Studies tracking HIV/AIDS-affected households over time have documented long periods of lower income and higher expenditures for families, resulting in significant welfare losses.1 Antiretroviral (ARV) treatment has been shown to prolong and improve the lives of HIV-infected individuals by reducing the likelihood of opportunistic infections such as pneumonia and tuberculosis. However, despite efforts to improve distribution of ARV therapy in recent years, only 28 percent of the estimated 4.6 million people in need of the therapy in sub-Saharan Africa were receiving it as of 2009.2
To date, research on economic outcomes for people living with HIV/AIDS has primarily focused on household assets and investments. This study contributes to the literature by seeking to understand the impact of ARV therapy on household welfare and examining how individuals reallocate time to household tasks in response to improvements in health. The results illustrate the potential of ARV therapy to improve socio-economic outcomes by offsetting certain negative effects of HIV/AIDS at the household level.
This evaluation took place in the rural Kosirai Division of western Kenya, which has an area of 76 square miles and a population of 35,383.3 The largest healthcare provider in Kosirai is the government-run Mosoriot Rural Health Training Center, which offers primary care services and an HIV clinic. Founded in 2001 by the Academic Model Providing Access to Healthcare (AMPATH)4, the HIV clinic provides free medical care – including all relevant medical tests and ARV therapy – to HIV-positive patients. As of February 2007, the clinic served approximately 3,714 individuals from both inside and outside of Kosirai.
Individuals become eligible for ARV treatment when their HIV infection progresses to AIDS. In developing countries, death usually occurs within one year of progression to AIDS without ARV treatment.5 ARVs are able to prolong the lives of HIV-infected individuals and improve functional capacity after several months of consistent treatment.
The researchers sought to estimate the impact of ARV treatment on household time allocation and related welfare outcomes in Kosirai. In three household survey rounds between 2004 and 2006, they collected detailed socio-economic data on demographics, health status, agricultural practices, marriage, and family history. Additional questions on non-market labor activities, asked in the first and third rounds and spaced 18 months apart, focused on time spent cleaning, cooking, collecting water and firewood, seeking health care or caring for sick family members, and missing work due to illness. This panel survey data complemented ongoing administrative records collected by the AMPATH clinic on each patient.
Two samples of respondents were enrolled in the study: an ARV-treated sample consisting of 200 households with at least one HIV-positive non-pregnant adult receiving ARV therapy from the AMPATH clinic; and a comparison group of 503 households randomly sampled from a census of non-AMPATH households in Kosirai. Using multivariate regression analysis, researchers compared the difference in weekly hours devoted to housework, chores, and healthcare, and days of work missed due to illness in ARV households between rounds one and three. To control for other factors that may have influenced time allocation patterns, the researchers used monthly indicators from the comparison sample for time-varying factors (such as seasonal fluctuations and unexpected shocks) and individual fixed effects for time-invariant individual and family characteristics.
Results and Policy Implications
Time Allocation for Adult ARV Patients:
Across the first and third rounds, and for both males and females, ARV recipients spent more time receiving health care than individuals in the comparison group. Additionally, the amount of time spent receiving care by ARV recipients was reduced by two-thirds between rounds one and three, suggesting an improvement in their health due to treatment. For women receiving ARV treatment, time devoted to collecting firewood and water between rounds one and three increased by 1.06 and 1.95 hours per week, respectively, representing large differences relative to the round one baseline figures of 2.18 and 3.14 hours per week, respectively. Similar effects were not seen for men, perhaps due to time reallocation to market rather than non-market labor as their health status improved, as reported in an earlier study by the same researchers.
Time Allocation for Household Members of Adult ARV Patients:
Adult household members of ARV recipients initially spent more time caring for sick household members than adults in the comparison group. The difference was insignificant in round three, suggesting that as patients’ health improved, they required less assistance from family members.
Boys in households from the ARV sample initially missed more days of work due to illness and caring for sick family members than boys in the comparison group. They also spent more time performing household chores, with older boys spending three times as much time collecting firewood than their peers in the comparison group at baseline. These differences were significantly smaller in the third round. While time allocation by girls to housework did not differ between samples and rounds, one notable exception was that in the first round, older girls in ARV households devoted more time to collecting water than girls of the same age in the comparison group. This difference disappeared in the third round.
These findings suggest that older children take over the more physically demanding chores abandoned by AIDS-afflicted adults due to poor health, but as the adults become healthier with treatment, non-income earning work is reallocated between adults and children of both sexes and, possibly, of different ages.
The results from this study support prior evidence that ARV therapy improves patients’ health and further demonstrate that it may mitigate negative effects of adult HIV/AIDS on household and child welfare. Given the high returns of reallocating time to income generating activities and school attendance, ARV treatment may have benefits that extend beyond those experienced directly by the patients receiving treatment. It may also have intergenerational impacts, as the consequences of not providing treatment may include diminished human capital formation for children in AIDS-afflicted households, potentially lowering rates of future economic growth. This study suggests that socio-economic and intergenerational welfare considerations should accompany traditional considerations about patients’ health when weighting the costs and benefits of ARV programs.
1 Yamano, T. and T.S. Jayne (2004), “Measuring the Impacts of Working-Age Adult Mortality on Small-Scale Farm Households in Kenya,” World Development, Vol. 32, No. 1, pp. 91-119; and Oni, A., C.L. Obi, T.D. Okorie and A. Jordan (2002), “The Economic Impact of HIV/AIDS on Rural Households in Limpopo Province,” South African Journal of Economics, Vol. 70, pp. 551-62.
2 WHO/UNAIDS/UNICEF (2007), Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector, World Health Organization, Geneva.
3 Kenya Central Bureau of Statistics (1999), Kenya Population and Housing Census, Nairobi: Central Bureau of Statistics.
4 AMPATH is 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.
5 Morgan, Dilys et al. (2002), “HIV-1 Infection in Rural Africa: Is There a Difference in Median Time to AIDS and Survival Compared with that in Industrialized Countries?” AIDS 16:587-603.
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