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Improved employment and children’s education outcomes in households of HIV-positive adults with high CD4 counts: evidence from a community-wide health campaign in Uganda.

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  1. Improved employment and children’s education outcomes in households of HIV-positive adults with high CD4 counts: evidence from a community-wide health campaign in Uganda H. Thirumurthy*, G. Chamie, J. Kabami, V. Jain, T. Clark, D. Kwarisiima, E. Geng, M.L. Petersen, M.R. Kamya, E.D. Charlebois, D.V. Havlir, and the SEARCH Collaboration *Department of Health Policy and Management, Gillings School of Global Public Health, UNC-Chapel Hill

  2. Background • HIV known to influence wide range of socio-economic outcomes • Several studies compare HIV and no-HIV households • Facility-based studies showing pre-ART SES decline and post-ART improvement • Association between CD4 and SES unknown, particularly among undiagnosed & untreated • Useful for assessing potential economic benefits of early ART initiation • Requires population-level data, with CD4 information

  3. Community-wide HIV testing • Community health campaigns are a vehicle for widespread HIV testing • Essential component of test-and-treat strategy of SEARCH Collaboration • Campaign in May 2011 in rural community (population 6,000) near Mbarara, Uganda • All individuals offered rapid HIV testing and screening for communicable & non-communicable diseases • Chamie et al., IAC 2012 Abstract # MOAE0103 • Jain et al., IAC 2012 Abstract # TULBE04

  4. Study objectives • Determine the association between CD4 cell counts of HIV-infected adults and • Employment measures • Education outcomes of children • Association examined for those on & not on ART • Primary research questions • Over what range of CD4 counts do we observe declining SES? • To what extent does poor adult health influence the well-being of children?

  5. Data and methods • Data collected on employment, education, and other characteristics of participants/households • All adult participants interviewed during CHC • After CHC, household survey of all HIV-infected and random sample of HIV–uninfected participants • Outcomes • Adult employment: # of days worked in past monthand # of hours worked on typical day in past week • Whether or not child reported to be enrolled in school • Regression analysis used to determine association with CD4 count

  6. Participant characteristics • 2,323 adults attended one of three CHC sites (74% participation) • 179/2282 (7.8%) of adults tested HIV+ • High female participation • Campaign resulted in new diagnoses of HIV-infected adults with high CD4 counts • 37% on ART

  7. Participant characteristics Primary occupation Asset comparison Significant differences in assets

  8. Employment and CD4 cell count • Among HIV+ adults not on ART, higher CD4 associated with more days worked per month Half-day increase in days worked for ΔCD4 of 100 Nonparametric regression results (kernel-weighted local polynomial, width=100, n=50)

  9. Significantly higher employment at CD4≥500 among adults not on ART • Compared to CD4<200, CD4≥500 associated with • 5.8 more days/month • 2.2 more hours/day (40% more than ref. mean of 5.5) CD4≥500 worked nearly 1 week/month more than those with CD4<200, and as much as HIV-uninfected adults • Linear regression model with age, age-squared, and sex included as controls • ** p<0.05, * p<0.10 • Reference group has CD4<200

  10. Positive employment-CD4 association among adults on ART • Compared to CD4<200, CD4 350-499 worked 6.4 more days/month • Controlling for CD4 count, those on ART worked less than those not on ART • Suggests benefit of avoiding CD4 decline through early ART initiation • Linear regression model with age, age-squared, and sex included as controls • ** p<0.05, * p<0.10 • Reference group has CD4<200

  11. Adult CD4 count and children’s education • In RLS with limited insurance & risk-coping mechanisms, adult health and productivity known to influence children’s outcomes • Older children likely to be diverted away from school to provide on-farm or other labor

  12. Better education outcomes at CD4≥350 • No association among young children • Older children’s enrollment rates 15% higher in households with CD4≥350 compared to CD4<350 • 75% enrolled in CD4<350 households • Linear probability model with age, age-squared, and sex included as controls • * p<0.10

  13. Conclusions • Population-representative data that includes undiagnosed adults shows strong association between CD4 and employment • SES decline may begin at CD4 counts well above 500 • Early ART initiation could potentially maintain SES at levels similar to HIV-uninfected adults and households • Longitudinal data and RCT design necessary for further establishing these benefits

  14. Acknowledgements Residents of Kakyerere Parish, Mbarara, Uganda Kakyerere Parish Local Councilors Uganda Ministry of Health Geoff Lavoy, MU-UCSF

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