HIV treatment and labor supply in rural South Africa (job market paper)
Antiretroviral therapy (ART) reduces HIV-related morbidity and mortality and has been shown to improve the productivity of HIV-positive workers. However, little is known about the impact of HIV illness and recovery (with ART) on labor supply of HIV patients and their households in Southern Africa, the epicenter of the HIV pandemic and a setting with slack labor markets. This paper assesses the impact of HIV treatment on labor supply in an area of rural South Africa with very high HIV prevalence (28\% among adults). Twelve years of longitudinal population-based surveillance data on nearly 50,000 working age adults and their households were linked to clinical records from the government ART program that serves this population. To construct a plausible counterfactual, HIV patients were matched to controls on employment and other characteristics 3-5 years before ART initiation and the matched sample was followed up over time. Three-to-six years after ART initiation, employment among HIV patients had recovered to 68\% of levels observed in matched controls and 85\% among survivors. Conditional on losing work, jobless spells were long; however, HIV patients on ART were not significantly disadvantaged in regaining employment relative to matched controls. Further welfare gains for people with HIV could be attained from recruitment into care prior to job-threatening illness. Employment declined for female household members of HIV patients in the last two years before ART and then recovered after treatment initiation, consistent with reduced care-giving burdens.
ART as social protection: the economic effects of HIV treatment on households in rural South Africa, with Till Bärnighausen, Frank Tanser, and Marie-Louise Newell
To what extent does ART protect households from the economic shock associated with HIV illness and death of a household member? Using long-run panel data from a large population surveillance site in South Africa, we examine changes in household assets, composition, and children's schooling relative to date of an ART initiation in the household or an HIV death in the household. Data on ART initiations were obtained from clinical records of the public sector treatment program and linked via national ID number. HIV deaths were identified via verbal autopsy. Confirming results from previous studies, we find significant declines in assets and household size in households experiencing an HIV death, with asset losses beginning prior to the death itself. No losses were observed in households where a member initiates ART, suggesting that public provision of HIV treatment substantially insures households against economic losses due to HIV.
Cash transfers and HIV risk in rural South Africa
Scholars have long viewed economic inequality in sexual relationships to be a key driver of HIV infection in Southern Africa. A recent experiment in Malawi found large reductions in incidence among young women in households that received unconditional cash transfers. However, no other causal evidence exists to support cash transfers as a strategy to reduce HIV risk. I assess the impact of South Africa's Old Age Pension and Child Support Grant on HIV infection rates, fertility, and sexual behaviors. Changes in eligibility and sharp age cut-offs provide sources of identification, and the availability of longitudinal population surveillance data enables analysis robust to changes in household composition.
Large increases in adult life expectancy in rural South Africa: valuing the scale-up of ART, with Till Bärnighausen, Abraham J. Herbst, and Marie-Louise Newell
The scale-up of antiretroviral therapy (ART) in regions with high HIV prevalence is expected to lead to significant increases in adult life expectancy in the general population. Using data from a population cohort of over 100,000 individuals in rural KwaZulu-Natal, South Africa, we measured changes in adult life expectancy for 2000-2011. Prior to the national, public-sector rollout of ART in 2004, adult life expectancy was 49.2 years in 2003; following the rollout, adult life expectancy increased to 60.5 years in 2011 – an 11.3-year gain. Conditional on survival to age fifteen, the median length of life increased 18.1 years from 2003 to 2011. Based on standard monetary values of a statistical life year, the survival benefits of ART far outweigh the costs of providing treatment in this community. These gains in adult life expectancy signify the social value of ART and have important implications for investment decisions of individuals, governments, and donors.