HIV/AIDS and Urbanization

Author(s): Tim Dyson

Source: Population and Development Review, Vol. 29, No. 3 (Sep., 2003), pp. 427-442
Published by: Population Council
Stable URL: http://www.jstor.org/stable/3115281
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HIV/AIDS and
Urbanization

TIM DYSON

THIS ARTICLE EXAMINES the relationship between HIV/AIDS and urbaniza-

tion in the developing world, with particular attention to selected countries
in sub-Saharan Africa. While it has long been known that urban levels o
HIV infection are usually appreciably higher than rural levels within coun-
tries, insufficient attention has been given to variation in levels of urban-
ization when trying to account for different rates of infection between popu
lations. The process of urbanization-that is, the rise in the proportion of
country's total population that lives in urban areas-is a fundamental fea
ture of socioeconomic development. Yet there has been little consideratio
of how, in the worst-affected populations, this process may be already con-
strained by the demographic impact of HIV/AIDS.

Background

Before the onset of the epidemiological and demographic transitions, death

rates tended to be positively associated with levels of population density.
Squalid and crowded urban living conditions, and relatively high rates of
social interaction, meant that pretransitional towns were highly conducive
to the maintenance and spread of infectious diseases. Furthermore, towns
often served as nodal points through which new diseases (such as plague
and cholera) were first introduced. Urban death rates exceeded urban birth
rates. Therefore, collectively the towns constituted a "demographic sink":
they were a net destroyer rather than a producer of people. Indeed, in such
circumstances the very existence of the urban sector, which the extremely
high urban death rates inevitably kept circumscribed, depended upon a con-
tinual net inflow of migrants from rural areas (e.g., de Vries 1990: 53-60).
In Europe the process of sustained urbanization dates from the first half
of the nineteenth century; in most of Asia and Africa, from various times in
the twentieth. This process-in which the population of the urban sector in-
creases faster than that of the rural sector-was, and still is, underpinned by

POPULATION AND DEVELOPMENT REVIEW 29(3):427-442 (SEPTEMBER 2003) 427

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428 HIV/AIDS AND URBANIZATION

the greater improvement of urban than rural death rates.' M

means that the urban sector ceases to be a "sink" and can gr
its own natural increase (i.e., excess of births over deaths) a
tinuing rural-to-urban migration (de Vries 1990: 57-59).
rates are appreciably lower in the urban than the rural sect
oping countries, and virtually all such countries are urbaniz
with the possible exception of parts of sub-Saharan Africa,
growth in most developing regions is caused more by urban
than by rural-to-urban migration (Preston 1979: 198-199).

Urban/rural differentials in HIV prevalence

In developing countries, estimates of HIV prevalence come c

urban sero-samples. Data for rural populations are rarer, an
ally unrepresentative of the rural sector as a whole-bein
larger villages and settlements close to roads and towns.2
It is agreed, nevertheless, that levels of HIV infection ar
nificantly higher in urban areas. For example, apropos su
Caldwell, Anarfi, and Caldwell (1997: 44) state that "urba
infection] are typically four to ten times those of rural are
107) reports that "[r]ural HIV and STD prevalences have
found to be much lower than urban prevalences"; and D
Anderson (2001: 118) state [u]rban centres and market to
a substantially higher occurrence of HIV than rural areas."
To illustrate, Table 1 shows estimates of HIV prevalen
sub-Saharan countries designated by UN/WHO in 2000
affected" by HIV/AIDS (United Nations 2001a: 105) and f
Census Bureau HIV/AIDS surveillance data base "Summa
tain a prevalence estimate based on the testing of pregnant
a rural and an urban area. In Zimbabwe the estimated lev
lence is a little lower in the urban than the rural site (ur
0.84), but this may simply reflect the location of the partic
involved and small sample sizes. However, for the remain
the urban/rural ratios of infection are well above unit
Lesotho (3.4), Malawi (2.7), Namibia (1.8), Rwanda (1.9),
The unweighted mean of the preceding ratios is 2.6, but
the rural figures are based on small sero-samples drawn fro
ments (and probably more seriously affected areas) the true
certainly higher. Studies in eastern Africa have found very
tion within the rural sector, with levels of HIV infection r
ing size of settlement (e.g., Mnyika et al. 1994; Bloom et
So there is strong evidence-as was usually the case w
diseases in past times-that HIV/AIDS prevalence tends to

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TIM DYSON 429

TABLE 1 Estimates of HIV prevalence obtained from the testing o

pregnant women in separate urban and rural sites, selected coun
in sub-Saharan Africa

Prevalence Sample
Country Geographic area Year (%) size

Burundi Bujumbura 1998 18.6 291

Jenda (rural) 1997 3.9 259
Lesotho Maseru 2000 42.2 n.a.
Mokhotlong (rural) 2000 12.3 n.a.
Malawi Blantyre 2001 28.5 650
Eight districts (rural) 2001 10.7 1,372
Namibia Windhoek 1998 22.7 207
Nankudu (rural) 1998 12.6 198
Rwanda Kigali (3 sites) 1998-99 13.3 1,268
Byumba (rural) 1998-99 7.0 414
Zambia Lusaka (4 sites) 1998 27.1 2,323
Minga (rural) 1998 10.3 497
Zimbabwe Harare 1999 31.1 177
Beitbridge (rural) 1998 37.0 n.a.

n.a. = not available.

SOURCE: U.S. Census Bureau (2002: Table 3).

sociated with population density. This statement is probably true for many
developed countries too. 4
Explanations for this positive relationship include the fact that the ur-
ban sector usually serves as a conduit for new influences-as in the growth
in use of injecting drugs, which has spread HIV in the countries of the former
Soviet Union during the 1990s. Also, rates of social interaction are higher
in urban areas, and fields of social interaction are wider too-phenomena
that doubtless have implications for patterns of sexual interaction. That ur-
banites tend to marry later may work to augment the extent of sexual mix-
ing in some contexts. And, more importantly, higher-risk behaviors (such
as commercial sex activities) tend to be more prevalent in towns and cities.
Surveys generally find that the proportions of people reporting nonregular
sexual relationships are higher in urban areas-although, unsurprisingly,
urban behavior also reflects behavior in associated rural areas (Carael 1995,
1997). Where urban populations are disproportionately male, the demand
for commercial sex may be higher (Caldwell et al 1997: 43). Moreover, as
noted in the quotation above from Carael, sexually transmitted diseases,
which sometimes facilitate HIV transmission, are usually more prevalent in
towns. Of course, none of these considerations precludes fairly high levels
of HIV infection in some rural areas (e.g., northwestern Tanzania and south-

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430 HIV/AIDS AND URBANIZATION

western Uganda). But they do suggest that HIV/AIDS pr

reproductive rate of the epidemic-the average number o
infections generated per initial case-will generally be ap
in the urban sector.

HIV prevalence and levels of urbanization

The preceding considerations do not necessarily mean that there will be a

positive relationship between levels of HIV infection and levels of urbaniza-
tion at higher levels of aggregation. After all, sub-Saharan Africa-the world's
worst-affected region-is predominantly rural. Nevertheless, the consider-
ations do imply that there probably is a positive relationship between levels
of HIV infection and levels of urbanization when considering countries within
regions that are comparatively homogeneous socioeconomically and with
respect to the epidemic's main features. Thus, other things equal, the higher
the level of urbanization in a country, the higher the overall level of HIV
prevalence is likely to be-both because the urban sector constitutes a larger
fraction of the total population and because levels of rural infection are likely
to be raised through greater migratory interaction between rural and urban
populations.5
A serious complication in exploring this issue is the considerable varia-
tion in what is held to constitute an urban area. For example, some countries
use a lower limit of just 200 people to define a settlement as urban, while
others employ a figure of 50,000 (United Nations 1998: 31). It is necessary,
therefore, to examine regional groupings of populations for which there are
estimates of HIV prevalence and which employ similar definitions of urban.
Groups that satisfy these criteria are (1) European countries of the former
Soviet Union, where HIV transmission is mainly through intravenous drug
use; (2) the populations of India's major states, where transmission is pre-
dominantly through heterosexual sex; and (3) the countries of eastern and
southern Africa categorized by UN/WHO as being "highly affected" by HIV/
AIDS, where, again, transmission is mainly through heterosexual sex. In each
case the sharing of a common administrative history (most countries in east-
ern and southern Africa are former British colonies) brings a rough measure
of similarity to what is held to be "urban." But there remains significant defi-
nitional variation within each grouping (this applies even to India, where the
designation of places as municipal, and therefore urban, varies widely be-
tween states). The estimates of HIV prevalence used here generally derive
from small samples and have sizable error margins. It is clear too that factors
other than the level of urbanization influence variation in HIV prevalence,
and that to some degree the level of urbanization may be acting as a proxy
for other aspects of development (e.g., better transport infrastructure).
With this as background, Figure 1 plots the relationship between levels
of urbanization and HIV infection for the three regional groups. Despite the

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FIGURE 1 The relationship between levels of urbanization and HIV
infection, populations in selected world regions
1.6
= (a): Countries of eastern Europe,
* 1.4 - formerly in the Soviet Union
x 1.2-

, 1.0 -

e ^ ,)
0.60.6
- -/ y= 0.024x - 0.9018
" 0 R2 =0.333
: 3 0.4- /
u
0.2 -

30 40 50 60 70 80

1.4
(b): Major states of
1.2 -
u

_ 1-

c 0.8 - + y=0.0229x- 0.1607

R2
o 0.6 -
=I 0.327

a 0.4 -

< 0.2 -

0
10 20 30 40 50

40

(c): Countries in eastern and southern Africa

' 35 -

30 -
p;g~~~~~, ~30 ~y = 0.3597x + 6.6012
25 - * R2 = 0.372
20 -

15

10

5 -

0 I I Il
0 10 20 30 40 50 60
Percent urban

NOTES: The countries in Figure 1 (a) are Belarus, Estonia, Georgia, Kazakhstan, Latvia, Lithuania, Moldova, the
Russian Federation, Ukraine, and Uzbekistan; they are all designated as European in UNAIDS/WHO (2002: 15).
The state populations in Figure 1 (b) are Andhra Pradesh, Assam, Bihar, Gujarat, Haryana, Karnataka, Kerala,
Madhya Pradesh, Maharashtra, Orissa, Punjab, Rajasthan, Tamil Nadu, Uttar Pradesh, and West Bengal. The
countries in Figure 1 (c) are Botswana, Burundi, Eritrea, Ethiopia, Kenya, Lesotho, Malawi, Mozambique,
Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe.
PRINCIPAL DATA SOURCES: for Figure 1 (a) UNAIDS/WHO (2002) and United Nations (2002a); for Figure 1 (b)
National AIDS Control Organization (2000) and Registrar General, India (2001); for Figure (c) United Nations
(2001a and 2002a).

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432 HIV/AIDS AND URBANIZATION

data problems and the very different nature of the epidemic i

settings in terms of HIV prevalence and the main modes of
around one-third of the variation in the level of infection is acc
variation in the level of urbanization. With only ten observatio
tion coefficient for the countries of the former Soviet Union fa
statistical significance at the 5 percent level. But the coefficien
dian and African groupings are significant at this level. Moreo
efficients would probably be higher were there greater standard
constitutes an urban area and were the estimates of seropreval
liable. Eastern and southern Africa embodies the greatest range
urbanization of the three groups-from under 10 percent in
Rwanda to roughly 50 percent (or more) in Botswana and South
ure l(c) suggests that in this composite region a 10 percent
level of urbanization is associated with a 3.6 percent increase in
lence among adults. Although the existence of a relationship at
aggregation does not necessarily imply the existence of a relat
other, it seems reasonable to surmise from Figure 1 that in both
of the former Soviet Union and the states of India levels of HI
are probably higher in urban areas.
Research aimed at accounting for variation in HIV preva
the major world regions has been limited, particularly so if th
Saharan Africa is excluded. Relevant work on Africa has focused on varia-
tion in such factors as sexual practices, prevalence of sexually transmitted
diseases, male circumcision, and levels of individual spatial mobility. In this
context the work on male circumcision has been distinctive in employing,
among other approaches, simple cross-national comparisons of the kind used
in Figure 1 (see Bongaarts et al. 1989). However, most research on regional
variation in HIV prevalence in sub-Saharan Africa has used data from only
a small number of countries and has compared either solely urban or solely
rural sites within these countries (e.g., Buve et al. 2001; Boerma et al. 2002).
Perhaps because of the lack of a standard definition of an urban area, cross-
national statistical analyses of variation in HIV prevalence generally do not
include the level of urbanization as a possible explanatory factor (e.g., World
Bank 1999: 27-29).

The impact of HIV/AIDS on urbanization

Assessments of the socioeconomic impact of HIV/AIDS usually focus on the

likely consequences for families, health, education, and the economy. As-
sessments of the demographic impact usually center on mortality (to a much
lesser extent, fertility) and the implications for population growth. Clearly,
the focus is on mortality because the disease kills people directly, triggers
secondary epidemics, and almost certainly raises the general level of mor-

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TIM DYSON 433

tality through less direct mechanisms such as increasing levels

hood. In both types of assessment the repercussions for urban
generally ignored. This may partly reflect the above-mentioned p
data on HIV prevalence by place of residence, and the fact that da
urban/rural composition of national populations usually come
suses (occasionally major surveys) that typically are conducted
ten years. Nevertheless, the lack of consideration of the disease's
pact on urbanization is surprising, given the near universality of
tion in the contemporary developing world and its central ro
development. In the most severely affected countries of sub-
rica, to which the following discussion pertains, the aforemen
torical, theoretical, and epidemiological considerations all suggest
AIDS will affect the pace of urbanization.
In severely affected populations HIV/AIDS may slow the p
urbanization by altering rates of migration between rural and
and by differentially affecting the crude birth and death rates in
eas.6 Estimates of these various rates do not exist separately fo
and rural sectors of most countries, but it is possible to make som
comments about the mechanisms that are probably at work.
Alterations in patterns of migration could contribute signific
slowdown in the pace of urbanization. Considerable anecdotal ev
gests that in much of sub-Saharan Africa many town dwellers wh
from rural areas return to those areas when they fall ill (e.g., Wa
49). More importantly, recent research suggests that surviving
members, both spouses and children, often return to rural areas
AIDS death (e.g., Mushati et al. 2003). Another reason for a de
rural-to-urban migration rates may be that, with increasing levels
in rural areas, more and more people are unable to move to towns
happen because they become ill themselves. But it could also
cause they have responsibilities-in farming and other househo
nance tasks-to assist others who fall ill, or those whose lives ar
seriously affected by the disease (e.g., orphans, widows, widow
dependent elderly). It is likely too that some people return to rura
the urban sector in order to provide such assistance.7
The effect of HIV/AIDS on crude birth rates in severely affec
tries is probably substantial. The disease can be expected to lower
through the selective loss of women of childbearing age, and r
suggests that HIV-positive women experience lower levels of fe
HIV-negative women (Zaba and Gregson 1998). To the extent
rates are being reduced by HIV/AIDS, the impact of this effect is
higher in urban areas because of their generally higher levels of i
Consequently urban rates of natural increase will be reduced by m
rural rates, thus reducing the speed of urbanization.

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434 HIV/AIDS AND URBANIZATION

Turning to death rates, it is clear that, again, because of h

of HIV infection in urban areas, HIV/AIDS will usually slo
urbanization by raising urban death rates by much more th
Mortality will be raised through direct and indirect mechanism
on urbanization will be additional to, and almost certainly
than, any effect operating through a reduction in the birth r
less, the combined effect of a much bigger rise in the urban d
greater fall in the urban birth rate compared to rural area
that in the most severely affected populations of sub-Saharan
rates of natural increase will normally be reduced by very mu
rural rates.
The main international data base on levels, trends, and projections of
urbanization is maintained by the United Nations. The data base is updated
regularly and published biennially with correspondingly revised projections.
The available national data on urbanization are adjusted so that the published
figures pertain to standard years (e.g., 2000, 2005). The UN's projections of
urbanization employ the urban/rural growth difference approach. Essentially
this method involves using data from the past few censuses to extrapolate
into the future from the most recently observed difference between the ur-
ban population growth rate and the rural rate. The main reason for revising
the urbanization projection for a country is the availability of new informa-
tion on its urban/rural composition (United Nations 1998, 2002a).
Table 2 gives data on levels of urbanization for the 16 countries of
eastern and southern Africa that were designated as being highly affected
by HIV/AIDS and that have already been considered in Figure 1(c). The
table displays the levels of urbanization projected (P) for the year 2000 by
the UN's World Urbanization Prospects published in 1998; it also shows the
levels of urbanization estimated (E) for these same countries by the corre-
sponding publication of four years later (United Nations 2002a). For six coun-
tries the projected and estimated figures are identical: this essentially indi-
cates that no new information on the level of urbanization had become
available with which to revise the projections. For the remaining ten coun-
tries, three (Kenya, South Africa, and Tanzania) had levels of urbanization
higher than previously projected (only slightly so in the case of Kenya),
while seven had levels that were lower (see column 4 of Table 2).
Why the level of urbanization indicated for Tanzania in 2000 is appre-
ciably above the projected figure is unclear, but it could simply reflect a
change in the designation of an "urban" area. For South Africa, the only
other country with a distinctly higher estimated than projected level of ur-
banization, the explanation almost certainly lies in an increase in net mi-
gration from rural to urban areas during the 1990s. Not only did apartheid
artificially confine people in the rural sector (presumably thereby inducing
considerable pent-up demand to move to the towns), but its collapse in the
early 1990s greatly increased people's freedom to migrate to urban areas.

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TIM DYSON 435

TABLE 2 Estimated HIV prevalence among persons aged 15-49, a

projected and estimated levels of urbanization for the year 2000
selected countries in eastern and southern Africa

Urbanization

Projected (P) Estimated (E)

in the 1996 in the 2001
HIV (%) UN Revision UN Revision Ratio E/P
Country (1) (2) (3) (4)

Botswana 35.8 73.6 49.0 0.67

Burundi 11.3 9.0 9.0 1.00
Eritrea 2.9 18.7 18.7 1.00
Ethiopia 10.6 17.6 15.5 0.88
Kenya 14.0 33.1 33.4 1.01
Lesotho 23.6 28.0 28.0 1.00
Malawi 16.0 15.4 14.7 0.95
Mozambique 13.2 40.2 32.1 0.80
Namibia 19.5 40.9 30.9 0.76
Rwanda 11.2 6.2 6.2 1.00
South Africa 19.9 50.4 56.9 1.13
Swaziland 25.3 35.7 26.4 0.74
Tanzania 8.1 27.8 32.3 1.16
Uganda 8.3 14.2 14.2 1.00
Zambia 20.0 44.5 39.6 0.89
Zimbabwe 25.1 35.3 35.3 1.00

SOURCES: Column 1: United Nations (2001a: 10

Nations (2002a: 27).

For the ten countries for whic

revised, Figure 2 plots the ratios
banization against the correspond
lence around the year 2000. Th
and statistically significant at th
suggests that, other things equal
HIV prevalence of roughly 10
have experienced only a modest r
pared to that projected by the
prevalence of roughly 20 per
have been about 10 percent less
figure. In fact the linear relati
statistical significance owes m
Table 2). Despite that country's
might be cautious in attributin
banization to the effect of HIV/
ship seen in the nine remaining
nificant (R2 = 0.22). Even so, th

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436 HIV/AIDS AND URBANIZATION

FIGURE 2 Deviations in urbanization from projected levels, by

level of HIV prevalence, selected countries in eastern and south
Africa

1.2

- 1.1 -

au

-- 0.9 0- .- y= -0.0133x+ 1.1411

4. R2 =- 0.410

O 8

0.7 -

0.6 1 I l 1
5 10 15 20 25 30 35 40 45

HIV prevalence amo

SOURCES: See Table 2.

remains virtually unchanged.8 To put the matter differently, the slowing

urbanization indicated for Botswana is almost exactly what the data for th
remaining nine countries would lead one to predict. Moreover, a case co
well be made for dropping South Africa from Figure 2-since a special c
sideration, the ending of apartheid, accounts for its higher than expec
ratio of estimated to projected level of urbanization. If South Africa is om
ted, the fit improves substantially (R2 = 0.61).9
In spite of the aforementioned data problems, the statistics used in Tab
2 and Figure 2 tentatively suggest that the process of urbanization-es
cially in the southernmost countries of Mozambique, Namibia, Swazila
and Botswana-is already being slowed by HIV/AIDS.'?
Of course, despite this evidence of slowdown, urbanization is still o
curring. Indeed, because of the end of apartheid in South Africa, wh
according to the UN contains about 87 percent of southern Africa's popula
tion, that region's level of urbanization estimated for the year 2000 (5
percent) was higher than the level previously projected (49.5 percent
However, it is worth considering what may happen in South Africa gi
that it has the lowest birth rate of any country in eastern and south
Africa. Thus for the period 2000-05 the UN estimates that birth rates
vary from 44.9 in Malawi to 30.6 in Botswana, whereas the figure for Sout
Africa is expected to be just 24.6 births per thousand population (Unit
Nations 2001b). This is relevant because, other things equal, it raises t
chance that in urban areas the death rate will exceed the birth rate-th

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TIM DYSON 437

urban sector will become a demographic sink. Some simple illustra

culations can help explore what could happen.
Table 3 summarizes UN estimates for South Africa for 1980-2000, w
projections to 2020. Column 1 gives the latest UN urbanization figu
projections. Columns 2 and 3 give the UN estimated and (for the
2000-20) assumed crude birth and death rates according to the m
variant population projection published in 2001.12 Columns 4 and
marize the corresponding urban and rural net migration rates imp
the UN's population and urbanization estimates and projections. Gi
lack of direct information, these rates were derived assuming no diff
in vital rates between urban and rural areas (see notes to Table 3
ever, since the urban birth rate is probably lower than the rural rate

TABLE 3 Illustrative calculations for South Africa on the consequences

urban/rural differentials in HIV prevalence
UN estimates/ Implied net Implied crude Implied rate of
assumptions migration rate death rate natural increase
Base-
Per- Crude Crude line Implied
cent birth death death percent
urban rate rate Urban Rural rate Urban Rural Urban Rural urban
Year (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)

1980 48.1 -- -- -. 48.1

1985 48.3 33.7 10.8 1.9 0.4 10.8 10.8 10.8 22.9 22.9 48.3
1990 48.8 30.3 9.7 2.2 -1.7 9.7 9.7 9.7 20.6 20.6 48.8
1995 52.6 27.0 8.7 15.7 -14.5 8.3 8.8 8.6 18.2 18.4 52.6
2000 56.9 26.7 10.8 15.3 -19.0 8.0 11.6 9.8 15.1 16.9 56.6
2005 60.8 24.6 17.1 13.4 -18.7 7.8 19.5 13.7 5.1 10.9 59.8
2010 64.2 22.3 21.9 11.2 -18.1 7.4 25.2 16.3 -2.9 6.0 62.2
2015 67.2 20.3 22.9 9.3 -17.0 7.1 26.2 16.6 -5.9 3.7 64.2
2020 69.6 18.8 21.9 7.5 -15.5 7.1 24.7 15.9 -5.9 2.9 65.8

NOTES: All rates are per thousand and refer to five-year period
calculated assuming no urban/rural differential in vital rates. T
Africa's urban population will increase from 29.961 million to
a corresponding rate of natural increase of -3.1 per thousand (18
(see column 4). The death rates in columns 7 and 8 reflect the as
great in urban areas. So the proportion of total excess deaths
proportion of the population in urban areas. To illustrate, again
the urban population will be 30.293 million-(29.961+30.624)/2
annual number of "baseline" deaths in 2015-20 will be 315,00
in urban areas. In addition, the "excess' death rate due to HIV/
of "excess" deaths in the country will be 656,000 (14.8 x 44,2
((2 x 0.684) + (1 - 0.684))-will occur in urban areas. The result
The rates of natural increase in columns 9 and 10 result from th
series in column 2. Thus for 2015-20 for urban areas, the rate
how urbanization proceeds when the 1980 urban and rural po
forward, period by period, according to the net migration rates
reflect greater urban HIV/AIDS mortality) in columns 9 and 10.
assumptions regarding mortality, may themselves prove to be in
emphasis.
SOURCES: Column 1: United Nations (2002a: 26-27); columns 2 and 3: United Nations (2001b: 412); column 6: United
Nations (1999: 65).

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438 HIV/AIDS AND URBANIZATION

migration rates may understate the extent to which rural-to-ur

tion contributes to urban population growth. Note the shar
migration indicated for the period 1990-95, coinciding with the
apartheid. The impact of HIV/AIDS on the overall death rate has
here by the difference between the death rates in column 3
line rates given in column 6; the latter are essentially the de
the UN considers would have occurred without AIDS. Therefore these two
columns permit the computation of excess mortality in each time period.
Note that the death rate is elevated first during 1990-95 (when the death
rates with and without AIDS are respectively 8.7 and 8.3 per thousand).
Also, the figures in column 6 imply, quite plausibly, that the death rate
would have fallen to, and stayed around, 7 deaths per thousand in the ab-
sence of HIV/AIDS.

The remaining columns in Table 3 summarize the results from calcu-

lations in which the rates in columns 2 to 6 were held constant. In each
period excess deaths were distributed between the urban and rural sec
so that the urban excess death rate was double the rural rate-reflectin
arbitrary, but possibly conservative assumption that levels of HIV infect
in urban South Africa are only twice those of rural areas.'3 Columns 7
8 show the resulting implied urban and rural death rates arising from
combination of baseline and excess deaths (see notes to Table 3). Colum
9 and 10 give the implied urban and rural rates of natural increase, a
assuming that the birth rates in column 2 apply in both urban and r
areas. Finally, column 11 gives the revised time path of urbanization,
path that results when the urban and rural populations are brought
ward from 1980 on the basis of their respective net migration rates in c
umns 4 and 5 plus the rates of natural increase (which incorporate th
sumed urban/rural mortality differentials due to HIV/AIDS) shown
columns 9 and 10.
To reiterate, these calculations involve making some weighty assump-
tions and are purely illustrative. Nevertheless they probably understate the
impact of HIV/AIDS on South Africa's urbanization. In particular, they make
no allowance for a possible decline in net rural-to-urban migration, which
could well occur if the boost to migration arising from the collapse of apart-
heid wanes and the wider effects of the epidemic on families and house-
holds take hold. The calculations also take no account of the likely greater
impact of HIV/AIDS on the urban birth rate. It is probable, too, that the rate
of natural increase in urban areas is lower than in rural areas. Moreover,
the urban/rural ratio of HIV/AIDS mortality used here may well be too low.
Nonetheless some interesting points emerge.
It is clear that HIV/AIDS could well exert a major influence on urban/
rural mortality differentials in the near future. Thus by 2005-10 the urban
death rate is projected to exceed the rural rate by 9 points (see columns 7

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TIM DYSON 439

and 8 of Table 3). The especially sharp rise in the urban dea
that the urban rate of natural increase becomes negative du
although the rural rate remains slightly positive throughout (s
and 10). However, because the urban birth rate is probably l
rural rate, and because the former may be depressed more
the country's urban sector could well become a demographi
the period 2005-10. Indeed, this may already be the case. In
notice that the UN projections imply that South Africa as a wh
demographic sink by 2010-15 (see columns 2 and 3).14 Give
tion of continuing net rural-to-urban migration, the figures i
ply that the size of the urban population will expand by 17 per
period 2000-20. But by 2015-20 the urban population begins
size (the population increase for that quinquennium is only
The rural population, which was probably already declining
2000, shrinks by 21 percent during 2000-20. Consequently
urbanization continues, although-as the figures in column
a sharply declining rate. Note that these simple calculations
some allowance for HIV/AIDS suggest that the United Nation
urbanization projections will have to be revised downward
umns 1 and 11). Finally, if there are major changes in net
migration in the future, then urbanization may be far more r
is indicated in Table 3.

Conclusion

That HIV prevalence in urban areas is usually much greater than in rural
areas accords with previous experience with infectious diseases and with
epidemiologic theory. On the other hand, of course, in some ways towns
offer economies of concentration when it comes to combating infectious
diseases. This article used data from various parts of the world, with very
different economic and socio-cultural characteristics, to show that within
regions that are relatively uniform with respect to the epidemic's main fea-
tures, a population's level of urbanization is an important factor influenc-
ing its level of infection. That higher levels of urbanization tend to facilitate
the spread of HIV is a fact worth recalling as the virus becomes more en-
trenched in various parts of the world.
The article also argued that, in the most severely affected countries,
HIV/AIDS can be expected to exert a significant limiting effect on the pro-
cess of urbanization by differentially affecting mortality, migration, and fer-
tility between the urban and rural sectors. In fact, such an effect seems al-
ready to be detectable in parts of Africa, despite the admittedly very
unsatisfactory data base. Other things equal, the higher the urban/rural ra-
tio of infection and the lower the birth rate, the greater the likelihood of

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440 HIV/AIDS AND URBANIZATION

slowdowns in urban growth and urbanization; indeed, in

the greater the likelihood of eventual de-urbanization. B
tion is a central characteristic and motivator of societal dev
conclusions should be of considerable concern.
For most countries, the available data on HIV prevalence are heavily
biased toward the urban sector. The importance of remedying this situation
by collecting more representative information for rural areas is clear. In-
deed, with encouragement from UNAIDS/WHO, most countries in eastern
and southern Africa are beginning to increase the number of testing sites
located in truly rural areas, even though a fairly large number will be re-
quired to provide population samples of sufficient size.
Finally, for those countries most severely affected by HIV/AIDS, it seems
that projections of future urbanization must be revised downward to take
account of the likely impact of the disease.

Notes

5 On such migratory movement see

I thank Simon Gregson and Mike Murphy
for their helpful and incisive remarks.Wawer (1996: 49). Higher levels of urbaniza-
tion also tend to be assocated with better trans-
1 Note that urban population growth is
port infrastructures, which, in turn, may in-
different from urbanization. Thus it is possible
crease
to have urban population growth without ur-levels of individual mobility and so
heighten risks of contracting HIV.
banization. Contrary to what is commonly
stated, the speed of urbanization in the con- 6 For simplicity the discussion here ig-
nores the reclassification of rural areas as ur-
temporary developing world is not exceptional
ban, of
by historical standards, although the speed which can also alter the level of urban-
urban population growth certainly is (seeization
Pres- over time.
ton 1979: 196-198).
7 Whereas it is relatively easy to document
2 Organizations such as UNAIDS arecases
well of return migration to rural areas of
aware of this potential bias, and they endeavor
people who fall ill, by its very nature it is more
to adjust for it when producing nationaldifficult
esti- to detect potential migration that does
mates of HIV prevalence. not happen in the first place.
3 Antenatal data are used here because
8 The linear regression, excluding Bots-
they are generally thought to be the most rep-isy = -0.0134x + 1.1424.
wana,
resentative form of data on the level of HIV
prevalence in the general population. In in- 9 The linear regression, excluding South
terpreting these ratios one should also noteAfrica, is y=-0.0141x + 1.1281.
that the sample sizes involved are often very 10 Although these four countries tend to
small (see Table 1). export people to South Africa, their estimated
4 As national epidemics develop there mayrates of net migration, as published by the
be some decline in urban/rural ratios of infec- United Nations (2001b), are so low that
tion (e.g., Gamett, Grassly, and Gregson 2001: changes in international migration seem very
392). Nevertheless in Great Britain, for example, unlikely to account for the urbanization reduc-
over 70 percent of HIV/AIDS cases are reported tions shown in Table 2. The HIV prevalence
to be in London and its environs (Adler 2001: levels for Lesotho and Zimbabwe in Table 2
4); for a broadly analogous situation in the suggest that urbanization in these countries
United States see Luna (2001: 629). may well be slowing too.

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TIM DYSON 441

11 It is worth noting, however, that 13 Afor

recent study of South Africa suggests
the United Nations region of eastern Africa,
a national HIV prevalence rate for the popula-
which incudes among other countries tion Ethio-
aged two years and above of 11.4 percent.
pia, Malawi, and Zambia, all of which appear
The corresponding figures for the urban infor-
to have experienced some slowdown in mal,urban-
urban formal, tribal, and farm sectors
wereof
ization (see Table 2), the projected level 21.3,
ur-12.1, 8.7, and 7.9 percent (Shisana
banization for the year 2000 (25.1 percent) was 2002). By most standards an ur-
and Simbayi
higher than the subsequently provided ban/rural ratio of infection of 2.0 is low. How-
esti-
mate (24.5 percent) (see United Nations 1998:
ever, such ratios may tend to fall with increas-
89 and 2002a: 27). ing levels of urbanization, partly because, other
things for
12 The medium variant projection equal, there will be greater interaction
South Africa from the UN's 2000 revision of between the populations of the urban and ru-
ral sectors.
world population prospects (see United Nations
2001b) is used in the calculations in Table 3 14 These statements are strengthened by
because the version of the projections of thethe fact that the UN's recently released 2002
2002 revision currently available (see Unitedrevision projections imply that the country as
Nations 2002b) does not contain the "withouta whole may be a sink by 2005-10, with pro-
AIDS" (i.e., baseline) crude death rates re-jected birth and death rates of 21.0 and 22.9
quired by the table. respectively (United Nations 2002b).

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