The 2001-03 Famine and the Dynamics of HIV in Malawi: An (Un)natural Experiment

Pre-submission version.The number of people without secure access to food has risen over the past 15 years, in large part propelled by high and volatile food prices. This pattern is likely to continue under the influence of speculation, increasing demand from rapidly growing economies and for biofuels and due to the effects on production of climate change and variability. Most vulnerable are consumers and small farmers in countries where farming is predominantly rainfed. The impact of rising levels of hunger on human health and major diseases is of wide concern, however our ability to predict their impact is limited. With respect to HIV, much of what is known about the effect of hunger and other facets of poverty comes from cross-sectional or longitudinal studies of limited duration that shed little light on dynamic effects, whether trends, cycles, or major shocks. The fact that hunger is both a cause and a consequence of HIV further limits the ability of these methods to disentangle the effect of change in either of them. The evidence reported here brings new light to bear on this question. It assesses the 2001-03 famine in Malawi as a country-scale “unnatural experiment” on the effect of hunger on the dynamics of HIV. As described below, the famine “intervention” was “sharp, well-defined but unplanned” and its effects were unequally experienced among rural areas, between rural and non-rural areas and between men and women – characteristics of a natural experiment. The Malawi famine was unnatural in that it was a consequence largely of actions and policies that, as in many famines, restricted people’s access to food. Analysis of this experiment suggests important implications for the understanding of HIV dynamics and conception of prevention, discussed in the final section