Transmission Patterns, Socioeconomic Effects, and Project Assessment Efforts
November 26, 2007—Sub-Saharan Africa—home to just 10 percent of the world’s population—accounts for 68 percent of global HIV-positive people and nearly 90 percent of all HIV-positive children. There are an estimated 11.4 million children orphaned by AIDS in the region.
According to new UNAIDS data (November 2007), an estimated 1.7 million people in Sub-Saharan Africa became HIV-positive in the past year, a significant decline from 2001. However, AIDS remains the primary cause of death in the region, where an estimated 1.6 million people died of it in 2007, and 22.5 million people live with HIV.
Despite some successes, especially in the delivery of anti-retroviral therapy (ART) in parts of Africa and Asia, much remains to be done to deliver on HIV/AIDS promises. Governments, donors and development workers urgently need more evidence-based information in order to take more effective action against HIV/AIDS.
World Bank research attempts to fill critical knowledge gaps, including:
how HIV spreads through society;
approaches that work best for prevention and treatment delivery;
the impact of AIDS-related deaths on people, households and economies.
In parts of Sub-Saharan Africa, married women bring HIV home too
By analyzing Demographic and Health Survey data, Damien de Walque , an economist in the Bank’s research department, recently found that a full two-thirds of cohabiting couples affected by HIV in Burkina Faso, Cameroon, Ghana, Kenya, and Tanzania had only one partner infected.
Also, in 30 to 40 percent of these affected couples, only the woman was infected, implying substantially prevalent female extramarital sex—not widely suspected earlier. Women have often under-reported extramarital sex, and the main link between high-risk groups and the general population was believed to be unfaithful men.
“This research is significant for HIV/AIDS prevention policies,” said de Walque, “It shows that discordant couples should be educated about HIV prevention, and highlights that prevention efforts should be targeted just as much toward women as men.”
According to the 2007 UNAIDS update, 61 percent of all HIV-positive people in Africa are women.
In Kenya, gender inequality leaves younger women vulnerable to HIV
In Kenya, young women aged 15-24 are about five times as likely to be HIV-positive as young men of the same age group. Also, adolescent married girls are more likely to be HIV-positive than their single and sexually active counterparts.
However, as dropping out of school and marrying young are highly correlated, it does not immediately follow that marriage itself is a risk factor for HIV among young women.
World Bank researchers Kathleen Beegle and Berk Özler have found that higher economic gender inequality (specifically between younger women and older men) is strongly associated with greater likelihood of being HIV-positive.
They also find that, controlling for gender inequality, poverty does not increase the risk of HIV. This suggests that while young women make good targets for HIV prevention efforts, they are not necessarily among the poorest in society.
While many focus on the “sugar daddy” syndrome and risky transactional sex, it is important to be aware that in an environment of high gender inequality, everyone, including married men and women, may be at higher risk of HIV.
ART delivery in Africa: What works?
With millions living with HIV in Sub-Saharan Africa today, delivering ART is critical. The World Bank operates several initiatives to improve access to ART for patients in Africa. For example, the Treatment Acceleration Project (TAP) supports various public-private partnership models of ART delivery in Burkina Faso, Ghana and Mozambique.
Damien de Walque, Varun Gauri and Harounan Kazianga of the World Bank are working with former World Bank researcher Mead Over, currently of the Center for Global Development, and with external research partners to measure the impact of ART-delivery programs under the TAP, as well as in Rwanda, Kenya, South Africa and India.
Beyond lives saved and health results, the evaluation also covers how treatment affects family members, how ART affects HIV transmission and prevention, what determines successful treatment, and how to encourage cost-effectiveness and capacity building to reinforce the sustainability of delivering ART.
Preliminary results from health facility surveys in Burkina Faso and Rwanda show a high level of patient satisfaction with HIV/AIDS services. However, getting to the facilities seems to cost so much that transportation might be a barrier to care.
The analysis from household surveys in Burkina Faso, Ghana and Rwanda also yields interesting early results. In Rwanda, HIV/AIDS patients are more likely to have used a condom at their last sexual intercourse, indicating that counseling has been efficient.
In Burkina Faso and Ghana, people who were better informed about ART availability were more likely to have tested for HIV. This suggests that scaling up treatment will lead to more demand for voluntary counseling and testing and early detection.
In Tanzania, children who lose mothers early fare worse than other orphans
Kathleen Beegle was part of a research team that tracked living standards in Tanzanian households between 1991 and 2004, including those that experienced the death of an adult member.
“We found that household consumption dropped on average by seven percent within five years of an adult family member dying,” said Beegle, “and the steepest declines in consumption followed the death of an adult woman. But there is no evidence of a persistent impact of shocks after five years, suggesting a strong recovery.”
In a paper with Stefan Dercon of Oxford University, Beegle and Joachim de Weerdt also found that adult mortality had a significant impact on the health and education of orphans in Tanzania, especially those who lost their mothers.
Over ten years, nearly 20 percent of a sample of children with both parents alive in 1991-94 had lost one parent by age 15. When evaluated in 2004, maternal orphans among them were shorter by an average 2 cm at final height, and had at least one year less education. Download policy research working paper.
A family of 28 in rural Tanzania
Martha Ainsworth and Deon Filmer of the World Bank have recently documented big differences across countries in the extent to which orphans are under-enrolled in school. Their research suggests that orphan under-enrollment is very country-specific.
Ainsworth and Filmer find that single-parent orphans are not significantly under-enrolled when compared to non-orphans. Children who have lost both parents, however, are usually less likely to attend school.
Importantly, the enrollment gap between rich and poor children is now known to be substantially greater than that between orphans and non-orphans in almost all the countries studied.
Policies should therefore assess the interaction between orphan status, poverty, and the education system in each country.
HIV/AIDS and related data collection at the World Bank
World Bank research efforts on HIV/AIDS often begin with accurate data collection through household surveys, sometimes spanning several years.
For example, a new data collection effort to support research in Malawi is looking at marriage and how it relates to the spread of HIV. Respondents are being interviewed, observed through courtship and marriage, and periodically tested for HIV.
This unique survey, which will be completed in 2009, was prompted by the much higher HIV prevalence rates among young women than men.
Data collection in Sub-Saharan Africa
Also in Malawi, data collection has begun to assess the impact of a randomized conditional cash transfer program for schooling on HIV/AIDS risk among school-aged girls/young women.
The Tanzania research on the impact of adult mortality was based on the Kagera Health and Development Survey, which is a World Bank Living Standards Measurement (LSMS) Survey spanning 13 years.
Measures of inequality for Beegle and Özler’s Kenya research work were derived from the Kenya Poverty Map, which combines household survey data with census information.
Recent World Bank research papers on HIV/AIDS
The work described above is only a sample of recent World Bank research on HIV/AIDS. Here is a complete list of recent research related to this subject:
Ainsworth, Martha and Deon Filmer. 2006. “Children's Schooling: AIDS, Orphanhood, Poverty, and Gender” . World Development. 34(6):1099-1128.
Beegle, Kathleen and Berk Özler. 2007. “Young Women, Rich(er) Men, and the spread of HIV.” mimeo.
Beegle, Kathleen, Joachim De Weerdt, and Stefan Dercon. 2006. “Adult Mortality and Economic Growth in the Age of HIV/AIDS.” Economic Development and Cultural Change forthcoming.
Beegle, Kathleen, Joachim de Weerdt, and Stefan Dercon. 2006. “Orphanhood and the Long-Run Impact on Children.” American Journal of Agricultural Economics 88 (5): 1266-1272 (By subscription) | Download (free) earlier policy research working paper.
Dandona, Lalit, Pratap Sisodia, TLN Prasad, Elliot Marseille, M Chalapathi Rao, A Anod Kumar, SG Prem Kumar, YK Ramesh, Mead Over, M Someshwar and James G Kahn. 2005. Cost and efficiency of public sector sexually transmitted infection clinics in Andhra Pradesh, India, BMC Health Services Research 5:69
De Walque, Damien. 2007. “How Does the Impact of an HIV/AIDS Information Campaign Vary with Educational Attainment? Evidence from Rural Uganda” in Journal of Development Economics, 84, 686-714. (By subscription) | Download (free) earlier policy research working paper.
Gauri, Varun and Evan S. Lieberman. 2006. “Boundary Institutions and HIV/AIDS Policy in Brazil and South Africa.” Studies in Comparative International Development, 41(3): 47-73.
Gauri, Varun, Beyrer Chris and Denise Vaillancourt. 2007. “Human Rights and Health Systems” in Chris Beyrer, editor, Public Health and Human Rights, Johns Hopkins University Press, 2007 (forthcoming).
Over, Mead, Heywood P, Gold J, Gupta I, Hira Subhash, Marseille, E. 2004. HIV/AIDS Treatment and Prevention in India. Modeling the Cost and Consequences. The World Bank.
Over, Mead and Sevgi Aral. 2006. The Economics of Sexually Transmitted Diseases”, Sexually Transmitted Diseases, October Supplement 2006, Vol. 33, No. 10, p.S79–S83
Over Mead, Marseille Elliot, Sudhakar Kurapati et al. 2006. Antiretroviral Therapy and HIV Prevention in India: Modeling Costs and Consequences of Policy Options. Sexually Transmitted Diseases, October Supplement 2006, Vol. 33, No. 10, p.S145-S152.
Revenga, Ana, Over Mead, Emiko Masaki, Wiwat Peerapatanapokin, Julian Gold, Viroj Tangcharoensathien, Sombat Thanprasertsuk. 2006. The Economics of Effective AIDS Treatment. Evaluating Policy Options for Thailand. The World Bank.