RATIONALE: HIV / AIDS causes over half of all working-age adult deaths in Southern and East Africa (UNAIDS, 2010). Since 2000, the international community has provided tens of billions of dollars to expand antiretroviral therapy (ART) throughout sub-Saharan Africa (Pepfar, 2012; Global Fund, 2012) and reduce this disease burden. The roll-out of ART programs has dramatically improved survival, increasing prime-age adult life expectancy by over 10 years (Bor, et al. 2013). However, little is known about the economic effects of ART scale-up on the treated and whether externalities exist for the aid-recipient communities.
OBJECTIVES: This paper uses variation in roll-out of antiretroviral therapy (ART) in Malawi to identify the mortality, demographic, and economic effects of HIV treatment. A difference-in-difference methodology is employed to compare areas in Malawi with high versus low ART coverage per capita. Given that poverty is most often the root cause of illness, this work intends to determine whether providing widespread HIV treatment can simultaneously impact health and poverty.
METHODS: Three separate nationally representative data sets from Malawi are used to evaluate the effect of ART roll-out. These include the Malawi Integrated Household Survey (IHS), the Malawi Demographic and Health Survey (DHS), and a full national census in 2008. The former two surveys included survey waves in 2004, before ART expansion began, and again in 2010, once ART expansion had substantially advanced. All three surveys measure labor supply, migration, (subjective) disability, and household assets, while the IHS and DHS also measure a wider range of health status, HIV/AIDS knowledge, risky-sexual behavior, and demographic information. Uniquely, the DHS includes measured HIV status for a subset of respondents, allowing us to investigate changes in disease prevalence over time, and also provides sibling survivorship histories, which we use to estimate age-specific mortality rates over time.
RESULTS: We find that increasing treatment from 1 to 3 per thousand population is associated with a two percentage point decrease in HIV prevalence, a shift in prevalence from younger to older ages as ART both reduces transmission and increases survival of the HIV positive, and a 1.5 deaths per 1000 reduction in adult mortality. Our economic analysis finds that labor force participation among males increases by 10% with a variable pattern by age depending on the data set used. Female labor force participation also shows statistically significant increases, but the results are smaller and not uniform between data sets.
CONCLUSIONS: These results show that donor funding for HIV/AIDS treatment, in addition to significantly reducing mortality burden, also generates positive economic benefits in the districts receiving aid both for those on treatment and overall. Although funding for ART is promoted solely for its health benefit, this study indicates that, if well-designed, ART investment may also be able to help address the poverty at the root of the HIV/AIDS epidemic.