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Adult Antiretroviral Treatment and Children's Welfare in Kenya

Development Challenge

The intergenerational transfer of parents' and guardians' health to their children's well-being presents a critical issue for long-term development.  The provision of antiretroviral (ARV) drugs has emerged as a central feature of the medical and policy response to HIV/AIDS across the world, including in Sub-Saharan Africa.  While extensive research indicates large and immediate gains in the health and functional capability of treated patients, less evidence exists on the welfare effects for children living in households with an ARV-treated adult.  This study evaluates the effect of adult ARV treatment on key indicators of children’s welfare: school attendance, labor market participation, and nutrition. 

Context

The study took place in the rural Kosirai region of western Kenya, among households largely engaged in subsistence farming and animal husbandry. The area is home to one of the first rural HIV clinics in Sub-Saharan Africa, operated within a government health center by the Academic Model Providing Access to Healthcare (AMPATH), a partnership between Moi University School of Medicine, Moi Teaching and Referral Hospital, and a consortium of U.S. medical schools led by Indiana University.

Most individuals with untreated HIV experience weakened immune systems and eventually develop AIDS, which can result in substantial weight loss, opportunistic infections such as pneumonia and tuberculosis, and often death within one year.  ARV treatment generally arrests this deterioration in health with the most significant improvements taking place during the first 3 months of treatment.1

Evaluation Strategy

The researchers conducted two rounds of interviews between 2004 and 2005 with 206 households in which at least one known adult was receiving ARV treatment and with 503 randomly sampled households in the survey area, which comprised a comparison group of the general population.  To identify the relationship between ARV treatment and the welfare of children living in the patient’s household, the study exploits the asymmetry in the health response to ARVs by the amount of time on treatment as well as through comparing all ARV households with the set of randomly sampled households from the general population.  The researchers hypothesized that children of patients receiving ARV treatment for 100 days or less at baseline (“early-stage” ARV treatment) would show greater improvements in school attendance and nutrition than both the group receiving treatment for greater than 100 days at baseline (“late-stage” ARV treatment) and the general population group, reflecting the fact that this adult patients in this group witnessed the largest improvements in health during the study period..

To analyze the effect of ARV treatment of adults on the school attendance of children aged 8-18 years in the household, surveyors asked how many hours of school children attended in the seven days prior to the interview.  To evaluate the effect of treatment on children’s market labor participation, researchers analyzed the number of hours children worked on income-generating activities in the week prior to the survey.  To measure the nutritional status of children under age 5, researchers used weight-for-height as an indicator because it is an acute measure of health, highly sensitive to short-term disturbances caused by inadequate food and illness.  Very low weight-for-height indicates wasting. 

To verify that changes in children’s outcomes were a function of treated adults’ improved health, the researchers used an instrumental variables strategy.  Using data from AMPATH, the authors first estimated the impact of ARVs on patients’ weight, confirming evidence of large increases in the early stages of treatment.  Then, researchers analyzed the relationship between adult weight and children’s school attendance and labor market participation to isolate the effect of improved health on children’s outcomes. 

Results and Policy Implications

Researchers found that school attendance for children in the early-stage ARV households increased by 6 hours/week compared with children in both the late-stage ARV households and the comparison group.  These gains were concentrated among younger children.  The authors found a positive and significant relationship between school attendance and improved health of the adult.  For children in ARV households, each 1 kg increase in the weight of the adult patient led to a 0.9 hour increase in school attendance.   There is a gendered effect to these results with increases in school attendance for girls more concentrated in the early stages of treatment relative to boys. 

On labor market participation, the authors found suggestive evidence that ARV treatment leads to reductions in children’s labor activity.  Again, there is a gendered effect with boys in ARV households showing a significant decline in labor supply compared with girls who experienced no significant change.  The authors conclude that these findings provide evidence that at least some of the increased school attendance is a function of reductions in children’s non-market labor such as caregiving.

With respect to nutrition, researchers hypothesized that increased income as a function of improved adult health would positively affect young children’s nutritional status. Children in early-stage ARV households did not experience a significant change in weight-for-height compared with children in late- stage ARV households, but did experience an increase of 0.60 standard deviations relative to children in the comparison group.  The concentration of improved nutrition among children in early-stage ARV households provides suggestive evidence that improved economic conditions in the early stages of ARV treatment lead to improved nutrition.  The researchers note the small sample size of this portion of the study as an analytical limitation.

Timeline

2004-2005

Wools-Kaloustian, Kara, et al. (2006). “Viability and effectiveness of large-scale HIV treatment initiatives in sub-Saharan Africa: experience from Western Kenya.  AIDS 20, 41-48 and Thirumurthy, Harsha, Zivin, Joshua Graff, and Goldstein, Markus, (2008). “The economic impact of AIDS treatment: labor supply in Western Kenya. Journal of Human Resources 18, 511-522.