1 Introduction

Over the last three decades, the health systems of less developed countries (LDC), which were already very weak and unable to satisfy their citizens’ basic needs, have been put to the test because of the HIV/AIDS pandemic, which has hit the countries of sub-Saharan Africa in particular.

HIV/AIDS represents a serious social problem. The pandemic has a strong impact on the societies and on the economies of the countries that are most badly affected by the virus [1]. In the LDCs the pandemic is gradually thwarting the progress towards development which, despite countless difficulties, was slowly happening over the last years.

The negative impact of the AIDS pandemic on economic growth has been widely studied [2,3,4]. However the question remains: what is the best approach for reduction of the effects of the pandemic and possible elimination of the virus?

The evaluation of the cost-effectiveness or cost-benefit ratios is therefore a fundamental aspect in evaluating the best approach to adopt in fighting AIDS and especially how to assess the sustainability of HIV/AIDS programmes. In the literature however, there are only a few evaluations of the positive impact of AIDS treatment programmes adopted to reduce its negative effect on health [5,6,7] and on the economy [8,9,10].

This chapter analyses the impact of the DREAM programme that mixes antiretroviral therapy with a range of correlated services (psychosocial support, health education, nutritional support), on the social, economic and working conditions of HIV+ patients.

ARV (antiretroviral) therapy, administered correctly, greatly reduces morbidity and mortality in people with HIV, both in developed countries [11,12,13,14] and in LDC [15,16,17,18].

The treatment has a positive impact on income first of all because it makes it possible for people who had been weakened by the disease to be reintegrated into the workforce, thus increasing the work offer, and secondly because together with increased income, there is also a reduction in expenses related to the disease; therefore both public and private savings and investments increase, both in terms of physical capital and human capital. So it is advisable, also in order to provide a useful instrument for cost-benefit analyses in this field, to analyse the impact of the programme on the work offer and average income.

In this analysis, the study population was selected from a cohort of patients enrolled in the DREAM programme in Malawi, in two ART centres both in rural and urban settings (the Mtemgowamtemga centre in the rural area of Dowa, Lilongwe and the Blantyre centre, the largest trading town, respectively) with the following inclusion criteria: HIV positivity, age >15 and ART initiation within 2 months of enrolment.

Forms provided by the Medical Outcomes Study HIV Health Survey (MOS-HIV) [19] and WHO performance questionnaires [20] were used to design the questionnaire. General principles used in social research questionnaires were also applied [21]. These forms were then adapted to meet specific requirements for this study. The income was reported by respondents in Malawi Kwacha and then converted to USD at purchasing power parity (PPP) using criteria adopted by the WHO for economic analysis in health programmes [22]. A patient self-evaluation of their own health and economic status was taken into consideration to counterpose information coming from the economic data.

Most of the people selected were women (70%). Nonetheless this composition of the study population reflects the general situation regarding HAART recipients in sub-Saharan Africa [23].

A total number of 165 subjects were followed from January 2008 to March 2009. All subjects had at least 8 months of follow-up post-ART initiation.

A certain loss was observed at the follow-up (23%), mainly due to the patients’ work and social mobility. Nonetheless, considering the low number of people lost to follow-up, and considering the fact that the cause of this loss did not concern their state of health, these patients were excluded from the analysis. The patients who were excluded presented a similar state of health and economic situation as those who were included.

Health, income and productivity parameters were evaluated through paired t-test.

2 Results

The overall health status of subjects improved significantly based on clinical and virologic parameters (see Table 8.1).

Table 8.1 Clinical and virologic parameters of the sample
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The main impact observed was in the variation of mean HIV-1 RNA (viral load). In fact this parameter reacted to therapy before the other ones, which has biological plausibility. Nonetheless there was also a significant difference in mean CD4 cell count levels. Since this parameter measures the strength of the person’s immune system, it is a clear indicator of his/her state of health. In fact it is more likely that a person with a high viral load (negative information) but who also has a high number of CD4 cells will feel better than a person with a low number of CD4 cells and a low viral load. Actually, the most predictive variable of good health is the BMI (body mass index). Nonetheless this variable responds more slowly to therapy, and above all it is greatly influenced by external factors like a good diet. Although the haemoglobin value is strongly related to antiretroviral treatment, it can also be influenced by many other factors.

Looking at the socio-economic data generated, a positive overall impact on productivity and income was noted. Hours worked in the last week increased by 25%, hours worked in the last month increased by 31%, income generated in the last week increased by 85%, and income in the last month increased by 80% (Table 8.2).

Table 8.2 Impact of treatment on work offer and income
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For patients who were unemployed at baseline (n = 37), mean income was too low (<4$ per month) to be relevant for the analysis. With the exclusion of unemployed patients at baseline, the increase in last week/last month hours worked was +35% and +43%, respectively, and last week/last month income +93% and +89%, respectively (+400$ per year).

2.1 Patient Self-Evaluation

The patient’s answers to control questions asked during the second round of interviews confirmed the results of the analysis. The answers regarding their economic condition are distributed along a normal curve (Fig. 8.1); however, looking at answers regarding the variation of their economic situation with respect to the previous 10 months (Fig. 8.2), most patients interviewed said their situation had improved (43.3%), and only 25.3% said that it was worse. One has to bear in mind that these were ill people and that over the period during which the interviews were carried out, there was a serious economic crisis that hit many African countries and in particular the most vulnerable populations. In fact the crisis was caused by an increase in the cost of fuel, and therefore of transport, and by the rapid and high increase in the price of cereals, the basic element of the Malawian diet. This crisis set off revolutions in Malawi and also in neighbouring countries. So it is remarkable that in such a serious situation, and on a sample of people who are vulnerable because of disease, less than one third of the subjects said that their situation had become worse.

Fig. 8.1
figure 1

Perceived economic situation

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Fig. 8.2
figure 2

Perception of variation in economic situation

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Once the socio-economic situation of the study population was assessed through the variation in work offer and income, there was still the problem of characterising health, that is, improvement in health due to AIDS treatment, as the main cause of this phenomenon. It was considered appropriate to evaluate whether the patients themselves considered their state of health an important reason, if not the main reason, for the changes in their socio-economic situation. Those who said there had not been any particular changes in their situation over the previous 8 months were excluded from the analysis.

The answers reported in Fig. 8.3 indicated health as the main reason behind both positive and negative changes (54.6%); 46.5% said their health improved and also their economic situation. However 7% said that their health improved but that their economic situation did not. This reflects what was mentioned before that, during the study period, there was an economic crisis in Malawi, so even though the health of participating subjects improved, due to other reasons, their economic situation did not improve.

Fig. 8.3
figure 3

Causes of variation in economic situation

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3 Conclusions

The main objective of this study was to measure the impact of HIV/AIDS treatment administered in the DREAM programme on one of the most important aspects of development and economic growth: productivity, that is, work offer and increase in income. Of course income is just one of the factors involved in economic development, and the HIV/AIDS epidemic also reduces development through its impact on other fundamental factors. Nonetheless this is one of the aspects of development where the outcomes of actions taken to counter the disease can be noted and measured.

The mean increase of approximately USD400 is very important within a cost/benefit analysis. The cost of antiretroviral therapy, including the diagnostics, in large-scale programmes using generic drugs, is in fact around this value per year. This means that the cost of therapy is completely covered simply because of the increase in income due to therapy itself. However this calculation does not take into consideration the fact that without therapy the patient’s health would probably get worse, so his capacity to work would be further reduced. The decline in productivity due to the worsening of the state of health cannot be measured directly because ethical issues would arise. In fact, a control group should be monitored, which would not be given therapy even if needed. The value of this loss should be added to the benefit derived from the therapy estimated at USD600. This study does not even calculate the indirect effects of this action, for example, related to the savings for the state in terms of hospitalisation costs for the patients, the costs saved by the companies with respect to the turnover of employees due to high mortality, the impact on public expenditures and income tax and all the other negative effects of AIDS described in Chap. 1.

In conclusion, the treatment of AIDS is completely sustainable from an economic point of view; actually it can really be considered an investment with a high return in human capital.