The Impact of AIDS Treatment on Savings and Human Capital Investment in Malawi

Baranov, Victoria; Kohler, Hans‐Peter

doi:10.1257/app.20150369

Cited by 42 publications

(40 citation statements)

References 84 publications

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“…Of these, several studies have highlighted beneficial economic impacts of ART initiation, which are primarily based on the positive labour market effects of improved health. Accordingly, empirical evidence has pointed to higher work performance and productivity, [10][11][12][13] lower absenteeism, 11 increases in savings rates, 15 as well as increased educational expenditures and attainment 15,16 following ART initiation.…”

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confidence: 99%

A stepped-wedge randomised trial on the impact of early ART initiation on HIV-patients’ economic outcomes in Eswatini

Steinert

Khan

Mlambo

et al. 2020

eLife

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Background: Since 2015, the World Health Organisation (WHO) recommends immediate initiation of antiretroviral therapy (ART) for all HIV-positive patients. Epidemiological evidence points to important health benefits of immediate ART initiation; however, the policy's economic impact remains unknown. Methods: We conducted a stepped-wedge cluster-randomised controlled trial in Eswatini to determine the causal impact of immediate ART initiation on patients' economic welfare. Fourteen healthcare facilities were non-randomly matched in pairs and then randomly allocated to transition from the standard of care (ART eligibility at CD4 counts of < 350 cells/mm3 until September 2016 and <500 cells/mm3 thereafter) to the 'Early Initiation of ART for All' (EAAA) intervention at one of seven timepoints. Patients, healthcare personnel, and outcome assessors remained unblinded. Data was collected via standardised paper-based surveys with HIV-positive, ART-naïve adults who were neither pregnant nor breastfeeding. Outcomes were patients' time use, employment status, household expenditures and household wealth. Results: A total sample of 3,019 participants were interviewed over the duration of the study. The mean number of participants approached at each facility and time step varied from 4 to 112 participants. Using mixed-effects negative binomial regressions accounting for time trends and clustering, we found no significant difference between study arms for any economic outcome. Specifically, the EAAA intervention had no significant effect on non-resting time use (RR= 1.00, [CI: 0.96, 1.05, p=0.93]) or income-generating time use (RR= 0.94, [CI: 0.73,1.20, p=0.61]). Employment and household expenditures decreased slightly but not significantly in the EAAA group, with risk ratios of 0.93 [CI: 0.82, 1.04, p=0.21] and 0.92 [CI: 0.79, 1.06, p=0.26], respectively. We also found no significant treatment effect on households' asset ownership and living standards (RR=0.96, [CI 0.92, 1.00, p=0.253]). Lastly, there was no evidence of heterogeneity in effect estimates by patients' sex, age, education, timing of HIV diagnosis and ART initiation. Conclusions: Given the neutral effect on patients' economic welfare but positive effects on health, our findings support further investments into scaling-up immediate ART for all HIV patients. Trial Registration: ClinicalTrials.gov, NCT02909218 and NCT03789448; ethical approval: Eswatini National Health Service Review Board & Harvard T.H. Chan School of Public Health Review Board.

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confidence: 99%

A stepped-wedge randomised trial on the impact of early ART initiation on HIV-patients’ economic outcomes in Eswatini

Steinert

Khan

Mlambo

et al. 2020

eLife

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“…The findings are consistent with increased access to AIDS treatment improving life expectancy and a reducing in the impact of the disease on human capital investment. As more data on ART become available, it will be important to further investigate how reductions in mortality, increases in life expectancy (Bor et al, 2013), and changes in behavior (Thirumurthy and Graff Zivin, 2012;Baranov et al, 2015;Baranov and Kohler, 2018;Friedman, 2018)…”

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confidence: 99%

The Impact of HIV/AIDS on Human Capital Investment in Sub-Saharan Africa: New Evidence

2019

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The risk of AIDS-related mortality increased dramatically throughout the 1990s. This paper updates previous work by Fortson (2011) to examine the impact of mortality risk on human capital investment during the deadliest period of the pandemic. We combine Demographic Health Survey data from 30 countries, across 60 survey waves, to generate a sample of over 1,300,000 observations. Cohort-specific analysis using the updated sample yields new evidence that the negative relationship between HIV prevalence and schooling steepened as mortality risk increased. The reduction in schooling is largest for women, and along the extensive margin of the schooling decision. The findings indicate that the decline in human capital investment associated with the HIV/AIDS pandemic prior to the availability of treatment was larger in magnitude than previously understood, but may be reversing rapidly as access to treatment is expanded.

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“…The Ministry of Health in Malawi began rolling out free ART to eligible individuals in urban areas in 2004, with rollout to smaller clinics beginning in 2006. In the MLSFH, median distance of respondents to the nearest ART clinic was 27 kilometers up until mid-2007, which made access to ART difficult given the limited means of transportation in this rural context ( Baranov, Bennett, and Kohler 2015 ; Baranov and Kohler 2014 ). ART-providing clinics opened between August of 2007 and March of 2008 in each of the three study regions (shortly before data collection for the 2008 round of the MLSFH), reducing the median distance to the nearest ART clinic to 8.9 kilometers by the 2008 MLSFH ( Baranov, Bennett, and Kohler 2015 ).…”

Section: Methodsmentioning

confidence: 99%

The population-level impact of public-sector antiretroviral therapy rollout on adult mortality in rural Malawi

Payne

Kohler

2017

DemRes

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BACKGROUNDRecent evidence from health and demographic surveillance sites (HDSS) has shown that increasing access to antiretroviral therapy (ART) is reducing mortality rates in sub-Saharan Africa (SSA). However, due to limited vital statistics registration in many of the countries most affected by the HIV/AIDS epidemic, there is limited evidence of the magnitude of ART’s effect outside of specific HDSS sites. This paper leverages longitudinal household/family roster data from the Malawi Longitudinal Survey of Families and Health (MLSFH) to estimate the effect of ART availability in public clinics on population-level mortality based on a geographically dispersed sample of individuals in rural Malawi.OBJECTIVEWe seek to provide evidence on the population-level magnitude of the ART-associated mortality decline in rural Malawi and confirm that this population is experiencing similar declines in mortality as those seen in HDSS sites.METHODSWe analyze longitudinal household/family-roster data from four waves of the MLSFH to estimate mortality change after the introduction of ART to study areas. We analyze life expectancy using the Kaplan–Meier estimator and examine how the mortality hazard changed over time by individual characteristics with Cox regression.RESULTSIn the four years following rollout of ART, life expectancy at age 15 increased by 3.1 years (95% CI 1.1, 5.1), and median length of life rose by over ten years.CONTRIBUTIONOur observations show that the increased availability of ART resulted in a substantial and sustained reversal of mortality trends in SSA and assuage concerns that the post-ART reversals in mortality are not occurring at the same magnitude outside of specific HDSSs.

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The Impact of AIDS Treatment on Savings and Human Capital Investment in Malawi

Cited by 42 publications

References 84 publications

A stepped-wedge randomised trial on the impact of early ART initiation on HIV-patients’ economic outcomes in Eswatini

A stepped-wedge randomised trial on the impact of early ART initiation on HIV-patients’ economic outcomes in Eswatini

The Impact of HIV/AIDS on Human Capital Investment in Sub-Saharan Africa: New Evidence

The population-level impact of public-sector antiretroviral therapy rollout on adult mortality in rural Malawi

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