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Crown W, Hariharan D, Kates J, Gaumer G, Jordan M, Hurley C, Luan Y, Nandakumar A. Analysis of economic and educational spillover effects in PEPFAR countries. PLoS One 2023; 18:e0289909. [PMID: 38157353 PMCID: PMC10756543 DOI: 10.1371/journal.pone.0289909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/13/2023] [Indexed: 01/03/2024] Open
Abstract
The United States President's Emergency Plan for AIDS Relief (PEPFAR) has been credited with saving millions lives and helping to change the trajectory of the global human immunodeficiency virus (HIV) epidemic. This study assesses whether PEPFAR has had impacts beyond health by examining changes in five economic and educational outcomes in PEPFAR countries: the gross domestic product (GDP) per capita growth rate; the share of girls and share of boys, respectively, who are out of school; and female and male employment rates. We constructed a panel data set for 157 low- and middle-income countries between 1990 and 2018 to estimate the macroeconomic impacts of PEPFAR. Our PEPFAR group included 90 countries that had received PEPFAR support over the period. Our comparison group included 67 low- and middle-income countries that had not received any PEPFAR support or had received minimal PEPFAR support (<$1M or <$.05 per capita) between 2004 and 2018. We used differences in differences (DID) methods to estimate the program impacts on the five economic and educational outcome measures. This study finds that PEPFAR is associated with increases in the GDP per capita growth rate and educational outcomes. In some models, we find that PEPFAR is associated with reductions in male and female employment. However, these effects appear to be due to trends in the comparison group countries rather than programmatic impacts of PEPFAR. We show that these impacts are most pronounced in COP countries receiving the highest levels of PEPFAR investment.
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Affiliation(s)
- William Crown
- Institute for Global Health and Development, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States of America
| | - Dhwani Hariharan
- Institute for Global Health and Development, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States of America
| | | | - Gary Gaumer
- Institute for Global Health and Development, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States of America
| | - Monica Jordan
- Institute for Global Health and Development, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States of America
| | - Clare Hurley
- Institute for Global Health and Development, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States of America
| | - Yiqun Luan
- Institute for Global Health and Development, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States of America
| | - Allyala Nandakumar
- Institute for Global Health and Development, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States of America
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Schröder H, Yapa HM, Gómez-Olivé FX, Thirumurthy H, Seeley J, Bärnighausen T, De Neve JW. Intergenerational spillover effects of antiretroviral therapy in sub-Saharan Africa: a scoping review and future directions for research. BMJ Glob Health 2023; 8:bmjgh-2022-011079. [PMID: 37068847 PMCID: PMC10111905 DOI: 10.1136/bmjgh-2022-011079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/24/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) may influence individuals who do not receive the intervention but who are connected in some way to the person who does. Relatively little is known, however, about the size and scope of, what we term, spillover effects of ART. We explored intergenerational spillover effects of ART in sub-Saharan Africa (SSA) and identified several directions for future research. METHODS We conducted a scoping review between March and April 2022. We systematically searched PubMed, PsycINFO, EconLit, OTseeker, AIDSInfo, Web of Science, CINHAL, Google Scholar and African Index Medicus. We analysed the distribution of included studies over time and summarised their findings. We examined the intergenerational impact of ART provision to working-age adults living with HIV on children ('downward' spillover effects) and older adults ('upward' spillover effects). We categorised types of intergenerational spillover effects according to broad themes which emerged from our analysis of included studies. FINDINGS We identified 26 studies published between 2005 and 2022 with 16 studies assessing spillover effects from adults to children (downward), and 1 study explicitly assessing spillover effects from working-age adults to older adults (upward). The remaining studies did not fully specify the direction of spillover effects. Most spillover effects of ART to household and family members were beneficial and included improvements in wealth, labour market outcomes, health outcomes and health services utilisation, schooling, and household composition. Both children and older adults benefited from ART availability among adults. Detrimental spillover effects were only reported in three studies and included financial and opportunity costs associated with health services utilisation and food insecurity in the first year after ART. CONCLUSIONS ART may lead to substantial spillover effects across generations and sectors in SSA. Further research is needed to capitalise on positive spillover effects while mitigating potential negative spillover effects. The returns to investments in large-scale health interventions such as ART may be underestimated without considering these societal benefits.
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Affiliation(s)
- Henning Schröder
- Heidelberg Institute of Global Health, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - H Manisha Yapa
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- The Kirby Institute, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Francesc Xavier Gómez-Olivé
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Janet Seeley
- Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK
- Africa Health Research Institute, Durban, South Africa
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Medical Faculty, Heidelberg University, Heidelberg, Germany
- Africa Health Research Institute, Durban, South Africa
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, USA
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health, Medical Faculty, Heidelberg University, Heidelberg, Germany
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Ware D, Rueda S, Plankey M, Surkan P, Okafor CN, Teplin L, Friedman MR. The longitudinal impact of employment, retirement and disability status on depressive symptoms among men living with HIV in the Multicenter AIDS Cohort Study. PLoS One 2020; 15:e0239291. [PMID: 33007781 PMCID: PMC7532049 DOI: 10.1371/journal.pone.0239291] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/02/2020] [Indexed: 01/21/2023] Open
Abstract
Many persons living with HIV (PLWH) either reduced their employment capacity or stopped work completely due to disease progression. With the advent of effective antiretroviral therapy, some PLWH were able to return to the workforce and many are now transitioning into retirement. We examined the histories of employment, retirement and disability status on depression among 1,497 Participants living with HIV from 1997 to 2015 in the Multicenter AIDS Cohort Study. Data were collected on depressive symptoms, employment, retirement, disability status as well as HIV-related and sociodemographic characteristics. Employment, retirement and disability status were lagged 2 years to assess whether the risk of depression at a given observation were temporally predicted by each respective status, adjusting for prior depressive symptoms and covariates. Being employed (aOR: 0.76; 95% CI: 0.71-0.82) had lower odds of depression risk two years later compared to those unemployed. There were higher odds of depression risk associated with disability (aOR: 1.43; 95% CI: 1.32-1.54) versus those not on disability. Retirement status was not associated with the risk of depressive symptoms. These findings could help inform policies and employment programs to facilitate the return to work for PLWH who are willing and able to work.
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Affiliation(s)
- Deanna Ware
- Division of Infectious Diseases, Department of Medicine, Georgetown University Medical Center, Washington, District of Columbia, United States of America
| | - Sergio Rueda
- Department of Psychiatry, Institute of Medical Science, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Michael Plankey
- Division of Infectious Diseases, Department of Medicine, Georgetown University Medical Center, Washington, District of Columbia, United States of America
| | - Pamela Surkan
- Johns Hopkins Bloomberg School of Public Health, John Hopkins University, Baltimore, Maryland, United States of America
| | - Chukwuemeka N. Okafor
- Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, Texas, United States of America
| | - Linda Teplin
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - M. Reuel Friedman
- Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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Abstract
Evolution of health research to reshape national health agendas
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Affiliation(s)
- Carissa Etienne
- Pan American Health Organization/World Health Organization (PAHO/WHO), Washington, DC, USA
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Galárraga O, Gao B, Gakinya BN, Klein DA, Wamai RG, Sidle JE, Papas RK. Task-shifting alcohol interventions for HIV+ persons in Kenya: a cost-benefit analysis. BMC Health Serv Res 2017; 17:239. [PMID: 28351364 PMCID: PMC5371255 DOI: 10.1186/s12913-017-2169-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/17/2017] [Indexed: 12/18/2022] Open
Abstract
Background Among HIV+ patients, alcohol use is a highly prevalent risk factor for both HIV transmission and poor adherence to HIV treatment. The large-scale implementation of effective interventions for treating alcohol problems remains a challenge in low-income countries with generalized HIV epidemics. It is essential to consider an intervention’s cost-effectiveness in dollars-per-health-outcome, and the long-term economic impact —or “return on investment” in monetary terms. Methods We conducted a cost-benefit analysis, measuring economic return on investment, of a task-shifted cognitive-behavioral therapy (CBT) intervention delivered by paraprofessionals to reduce alcohol use in a modeled cohort of 13,440 outpatients in Kenya. In our base-case, we estimated the costs and economic benefits from a societal perspective across a six-year time horizon, with a 3% annual discount rate. Costs included all costs associated with training and administering task-shifted CBT therapy. Benefits included the economic impact of lowered HIV incidence as well as the improvements in household and labor-force productivity. We conducted univariate and multivariate probabilistic sensitivity analyses to test the robustness of our results. Results Under the base case, total costs for CBT rollout was $554,000, the value of benefits were $628,000, and the benefit-to-cost ratio was 1.13. Sensitivity analyses showed that under most assumptions, the benefit-to-cost ratio remained above unity indicating that the intervention was cost-saving (i.e., had positive return on investment). The duration of the treatment effect most effected the results in sensitivity analyses. Conclusions CBT can be effectively and economically task-shifted to paraprofessionals in Kenya. The intervention can generate not only reductions in morbidity and mortality, but also economic savings for the health system in the medium and long term. The findings have implications for other countries with generalized HIV epidemics, high prevalence of alcohol consumption, and shortages of mental health professionals. Trial registration This paper uses data derived from “Cognitive Behavioral Treatment to Reduce Alcohol Use Among HIV-Infected Kenyans (KHBS)” with ClinicalTrials.gov registration NCT00792519 on 11/17/2008; and preliminary data from “A Stage 2 Cognitive-behavioral Trial: Reduce Alcohol First in Kenya Intervention” (NCT01503255, registered on 12/16/2011).
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Affiliation(s)
- Omar Galárraga
- Brown University School of Public Health, G-S121-7, 121 South Main Street, Providence, RI, 02912, USA
| | - Burke Gao
- Brown University School of Public Health, G-S121-7, 121 South Main Street, Providence, RI, 02912, USA.,Brown University Alpert Medical School, 222 Richmond Street, Providence, RI, 02912, USA
| | - Benson N Gakinya
- Moi University & Moi Teaching and Referral Hospital, Nandi Rd, Eldoret, Kenya
| | | | - Richard G Wamai
- Northeastern University, Integrated Initiative for Global Health, 360 Huntington Avenue, 220G RP, Boston, MA, 02115, USA
| | - John E Sidle
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rebecca K Papas
- Department of Psychiatry and Human Behavior, Brown University Alpert Medical School, Providence, RI, 02912, USA.
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Wagner Z, Barofsky J, Sood N. PEPFAR Funding Associated With An Increase In Employment Among Males in Ten Sub-Saharan African Countries. Health Aff (Millwood) 2016; 34:946-53. [PMID: 26056199 DOI: 10.1377/hlthaff.2014.1006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The President's Emergency Plan for AIDS Relief (PEPFAR) has provided billions of US tax dollars to expand HIV treatment, care, and prevention programs in sub-Saharan Africa. This investment has generated significant health gains, but much less is known about PEPFAR's population-level economic effects. We used a difference-in-differences approach to compare employment trends between ten countries that received a large amount of PEPFAR funding (focus countries) and eleven countries that received little or no funding (control countries). We found that PEPFAR was associated with a 13 percent differential increase in employment among males in focus countries, compared to control countries. However, we observed no change in employment among females. In addition, we found that increasing PEPFAR per capita funding by $100 was associated with a 9.1-percentage-point increase in employment among males. This rise in employment generates economic benefits equal to half of PEPFAR's cost. These findings suggest that PEPFAR's economic impact should be taken into account when making aid allocation decisions.
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Affiliation(s)
- Zachary Wagner
- Zachary Wagner is a doctoral student in health economics at the University of California, Berkeley
| | - Jeremy Barofsky
- Jeremy Barofsky is the Okun-Model Fellow at the Brookings Institution, in Washington, D.C
| | - Neeraj Sood
- Neeraj Sood is an associate professor of health economics and director of research at the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California, in Los Angeles
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Elzi L, Conen A, Patzen A, Fehr J, Cavassini M, Calmy A, Schmid P, Bernasconi E, Furrer H, Battegay M. Ability to Work and Employment Rates in Human Immunodeficiency Virus (HIV)-1-Infected Individuals Receiving Combination Antiretroviral Therapy: The Swiss HIV Cohort Study. Open Forum Infect Dis 2016; 3:ofw022. [PMID: 26955645 PMCID: PMC4777901 DOI: 10.1093/ofid/ofw022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 01/28/2016] [Indexed: 11/13/2022] Open
Abstract
Background. Limited data exist on human immunodeficiency virus (HIV)-infected individuals' ability to work after receiving combination antiretroviral therapy (cART). We aimed to investigate predictors of regaining full ability to work at 1 year after starting cART. Methods. Antiretroviral-naive HIV-infected individuals <60 years who started cART from January 1998 through December 2012 within the framework of the Swiss HIV Cohort Study were analyzed. Inability to work was defined as a medical judgment of the patient's ability to work as 0%. Results. Of 5800 subjects, 4382 (75.6%) were fully able to work, 471 (8.1%) able to work part time, and 947 (16.3%) were unable to work at baseline. Of the 947 patients unable to work, 439 (46.3%) were able to work either full time or part time at 1 year of treatment. Predictors of recovering full ability to work were non-white ethnicity (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.20-3.54), higher education (OR, 4.03; 95% CI, 2.47-7.48), and achieving HIV-ribonucleic acid <50 copies/mL (OR, 1.83; 95% CI, 1.20-2.80). Older age (OR, 0.55; 95% CI, .42-.72, per 10 years older) and psychiatric disorders (OR, 0.24; 95% CI, .13-.47) were associated with lower odds of ability to work. Recovering full ability to work at 1 year increased from 24.0% in 1998-2001 to 41.2% in 2009-2012, but the employment rates did not increase. Conclusions. Regaining full ability to work depends primarily on achieving viral suppression, absence of psychiatric comorbidity, and favorable psychosocial factors. The discrepancy between patients' ability to work and employment rates indicates barriers to reintegration of persons infected with HIV.
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Affiliation(s)
- Luigia Elzi
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research , University Hospital Basel
| | - Anna Conen
- Division of Infectious Diseases , Cantonal Hospital Aarau
| | - Annalea Patzen
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research , University Hospital Basel
| | - Jan Fehr
- Division of Infectious Diseases and Hospital Epidemiology , University Hospital Zurich
| | - Matthias Cavassini
- Infectious Diseases Service, University Hospital and University of Lausanne
| | - Alexandra Calmy
- Division of Infectious Diseases , University Hospital Geneva
| | - Patrick Schmid
- Division of Infectious Diseases , Cantonal Hospital , St. Gallen
| | - Enos Bernasconi
- Division of Infectious Diseases , Regional Hospital , Lugano
| | - Hansjakob Furrer
- Department of Infectious Diseases , University Hospital Bern and University of Bern , Switzerland
| | - Manuel Battegay
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research , University Hospital Basel
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McNairy ML, El-Sadr WM. Antiretroviral therapy for the prevention of HIV transmission: what will it take? Clin Infect Dis 2014; 58:1003-11. [PMID: 24429438 DOI: 10.1093/cid/ciu018] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The evidence in support of use of antiretroviral therapy (ART) for prevention of human immunodeficiency virus (HIV) transmission is encouraging and has stimulated optimism for achieving a dramatic change in the trajectory of the HIV epidemic. Yet, there are substantial challenges that, if not addressed, could be the Achilles' heel for this concept. These challenges require strengthening every step of the HIV care continuum, including expansion of HIV testing to reach all those with HIV infection, effective linkage to and retention in care, timely initiation of ART, and high levels of treatment adherence with viral load suppression. Also important is the identification of individuals with acute HIV infection whose contribution to HIV transmission may be substantial. Implementation research is needed to identify strategies that address these challenges and to determine the efficacy of ART for prevention in key populations as well as to evaluate the effectiveness of combination strategies for HIV prevention at the population level.
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Walensky RP, Ross EL, Kumarasamy N, Wood R, Noubary F, Paltiel AD, Nakamura YM, Godbole SV, Panchia R, Sanne I, Weinstein MC, Losina E, Mayer KH, Chen YQ, Wang L, McCauley M, Gamble T, Seage GR, Cohen MS, Freedberg KA. Cost-effectiveness of HIV treatment as prevention in serodiscordant couples. N Engl J Med 2013; 369:1715-25. [PMID: 24171517 PMCID: PMC3913536 DOI: 10.1056/nejmsa1214720] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The cost-effectiveness of early antiretroviral therapy (ART) in persons infected with human immunodeficiency virus (HIV) in serodiscordant couples is not known. Using a computer simulation of the progression of HIV infection and data from the HIV Prevention Trials Network 052 study, we projected the cost-effectiveness of early ART for such persons. METHODS For HIV-infected partners in serodiscordant couples in South Africa and India, we compared the early initiation of ART with delayed ART. Five-year and lifetime outcomes included cumulative HIV transmissions, life-years, costs, and cost-effectiveness. We classified early ART as very cost-effective if its incremental cost-effectiveness ratio was less than the annual per capita gross domestic product (GDP; $8,100 in South Africa and $1,500 in India), as cost-effective if the ratio was less than three times the GDP, and as cost-saving if it resulted in a decrease in total costs and an increase in life-years, as compared with delayed ART. RESULTS In South Africa, early ART prevented opportunistic diseases and was cost-saving over a 5-year period; over a lifetime, it was very cost-effective ($590 per life-year saved). In India, early ART was cost-effective ($1,800 per life-year saved) over a 5-year period and very cost-effective ($530 per life-year saved) over a lifetime. In both countries, early ART prevented HIV transmission over short periods, but longer survival attenuated this effect; the main driver of life-years saved was a clinical benefit for treated patients. Early ART remained very cost-effective over a lifetime under most modeled assumptions in the two countries. CONCLUSIONS In South Africa, early ART was cost-saving over a 5-year period. In both South Africa and India, early ART was projected to be very cost-effective over a lifetime. With individual, public health, and economic benefits, there is a compelling case for early ART for serodiscordant couples in resource-limited settings. (Funded by the National Institute of Allergy and Infectious Diseases and others.).
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Galárraga O, Wirtz VJ, Santa-Ana-Tellez Y, Korenromp EL. Financing HIV programming: how much should low- and middle-income countries and their donors pay? PLoS One 2013; 8:e67565. [PMID: 23861772 PMCID: PMC3702499 DOI: 10.1371/journal.pone.0067565] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 05/24/2013] [Indexed: 11/18/2022] Open
Abstract
Global HIV control funding falls short of need. To maximize health outcomes, it is critical that national governments sustain reasonable commitments, and that international donor assistance be distributed according to country needs and funding gaps. We develop a country classification framework in terms of actual versus expected national domestic funding, considering resource needs and donor financing. With UNAIDS and World Bank data, we examine domestic and donor HIV program funding in relation to need in 84 low- and middle-income countries. We estimate expected domestic contributions per person living with HIV (PLWH) as a function of per capita income, relative size of the health sector, and per capita foreign debt service. Countries are categorized according to levels of actual versus expected domestic contributions, and resource gap. Compared to national resource needs (UNAIDS Investment Framework), we identify imbalances among countries in actual versus expected domestic and donor contributions: 17 countries, with relatively high HIV prevalence and GNI per capita, have domestic funding below expected (median per PLWH $143 and $376, respectively), yet total available funding including from donors would exceed the need ($368 and $305, respectively) if domestic contribution equaled expected. Conversely, 27 countries have actual domestic funding above the expected (medians $294 and $149) but total (domestic+donor) funding does not meet estimated need ($685 and $1,173). Across the 84 countries, in 2009, estimated resource need totaled $10.3 billion, actual domestic contributions $5.1 billion and actual donor contributions $3.7 billion. If domestic contributions would increase to the expected level in countries where the actual was below expected, total domestic contributions would increase to $7.4 billion, turning a funding gap of $1.5 billion into a surplus of $0.8 billion. Even with imperfect funding and resource-need data, the proposed country classification could help improve coherence and efficiency in domestic and international allocations.
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Affiliation(s)
- Omar Galárraga
- Department of Health Services, Policy and Practice, Brown University, School of Public Health, Providence, Rhode Island, USA.
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