors may be asso-
ciated with Guinea-Bissau’s long war of independence, which saw
Portuguese soldiers descending on the colony and also led to large-
scale population movement, including into Senegal. That infection
rates are highest among the 50–69 years age group, which would
have been most sexually active during the war years of the 1960s
and 1970s, lends further weight to the theory that the conflict accel-
erated the virus’s spread.
2.2. How is the virus spreading and who is at risk?
Two further risk factors for HIV-2 transmission were identi-
fied by Poulsen and co-authors. Older women who had worked
as prostitutes or engaged in extra-marital sex were at higher risk
of infection, as were people who had received blood transfusions
in the 1960s. While transmission via unclean syringes has been a
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major contributor to the spread of HIV in other parts of the world
(for example in eastern Europe), in Africa heterosexual transmis-
sion has been responsible for the vast majority of infections [3].
HIV is transmitted in blood, semen, vaginal fluids and breast
milk. Most infections in adults are acquired through unprotected
sexual intercourse, while most infections in children are acquired
before or during birth or while breastfeeding. Kiwanuka et al. [4]
found that in the Rakai district, the risk of acquiring HIV was higher
among women who had two sexual partners, and much higher still
in those with three or more partners. Men and women who did not
use condoms, moreover, were at much higher risk than those who
used condoms consistently.
As highlighted by Gray and co-authors in their study of the his-
tory of HIV-1, trade and migration routes have been a key conduit
for the expansion of the epidemic across Africa. Two studies by
the Africa Centre DIS, based in Mtubatuba in Kwazulu-Natal, South
Africa, have shown that people living near primary roads are at
higher risk of HIV infection [5,6]. A number of other Africa Centre
studies have explored the link between mobility and HIV infection.
Coffee at al. [7] found that those who migrate temporarily (for work,
trade, family and other reasons) are more likely than non-migrants
to engage in high risk sexual behaviour. Migrant women in a study
of an urban area in South Africa were over four times more likely
than non-migrants to have two or more lifetime partners and were
less likely to use condoms [8]. A 2002 survey of truck drivers who
visited commercial sex workers – who themselves are at high risk
because of multiple partnering – found that 37% always stopped for
sex, with only 13% reporting using condoms with their wives [9].
Migrant men in rural Kwazulu-Natal are 26 times more likely to
be infected by partners outside their regular relationships than by
their regular partner [10]. Camlin et al. [11] found that each addi-
tional sexual partner increased the odds of HIV infection by 46% in
migrant women compared with 22% in non-migrant women.
This increased high risk behaviour translates into high HIV infec-
tion rates among migrants. A 2003 Africa Centre study found that
while HIV prevalence among non-migrant men was 13%, among
migrant men it was 26% [12]. The truck drivers surveyed by [9] had a
prevalence rate of 56%. A study by Agincourt HDSS in South Africa’s
Limpopo Province found that short-term migrants had a 1.1–1.9
times higher annual risk of death than non-migrants or long-term
migrants [13]. Research in Guinea-Bissau, too, found that short-
term migration was a significant risk factor for HIV in rural areas
[14], while on the contrary a finding from Magu HDSS in northern
Tanzania revealed that residents with long-term migrant partners
showed higher HIV prevalence [15].
A number of other factors put certain groups at higher risk of
infection, including alcohol consumption, socioeconomic status,
educational attainment and age. Researchers in Rakai found that
alcohol consumption increased intimate partner violence and sex-
ual coercion, which are jointly associated with HIV infection in
young women [16]. A study by the Nairobi HDSS in Kenya also
found an association between alcohol and drug use and sexual coer-
cion [17], and among urban women in South Africa [8] and in rural
Uganda, alcohol use is associated with increased HIV infection rates
[18].
Many infectious diseases tend to hit the poorest hardest, but
findings on the links between wealth and HIV are mixed. Work-
ing at the Ifakara DSS in Tanzania, Amuri at al. [19] found that
AIDS-related stigma, which may be a risk factor for infection and
for failure to access treatment, is higher among poorer communi-
ties. In Nairobi HDSS, Madise et al. [20] found HIV infection rates
to be twice as high among slum dwellers as non-slum dwellers. On
the other hand, [21] found that in the Magu HDSS area, men and
women living in sub-villages that had high levels of economic and
social activity had much higher rates of infection than those in sub-
villages with low levels of activity, while in a 2007 Africa Centre
Please cite this article in press as: O. Sankoh, et al., The history and impact of HIV&AIDS. A decade of INDEPTH research, HIV & AIDS
Review (2014), http://dx.doi.org/10.1016/j.hivar.2014.05.002
3
study by Bärnighausen et al. [22], families in the middle-income
bracket were most at risk. A review paper by Gillespie et al. [23]
concluded that while poorer households are likely to be hardest
hit by the impacts of AIDS when a member becomes infected, they
are not necessarily more likely to be exposed to the virus. ‘What
is clear,’ the authors affirm, ‘is that approaches to HIV prevention
need to cut across all socioeconomic strata of society.’
On the role of education in protecting people against HIV infec-
tion, the signals from HDSS studies are much clearer. While an early
study in Rakai found that education exacerbated the likelihood
of contracting HIV [24], more recent studies find that education
reduces behaviour that puts people at risk of infection. Amuri at al.
[19] found that in rural Tanzania education reduces the stigma sur-
rounding HIV/AIDS. At Agincourt HDSS, school students had fewer
lifetime partners than non-students, and male students (although
not female students) had lower rates of infection than male non-
students [25]. In Kwazulu-Natal, those who attended school made
their sexual debuts at a later age [26], and multivariable analysis
by [21] showed that each additional year of education reduced the
chance of contracting HIV by 7%.
A final group identified by INDEPTH centres as being at risk
of HIV/AIDS is very young children. A community-based survey
in rural South Africa revealed that 41% of deaths in children aged
below five years were attributable to HIV/AIDS. The virus was the
single largest cause of death in this age group [27]. Mothers of very
young children are also more liable to infection. The incidence rate
among pregnant women in Rakai is over twice that among non-
pregnant women, with breastfeeding women also at higher risk
[28]. Africa Centre researchers [29] have calculated that reducing
maternal HIV incidence during late pregnancy and breastfeeding
by 50% would, if combined with HIV screening in late pregnancy
and at immunisation visits, lead to a 28% reduction in annual cases
of mother to child transmission of HIV over a five-year period.
2.3. Tracking trends in the spread of the virus
Both globally and in Africa, the spread of HIV/AIDS accelerated
in the 1980s and 1990s before slowing in the past decade. Incidence
of HIV infection peaked in 1997, and during the period covered by
the papers in our review, new infections declined by 36%, from 3.6
million in 1999 to 2.3 million in 2012. By 2012, 35 million people
worldwide were living with HIV/AIDS – a global adult prevalence
rate of 0.8%.2
Sub-Saharan Africa accounts for 69% of people living with
HIV/AIDS. 25 million Africans were living with the virus in 2012,
although here too new infections have declined, from 2.7 million
in 1999 to 1.6 million in 2012. Prevalence in Africa stood at 4.7% in
2012, down from 5.7% thirteen years earlier.2
AIDS-related mortality has climbed and then fallen in the period
under review. Worldwide mortality increased between 1999 and
2012, from 1.5 million deaths to 1.6 million, but it has fallen from
its 2004–2006 peak of 2.3 million. The number of deaths in sub-
Saharan Africa showed a similar pattern, rising from 1.2 million in
1999 to 1.8 million in 2004–2005 before falling back to 1.2 million
in 2012. The emergence of antiretroviral treatment for AIDS has
been the main driver of these improvements.2
Data gathered by INDEPTH member centres show how these
global trends have affected communities on the ground. By allow-
ing for much greater detail than global figures, moreover – for
example by demonstrating urban and rural differences in incidence,
or differences in mortality by age, migration status or gender – they
2
UNAIDS (2013): UNAIDS Report on the Global AIDS Epidemic – 2013. Geneva.
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can serve as an important resource for policy-makers attempting
to tailor responses to local realities.
The Africa Centre HDSS is located in an area that has been very
hard hit by HIV/AIDS. An early study published in the South African
Medical Journal showed how the number of patient consultations
at a rural primary health clinic in the Hlabisa district of Kwazulu-
Natal almost doubled between 1991 and 2001 [30]. Admissions to
the local hospital increased by 81% over the same period. This sharp
increase points to a major impact of HIV/AIDS on the community,
a thesis confirmed in a later Africa Centre paper [31], which found
that 27% of females living in the HDSS area and 13.5% of males were
infected with HIV. The highest prevalence rates were found among
resident women aged 25–29 years (51% prevalence) and resident
men aged 30–34 years (44% prevalence).
As the virus spread, AIDS-related mortality climbed precipi-
tously. An Africa Centre study based on verbal autopsies with
caregivers calculated that AIDS caused 48% of adult deaths in the
locality, and that the dramatic increase in mortality as a result of the
virus meant that in 2000 the probability of dying between the ages
of 15 and 60 had risen to 58% for women and 75% for men [32].
A further study by Nyirenda et al. [33] found that after adjusting
for age, sex and socioeconomic status, individuals in the Hlabisa
area infected with HIV had a nine-fold greater risk of dying than
those who were uninfected. The introduction of an antiretroviral
therapy (ART) programme in Hlabisa in 2004 led to a significant
decrease in AIDS-related mortality – between 2002–2003 (before
the ART programme began) and 2004–2006 (the post-ART period),
age-standardised mortality declined from 22.5 to 17.6 per 1000
person-years in women aged 25–49 years, and from 26.5 to 18.7
per 1000 person years in men of the same age [34]. Success in treat-
ment, however, has not been matched in the area of prevention –
a recent study [35] concluded that HIV incidence did not decline in
the Africa HDSS between 2003 and 2007.
A number of other HDSSs in Africa have measured incidence,
prevalence and mortality in their localities over the past decade.
Rakai HDSS in Uganda reported adult HIV prevalence of 16.1% in
2000, with 73.5% of adult deaths attributed to HIV infection [36].
Agincourt HDSS in South Africa examined age-specific mortality
trends in a rural population between 1992 and 2003, and found
that the large increase in mortality as a result of HIV/AIDS reduced
life expectancy by twelve years for females and fourteen years
for males. Hardest hit by the rise in mortality were children aged
0–4 years, among whom mortality doubled, and adults aged 20–49
years, who experienced a five-fold mortality increase [37]. Magu
HDSS in Tanzania found that HIV prevalence rose from 6% in 1995
to 8.3% in 2001 before levelling off [38] and later that it declined in
urban but not in rural areas [39].
Like the Africa Centre in South Africa, Kisumu HDSS in Kenya [40]
found that women aged 25–29 years and men aged 30–34 years
had the highest prevalence rates (36.5% and 41.1%, respectively).
Like the Africa Centre too, Kisumu saw a decline in mortality –
albeit only among women – after the introduction of ART. Between
2003 and 2009, all-cause mortality among adolescent females fell
by 61.5%, and among young adult females, who in 2003 had experi-
enced mortality rates of 1613 per 100,000 population, it fell by 53%
[41].
As HIV waxes and wanes, so does it evolve. Bandim HDSS
and Rakai HDSS have both observed changes in the prevalence
of different strains or subtypes of the virus. UNAIDS reports that
Guinea-Bissau is one of the few countries to experience major
increases in HIV incidence between 2001 and 2011, and studies
from Bandim HDSS show that while the less virulent HIV-2 strain
has declined in importance [42,43], HIV-1 prevalence has climbed
steeply, from 0.5% in 1990 to 3.6% in 2007. At 7.2%, prevalence of
HIV-1 was highest among adults aged 45 to 54 years [44]. In Uganda,
meanwhile, Rakai HDSS found that prevalence of the HIV-1 subtype
Please cite this article in press as: O. Sankoh, et al., The history and impact of HIV&AIDS. A decade of INDEPTH research, HIV & AIDS
Review (2014), http://dx.doi.org/10.1016/j.hivar.2014.05.002
D, which progresses rapidly to disease, had reduced and given way
to some extent to the less virulent subtype A. The authors of the
paper reporting these findings posit that the change may be due to
‘the faster disease progression and lower transmissibility of HIV-
1D’ [45]. Such observations may be of importance in the quest to
develop an AIDS vaccine.
3. Two: social and economic impacts
3.1. Impacts on families
It is not just through mortality that HIV/AIDS affects families. An
infection in a household can have economic impacts and threaten
family cohesion.
Working at the Africa Centre in Kwazulu-Natal, [46] examined
the impacts of adult mortality – which has been sharply increased
in the DIS area by HIV/AIDS – on household dissolution. 21% of
households resident in the surveillance area between January 2000
and October 2002 experienced at least one adult death. These
households were four times more likely to dissolve than other
households. In total, 2% of households dissolved over the 34-month
period, and a further 8% left the area.
A similar study at Agincourt HDSS [47] observed decreases in
average household size and an increase in the proportion of house-
holds headed by females. Although remaining low at 5.5%, the
proportion of households containing a maternal orphan doubled
over a ten-year period. At the Magu HDSS in Tanzania, [48] found
strong effects of AIDS on household dissolution, with 44% of house-
holds in which the head of the family died dissolving completely
within a year. And at Rakai, researchers found that women with HIV
whose husbands are uninfected faced a higher risk of separation
and divorce than women in uninfected households or in households
where both female and male partners were infected [49].
3.2. Impacts on children
Strong impacts of the virus on children have also been docu-
mented by HDSS centres. Early in the epidemic there were fears that
the large number of adult deaths in Africa would leave millions of
households headed by children. A review of data from three HDSS
sites in South Africa, Tanzania and Malawi, however, found that
although orphanhood has increased in all sites (and especially in
South Africa), there was no significant increase in child-headed
households [50].
Orphans in some HDSS areas face other problems than being
forced to run households. Maternal orphans in the Agincourt study
area were found to face triple the risk of dying from tuberculosis or
HIV/AIDS than non-orphans [51]. At Magu HDSS, maternal orphans
had a 4.6 times higher risk of dying than non-orphans [52]. In West
Africa, on the other hand, a study by Bandim HDSS found no sig-
nificant differences between orphans and non-orphans in terms of
nutritional status, use of health services and other quality of life
indicators [53].
Children with mothers who are infected with HIV appear to face
threats to survival even while the mother remains alive. HDSSs have
produced a series of papers detailing the impacts of the virus on
children whose mothers are infected or who have been infected
themselves during mother-to-child transmission. Children infected
with HIV have been found to have lower dietary diversity [54],
poorer nutritional outcomes [55], slower growth [56] and, when
malnourished and compared with malnourished HIV-negative chil-
dren, lower weight-for-height, weight-for-age, height-for-age and
body mass index scores [57]. The infection of a mother, meanwhile,
heightens the likelihood that her children will be small for their
gestational age [58] and will not receive the childhood vaccinations
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that are crucial to survival [59]. A review of cohort studies at HDSSs
in Uganda, Malawi and Tanzania found that children with HIV-
positive mothers face a 2.9 times greater risk of death throughout
childhood than those whose mothers are not infected [60]. Infant
and child mortality among children with HIV-infected mothers at
the Magu HDSS site is approximately double that among children
of HIV-negative mothers [52].
3.3. Impacts on the elderly
To some extent, the impact of AIDS on children and working age
adults is being alleviated by elderly family members. Older women
in particular are playing increasing roles as carers, and their pen-
sions often provide financial support to families whose working age
members have fallen sick or died. A study at Agincourt DSS revealed
that households containing a woman aged over 60 years were three
times as likely as other households to contain an orphaned child and
twice as likely to contain a foster child [61]. As another Agincourt
study found, elderly women also face social stigma and isolation
as a result of either living with HIV/AIDS themselves or caring for
an individual who has the virus [62] ‘Elderly women,’ the author of
the first study observes, ‘face financial, physical and emotional bur-
dens related to the morbidity and mortality of their adult children,
and to caring for grandchildren left behind due to adult children’s
mortality, migration, (re)marriage and unemployment.’
These pressures can take a toll on the health of the elderly.
Chazan [63] reports that grandmothers in South Africa ‘have
become increasingly stretched. They are supporting growing num-
bers on shrinking incomes. Many are not yet eligible for pensions
and have had to resort to taxing work in order to feed their families.
Their wellbeing is at stake.’ Older people infected by the disease,
moreover, may be at higher risk than younger people of nega-
tive outcomes. In their report on high HIV infection rates among
elderly people in the Africa Centre demographic surveillance area,
[64] noted that ‘HIV infection in older people has several distinct
features – the speed of disease progression increases with age at
infection, older people do not respond as quickly to ART, and age-
related conditions may limit HIV treatment options.’ In a Nairobi
DSS survey of slum residents aged 60 or above, meanwhile, those
who were directly or indirectly affected by HIV/AIDS reported sig-
nificantly worse health outcomes than those who were unaffected
[65].
3.4. Economic impacts
The economic effects of HIV/AIDS have long been the subject of
speculation and debate. Some observers predicted that by wiping
out large swathes of working age people the virus would cripple
economic activity and sharply increase the dependency burden
on those who were left. Others noted that the epidemic hit poor
countries hardest, where many young people are unemployed or
underemployed, and forecast that the jobs of those who left the
workforce would quickly be filled and that per capita incomes of
survivors would increase.
Because their focus is on clearly defined but relatively small geo-
graphic areas, studies by INDEPTH member centres have primarily
contributed to this discussion at a micro – rather than national
level, showing in detail how the virus affects the economic status
of individuals and families.
Researchers in African HDSSs have noted the potential effect of
HIV/AIDS on fertility, with a study by Magu DSS in Tanzania find-
ing 29% lower fertility rates among women infected with HIV [66]
and researchers at the Africa Centre suggesting that AIDS-related
mortality in South Africa could lead to negative population growth
in rural areas [67] Reduced fertility can improve the prospects of
individual children, since more resources can be devoted to each
Please cite this article in press as: O. Sankoh, et al., The history and impact of HIV&AIDS. A decade of INDEPTH research, HIV & AIDS
Review (2014), http://dx.doi.org/10.1016/j.hivar.2014.05.002
5
child’s health and education needs, but it can also reduce the size of
a workforce whose numbers are already falling due to AIDS-related
deaths among people of working age.
Mortality among the latter group can cause great damage to
household finances. Rakai HDSS researchers [68] have found that
HIV/AIDS-related mortality in adults has increased the prevalence
of female-headed households and had harmful effects on their wel-
fare. At Magu HDSS, the expenditure on health care by families with
a member terminally ill with AIDS was found to be higher than
those for other causes of death, primarily due to the length of the
illness [69]. In the Agincourt DSS area, adult mortality was found
to decrease food security, with households that had experienced
an adult death significantly more likely to have skipped meals and
less likely to cultivate maize due to an absence of labour and reduc-
tions in assets. That male deaths had a more damaging impact than
female deaths on food security suggests that it is the loss of wages
that causes the reduction in food intake [70].
A recent Africa Centre study shows how the effect of HIV/AIDS
on wages can be reversed by antiretroviral treatment. Bor et al. [71]
used fixed-effects regressions to track the employment rate among
2000 individuals in whom the disease had advanced sufficiently
for them to require ART. In the year before beginning treatment,
when the study subjects were likely to have been quite sick, the
employment rate among them fell by 38%. Within four years, it
had recovered to 90% of the pre-illness level. As this study shows,
although HDSS centres have not played a major role in determining
the national and global economic effects of HIV/AIDS, their work
provides clear micro-level evidence of its economic impacts on
individuals and families.
4. Conclusion
HDSS field sites run by the member centres of INDEPTH have
played a pivotal role in tracing the progress of the HIV/AIDS
epidemic and in identifying the hardest hit population groups.
Although many groups continue to be very hard hit by AIDS and
millions of individuals continue to suffer the effects of the virus,
the period under review has seen a decline in both prevalence and
mortality as a result of the virus.
In the years to come it will be important for HDSS centres to keep
track of the epidemic’s progress, including among discrete popu-
lation groups. As treatment becomes more widely available there
may be a risk that policy-makers and the public will become com-
placent and that the virus will therefore resurge in some areas or
among some groups of people. Monitoring and highlighting such
developments is a vital role for INDEPTH members, while continu-
ing to examine the causes of declining infection rates will provide
guidance not only for efforts to contain HIV/AIDS but perhaps also
to curb future epidemics of other diseases.
Financial disclosure
Osman Sankoh is funded by core support grants from the
William & Flora Hewlett Foundation, Sida/Research Cooperation
Unit and The Wellcome Trust. Samuelina Authur is funded by a
project grant to INDEPTH by the William & Flora Hewlett Founda-
tion on Sexual and Reproductive Health.
Conflict of interest
None declared.
Acknowledgements
Osman Sankoh is funded by core support grants from Sida, The
Wellcome Trust and The William and Flora Hewlett Foundation.
G Model
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6 O. Sankoh et al. / HIV & AIDS Review xxx (2014) xxx–xxx
Samuelina Arthur is funded by an INDEPTH project supported by
The William and Flora Hewlett Foundation.
The authors wish to thank all member centres of the INDEPTH
Network for providing their peer-reviewed papers into an INDEPTH
publications database and for commenting on an earlier version of
the manuscript.
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