From population to HIV: the organizational and structural determinants of HIV outcomes in sub‐Saharan Africa

Abstract

BackgroundThere exists no consistent explanation for why some countries are successful in combating HIV/AIDS and others are not, and we need such an explanation in order to design effective policies and programmes. Research evaluating HIV interventions from a biomedical or public health perspective does not always take full account of the historical and organizational characteristics of countries likely to influence HIV outcomes. The analysis in this paper addresses this shortcoming by testing the impact of organizational and structural factors, particularly those resulting from population interventions, on HIV outcomes at the country level in sub-Saharan Africa.MethodsThe primary independent variables are factors that originated from efforts to slow population growth: whether a country has a long-time affiliate of the International Planned Parenthood Federation and whether a country has a population policy. Additional structural factors likely to impact HIV outcomes include the level of wealth, the level of cultural fractionalization, and the former colonial power. The present study uses multivariate regression techniques with countries in sub-Saharan Africa as the unit of analysis, and four measures of success in addressing HIV: the change in prevalence between 2001 and 2009; the change in incidence between 2001 and 2009; the level of overall antiretroviral coverage in 2009; and the level of antiretroviral coverage for prevention of vertical transmission in 2009.ResultsCountries with the greatest declines in HIV prevalence and incidence had older International Planned Parenthood Federation affiliates and had adopted population policies, even after controlling for age of epidemic, level of antiretroviral coverage, and funding for HIV. Population policies are also important predictors of levels of overall antiretroviral coverage and of coverage of HIV-positive pregnant women to prevent vertical transmission. Structural factors with significant impacts include wealth, cultural fractionalization and former colonial power.ConclusionsThe organizational and structural context of African countries is strongly predictive of HIV outcomes. This finding implies that policy and programmatic efforts should be put towards strengthening existing organizations and perhaps even creating new ones. The fact that cultural fractionalization also influences HIV outcomes suggests that efforts must be put towards identifying ways to reach political consensus in diverse societies.

Popular Moralities and Institutional Rationalities in Malawi's Struggle Against AIDS

“…Concurrently, new national NGOs were organized and staffed by Malawians, including national-level groups such as The Evangelical Alliance Relief Fund (TEARFUND) and Malawi's National Network of People Living with HIV/AIDS (NAPHAM), and community-based organizations such as the Chimwemwe Orphan Support Group in Zidyana Village and the Imam AIDS Support and Drama Group in the Balaka mosque (Hannan 2012). International NGOs that antedated the epidemic adopted the struggle against AIDS as part of their core mission, such as Save the Children, World Vision, and Population Services International (Robinson 2011). A study of the growth of AIDS-related NGOs in Malawi between 1999 and 2004 found that the number of NGOs registered by the government as AIDS organizations increased from 31 to 55, and those registered as working on orphan support increased from 17 to 53; the number of NGOs in other sectors, such as water and sanitation, the environment, and health in general either remained the same or declined (Morfit 2011).…”

The demography of words: The global decline in non-numeric fertility preferences, 1993–2011

“…We interpret this relationship as perhaps being an indicator of greater exposure to HIV prevention programming, much of which overlaps with family planning rhetoric. More broadly, higher national-level HIV prevalence might suggest a context in which sex is more frequently discussed as something requiring caution and planning (Cleland and Watkins 2006; Robinson 2011). The significance of this association diminishes among the sample that is limited to sexually active women (Model 2), but this is likely due to the smaller number of countries in this sample (84).…”

The demography of words: the global decline in non-numeric fertility preferences, 1993-2011

“…We interpret this relationship as perhaps being an indicator of greater exposure to HIV prevention programming, much of which overlaps with family planning rhetoric. More broadly, higher national-level HIV prevalence might suggest a context in which sexual intercourse is more frequently discussed as something requiring caution and planning (Cleland and Watkins 2006;Robinson 2011). The significance of this association diminishes among the sample that is limited to sexually-active women (Model 2), but this is likely a result of the smaller number of surveys in this sample (see online Appendix C for further details).…”