The Impact of Drought on HIV Care in Rural South Africa: An Interrupted Time Series Analysis

Abstract

This analysis investigates the relationship between drought and antiretroviral treatment (ART) adherence and retention in HIV care in the Hlabisa sub-district, KwaZulu-Natal, South Africa. Data on drought and ART adherence and retention were collated for the study period 2010–2019. Drought was quantified using the 3-month Standard Precipitation Evapotranspiration Index (SPEI) and Standard Precipitation Index (SPI) from station data. Adherence, proxied by the Medication Possession Ratio (MPR), and retention data were obtained from the public ART programme database. MPR and retention were calculated from individuals aged 15–59 years who initiated ART between January 2010 and December 2018 and visited clinic through February 2019. Between 01 January 2010 and 31 December 2018, 40,714 individuals started ART in the sub-district and made 1,022,760 ART visits. The SPI showed that 2014–2016 were dry years, with partial recovery after 2016 in the wet years. In the period from 2010 to 2012, mean 6-month MPR increased from 0.85 in July 2010 to a high of 0.92 in December 2012. MPR then decreased steadily through 2013 and 2014 to 0.78 by December 2014. The mean proportion retained in care 6 months after starting ART showed similar trends to MPR, increasing from 86.9% in July 2010 to 91.4% in December 2012. Retention then decreased through 2013, with evidence of a pronounced drop in January 2014 when the odds of retention decreased by 30% (OR = 0.70, CI = 0.53–0.92, P = 0.01) relative to the end of 2013. Adherence and retention in care decreased during the drought years.

Associations of inter-annual rainfall decreases with subsequent HIV outcomes for persons with HIV on antiretroviral therapy in Southern Africa: a collaborative analysis of cohort studies

“…Otherwise, previous cross-sectional studies of weather and HIV in sub-Saharan Africa have found associations between local rainfall shocks and heightened HIV prevalence [ 25 ], as well as between drought and increased HIV prevalence and riskier sexual behaviour in young women in rural areas [ 26 ]. A recent study in South Africa found that adherence and retention in care decreased during years of drought [ 14 ]. Another study found evidence that unusually heavy rainfall was associated with a higher HIV burden across 21 sub-Saharan African countries [ 27 ].…”

“…That much of this literature found associations between droughts and HIV-related outcomes among women living in rural areas show both the gender and urban/rural divides in the pathways linking drought and HIV. Studies suggest that the impacts of climate on HIV are seen particularly among women because of greater dependence on transactional sex [ 30 ], and that the effects are concentrated in rural areas, due to changes in climate having very direct impacts on the livelihoods and behaviours of farmers, whilst any affects in urban areas would likely be less direct, potentially occurring through drought affecting the general economy [ 14 ]. Other literature has looked at the effects of drought in sub-Saharan Africa on other health outcomes that, like HIV, would be more indirectly affected by climate.…”

“…For instance, evidence suggests that the resulting income shocks caused by drought and food insecurity can disrupt antiretroviral therapy (ART) treatment schedules [ 13 ]. This may occur through reduced adherence [ 14 ] due to people finding it difficult to travel to clinics because they have to prioritise food and money over attending clinics for ART [ 13 ], potentially leading to decreases in CD4 cell counts [ 15 ] and increases in viral load [ 16 ]. Additionally, some ART medications are more effective when taken with food [ 17 ], while some can be taken with or without food.…”