Fehmida Visnegarwala, MD, MPH 1,2, Anuradha Nalli 1, Ram Babu 1, Saranya Satish 1, Lekha Pradeep 1, Glory Alexander 1 1 ASHA Foundation, Bangalore, & 2 Institute of Health Management Research, (IHMR)-Bangalore Impact of Anti-retroviral Therapy (ART) on Socio-Economic (SES) productivity of HIV infected individuals in an Urban Indian Private Setting A MOPDE02 Presented at Presented at XIX International AIDS Conference July 2012 | Washington D.C., USA

Background and Methods HIV/AIDS, leads to impoverishment due to both direct/indirect costs of illness. In countries such as India, the maximum socioeconomic impact due to HIV/AIDS is felt only at the household levels. The use ART has translated into substantial cost-effectiveness at the societal level, but the overall impact of ART on productivity of households of PLWHA are limited. Thus we sought to evaluate the effect of ART on an urban sample of Indian households, with particular emphasis on individual and household productivity, acquisition of fixed and liquid assets, and overall socioeconomic status using a comprehensive assessment tool. This tool is a well-validated tool to assess SES in the Indian setting. 1  Since 2007, ASHA Foundation, (a NGO in Bangalore, India) has implemented the above SES assessment tool for evaluation of free-ART eligibility under PPP model. This tool was filled by trained social-workers during a face-to-face interview with the patient, before ART initiation at ASHA foundation.  Description of the Tool: There are a total of 22 questions, which assess monthly household: income; educational status of parents and children and societal and professional positions held; occupation; number of earning members; the kind of dwelling; number of children; family Possessions, i.e., urban, agricultural or non-agricultural land and animal stock; type and locality of residence; income tax paid; caste; deployment of domestic help among other things. The highest score attainable is 100 and lowest score is 5. The social status is then divided into 6 strata based on total score as lower, middle and upper class. 1 : Agarwal OP, J of Community Medicine 2005 Abstract number:

Study Design and Statistical Analysis Fehmida Visnegarwala, Abstract number:  The SES status, demographic, clinical and adherence data were collected in both retrospective and prospective manner.  The study was approved by the ethical review board, and data in the prospective study was collected after obtaining written informed consent. All measures to preserve the confidentiality of subject identifiers were taken. Sample Size Calculation Our objective was to evaluate the mean change in SES scores. Thus to detect a mean delta in SES scores of 2.5 pre and post ART; with 80% power and a 2- sided alpha of 0.05 with a paired sample t-test, a sample size of 69 was required. We followed a cohort of 136 patients. Statistical Analysis Descriptive statistics were used to analyze the frequency of data. The pre and post scores were compared using “paired t-tests. Correlation coefficients were done as well. Univariate regression analysis was done to evaluate factors predictive of highest quartile increase in SES score. Those factors significant at 0.2 level of less were placed in multivariate analysis. All study data was transcribed in a Excel Database and analyzed by SAS. Retrospective Data on Baseline SES Questionnaire filled in 2007 or Earlier HAART Initiation Prospective Follow up SES scoring done using the same tool at 6 and 18 months after ART An ambi-spective (both retro and prospective) cohort study design

Results-I At the end of two years 136 patients had continuous follow-up. The median follow up of both the retrospective and prospective components of the cohort was 58 months. From highest score change of + 27 to – 9 was recorded. Overall the median change in score was +3 which was significant. Overall 115 patients had an increase in the Total SES score. The change in monthly income score also was significant. The change was sustained over 18 months

Results-II 5 P<0.001

Fehmida Visnegarwala, Abstract number: Results-III Correlation between Change in CD4 and Change SES r = with P = Correlation between Change in Weight and Change in SES r = 0.22 with P = The univariate analysis of factors predicting highest quartile change in SES scores: change in CD4, change in weight was positively associated while being a housewife was negatively associated. On multivariate analysis, only being a housewife ( % CI; p<0.05) remained significant.

Discussion and Conclusion Overall > 95% of our patient cohort had 100% adherence to ART Use of ART is associated with significant improvement in the overall household incomes of PLWHA regardless of the costs incurred for HIV Care This change in SES status is associated with increase in CD4 and increase in body weight suggesting that improvement in clinical parameters with ART are associated with better economic productivity. This prospective cohort study showed, that this improvement in income appears to be sustained even after more than 18 months of ART, this to our knowledge is the longest median duration of f/u after ART initiation. Not surprisingly, being a housewife was independently associated with non- improvement in the SES scores. Our Data are consistent with other studies from Africa which show a significant improvement of SES, and thus the overall quality of life with the use of ART, which can be used to increase the overall uptake of ART and its adherence in the developing countries. Overall these data have significant policy implications in scaling up of ART in the national and global perspective especially when we can bring this bend to fight the stigma and discrimination for ART take up.

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