Workforce participation increases with time on HIV treatment

The probabilities of being employed and being able to perform normal daily activities increased over a period of three years and beyond amongst adults on antiretroviral treatment in three South African settings, reported Sydney Rosen and colleagues in a study presented at the Fifth IAS Conference on Pathogenesis, Treatment and Prevention in Cape Town, South Africa in July.

While improved survival and reduced mortality are proven outcomes of antiretroviral treatment programmes, long-term sustainability for resource-constrained countries is likely to be viewed more positively when treatment allows individuals to remain economically active.

Economic analysis and cost-effectiveness studies can provide ministers of finance in resource-constrained settings with important tools as they face difficult budgetary decisions relating to health and social concerns.

Monitoring the numbers of those returning to work or school following antiretroviral treatment is important in order to justify and support budgetary outlays and to project the potential positive impact of expanded treatment on a country’s growth and development.

A five-year prospective cohort study of the economic and social outcomes of antiretroviral treatment in South Africa was undertaken by Sydney Rosen and colleagues from Boston University, Center for International Health and Development.

A random sample of 1069 adult patients, who were either waiting for treatment or on treatment for less than six months was enrolled from three study sites in Gauteng and Mpumalanga Provinces in South Africa.

Enrolment took place during 2005 and 2006. Interviews were conducted up to four times a year during routine clinic visits to assess ability to perform normal activities, general condition, employment, income sources and costs of obtaining treatment.

Analytic data (up to September 2008) included all interviews conducted between one month (30 days) before starting ART and three years (1080 days) after beginning ART.

Women account for approximately 80% (845) of the cohort with a mean age of 33.6 years and 37.4 years for men. Twenty-two per cent of women and 19% of men were employed in the formal sector; 21% of women and 22% of men were seeking work or unemployed. Just over 50% had permanent housing or lived in a flat.

The prevalence of pain, fatigue, nausea and skin problems decreased steadily over the entire three years on antiretroviral treatment. The probabilities of pain and fatigue fell from 74% to 29% and 75% to 11% respectively and the probabilities of nausea and skin problems fell from 31% to 4% and from 50% to 9% respectively.

The inability to perform normal daily tasks decreased steadily from 50% to 20% over a period of a year and from 20% to 8% after three years. No difference was seen by age or gender.

The probability of having a job increased over time on antiretroviral treatment from 29% in the month before starting ART to 47% after three years. Significant differences were apparent after one and a half years on ART. There were no differences according to gender but the probability of being employed increased with age.

Important limitations noted by the authors include the high rate of loss from the treatment programme as well as significant loss to follow-up.

In addition data collection (interviews) depended on the unpredictable situation of catching patients at the time of their clinic visits. The number of interviews per patient as well as intervals between interviews can vary considerably. The analysis did not include patients who died, discontinued treatment or who transferred to a different site.

The authors conclude “Improvement in economic outcomes appears to be substantial by end of the first year on ART and is sustained or increased over the second and third year”.