Intergenerational spillover effects of antiretroviral therapy in sub-Saharan Africa: a scoping review and future directions for research

Abstract

BackgroundAntiretroviral therapy (ART) may influence individuals who do not receive the intervention but who are connected in some way to the person who does. Relatively little is known, however, about the size and scope of, what we term, spillover effects of ART. We explored intergenerational spillover effects of ART in sub-Saharan Africa (SSA) and identified several directions for future research.MethodsWe conducted a scoping review between March and April 2022. We systematically searched PubMed, PsycINFO, EconLit, OTseeker, AIDSInfo, Web of Science, CINHAL, Google Scholar and African Index Medicus. We analysed the distribution of included studies over time and summarised their findings. We examined the intergenerational impact of ART provision to working-age adults living with HIV on children (‘downward’ spillover effects) and older adults (‘upward’ spillover effects). We categorised types of intergenerational spillover effects according to broad themes which emerged from our analysis of included studies.FindingsWe identified 26 studies published between 2005 and 2022 with 16 studies assessing spillover effects from adults to children (downward), and 1 study explicitly assessing spillover effects from working-age adults to older adults (upward). The remaining studies did not fully specify the direction of spillover effects. Most spillover effects of ART to household and family members were beneficial and included improvements in wealth, labour market outcomes, health outcomes and health services utilisation, schooling, and household composition. Both children and older adults benefited from ART availability among adults. Detrimental spillover effects were only reported in three studies and included financial and opportunity costs associated with health services utilisation and food insecurity in the first year after ART.ConclusionsART may lead to substantial spillover effects across generations and sectors in SSA. Further research is needed to capitalise on positive spillover effects while mitigating potential negative spillover effects. The returns to investments in large-scale health interventions such as ART may be underestimated without considering these societal benefits.

“I am adhering to HIV treatment so that I can live to support her”: A qualitative study of upward intergenerational support in South Africa

“…As overarching themes, we considered different pathways of how ART among young or middle-aged adults may affect older adults. Spillover effects were defined broadly as any change that ART among young or middle-aged individuals induces to the health, development, socioeconomic situation, well-being or living arrangements of older household or family members [31]. We then summarised our qualitative findings by the types of spillover effect which were identified based on our analysis of transcripts.…”

“…While all younger adults were on ART (inclusion criteria), we elicited the perspectives of older adults regardless of their HIV status or whether they themselves were on treatment or not. This approach complements the traditional focus of 'modern medicine' which emphasises the effects of the treatment on the treated individual but misses potential ripple effects within the broader community (which we termed spillover effects) [31]. Employing a thematic analysis approach, we find that both respondent groups reported considerable and generally positive spillover effects of ART to older adults including effects on older adult's support structures over time, caregiving and financial support, health and well-being, living arrangements and relationships, and reputation in the community.…”

“…A better understanding of the broader societal effects of health interventions is needed to capitalise on the positive spillover effects while mitigating potential detrimental spillover effects [31]. Building on the qualitative findings of this study, future research could, for example, quantify the level and extent of upward spillover effects of ART for older adults.…”

“…As of 2022, 81% of people living with HIV received ART in SSA [26]. ART is shown to restore health and prevent AIDS-related mortality among treated individuals [27][28][29][30] and has been shown to have indirect effects on their household and family members, what we term 'spillover effects' [31]. Findings from Thailand, for example, suggest that ART among younger adults may lead to considerable benefits for older adults such as their parents or grandparents (also known as 'upward' spillover effects from ART among the younger generation to the older generation).…”

“…However, relatively little is known about such possible upward spillover effects from ART in younger adults to older adults in SSA. In a recent systematic scoping review on intergenerational spillover effects [31], we identified only one study which explicitly considered spillover effects from the younger to the older generation. The identified study was a multi-country quantitative study, which found that increased ART coverage was associated with improvements in the living arrangements of older adults, including fewer missing generation households [6].…”