In Zimbabwe, socioeconomic development has a complicated and changeable relationship with HIV infection. Longitudinal data are needed to disentangle the cyclical effects of poverty and HIV as well as to separate historical patterns from contemporary trends of infection.

We analysed a large population-based cohort in Eastern Zimbabwe. Wealth index (WI) was measured at baseline based on household asset ownership. The associations of WI with HIV incidence and HIV mortality, sexual risk behaviour, and sexual mixing patterns were analysed.

The largest decreases in HIV prevalence were in the top one-third of the WI distribution (tercile) in both men at 25% and women at 21%. In men, HIV incidence was significantly lower in the top WI tercile (15.4 per 1000 person-years) compared with the lowest tercile (27.4 per 1000 person-years), especially amongst young men. Mortality rates were significantly lower in both men and women of higher WI. Men of higher WI reported more sexual partners, but were also more likely to use condoms. Better-off women reported fewer partners and were less likely to engage in transactional sex. Partnership data suggests increasing like-with-like mixing in higher wealth groups resulting in reduced probability of serodiscordant couples.

HIV incidence and HIV mortality, and perhaps sexual risk, is lower in higher socioeconomic groups. Reduced vulnerability to infection, led by the relatively well-off, is a positive trend. But, in the absence of analogous developments in vulnerable groups, HIV threatens to become a disease of the poor.