1. Reproductive Health, HIV/AIDS and Poverty Peter Glick Cornell University, USA pjg4@cornell.edu

2. Reproductive Health (WHO definition ) A state of physical, mental, and social well-being in all matters relating to the reproductive system at all stages of life

3. Reproductive Health Services (RHS)—‘standard’ and other Family planning Maternal/antenatal care STI treatment HIV/AIDS prevention, testing and treatment Condom provision/promotion Male circumcision Most of the HIV programs above are typically not part of standard RHS provision, but some argue they should be.

4. Interrelationships of Poverty, Reproductive Health, and HIV/AIDS Poverty HIV incidence/ prevalence Reproductive Health Services/ HIV interventions Reproductive/ sexual behaviors & knowledge Reproductive Health (non-HIV STIs, etc.)

5. What do we know about the links? Evidence Policy issues Methodological approaches Gaps in knowledge: for further research –Focus on what is useful and feasible for this project and for AERC researchers

6. HIV incidence/ prevalence Reproductive Health Services/HIV interventions Reproductive/ sexual behaviors & knowledge Reproductive Health (non-HIV STIs, etc.) Pathways from reproductive health (and RH/HIV interventions) to HIV/AIDS

7. Male circumcision: Possibility of ‘risk compensation’ Our focus is on behavioral factors. Even for essentially medical interventions these can be important.. Antiretroviral (ARV) therapy:  Lower infectivity but increased sexual activity of the treated  Among others: ‘Treatment optimism’ effects on behavior Impacts of HIV interventions:

8. Voluntary counseling and testing (VCT) Behavioral interventions/services Information campaigns (e.g., ‘ABC’ approach) Condom provision, condom social marketing Other behavior change/education interventions Family planning/antenatal care (‘standard’ RHS)

9. Individual level randomization not very common, in part due to ethical considerations  VCT study (Kenya, Tanzania): reductions in risky sex among those who test positive and in serodiscordant couples, less among negative testers  Male circumcision - ANRS Trial (S. Africa): cuts HIV acquisition by 2/3 Methodological challenges to evaluating behavioral HIV interventions Randomized control trials (RCT) ideal Community level randomization:  Captures effects of local interactions and externalities—through social networks, learning  Intention to treat: accounts for uptake of programs

10. STD control: Masaka and Rakai, Uganda; Mwanza, Tanzania – Does efficacy varies with stage of the epidemic? Community (or group) randomized trials School HIV education programs Rakai, UG; Mwanza, TZ; rural Western Kenya; rural E. Cape, S. Africa – Mixed findings for bio endpoints, behavior Many other studies use a variety of non-experimental evaluation approaches: pre-,post-test designs, comparison groups, and (less commonly) instrumental variables, propensity score matching

11. Gaps in knowledge about impacts of HIV prevention strategies ‘ABC’ or just ‘C’? or just ‘A’? Behavioral impacts of ARV provision Efficacy of programs aimed at youth Advantages and disadvantages of integration of standard RHS and HIV prevention and care Mandatory/routine testing vs. VCT (opt out vs. opt in testing) For many of these, social scientists can link up with planned interventions to assess behavioral outcomes.

12. Feedback linkages: HIV prevalence to reproductive/sexual behaviors Effects on sexual risk behaviors (may have occurred in Uganda and elsewhere, though hard to separate from effects of prevention campaigns): Delayed age at first intercourse Reduction in number of partners Increased use of condoms Effects on fertility not clear: Reduction via reduced fecundity of HIV+ women Reduction via fall in desired number of children (A. Young) or increased prevention behavior (e.g., increase in AFI)..? Increase via, e.g., ‘precautionary demand’ motive..? Can examine the above using multi-country data (repeated DHSs) matched to HIV trends, or smaller multi-year datasets

13. Poverty HIV incidence/ prevalence Reproductive Health Services/ HIV interventions Reproductive/ sexual behaviors & knowledge Reproductive Health (non-HIV STDs, etc.) Pathways from poverty to reproductive health, services, and behavior and to HIV/AIDS

14. Poverty impacts on HIV/AIDS Potential impacts on HIV via reproductive health or risk behaviors and knowledge: The poor are Less likely to know about prevention behaviors Less likely to have had an HIV test Less likely to have access to condoms More likely to have untreated cofactor STIs Other pathways: The poor are more likely to have poor nutrition and health that can compromise immune defenses or increase receptivity to HIV infection

16. Yet both within and across countries in Africa, HIV tends to be associated with greater wealth, not less… HIV prevalence is highest in relatively wealthy countries of Southern Africa (Botwana, S. Africa) More compelling: numerous recent DHS surveys with serotesting, as well as some earlier micro evidence, show generally positive associations of HIV prevalence and wealth Why is a positive association of wealth and HIV observed?

17. The wealthy (and better educated) are more likely to have multiple concurrent partners:

18. The better-off in Africa : Can ‘afford’ more sexual partners (having multiple partners is a ‘normal’ good) Are more mobile Less causally: HIV prevalence is higher in urban areas, which are wealthier HIV+ who are wealthy tend to survive longer, so more likely to show up in surveys

19. Impacts of Poverty on HIV/AIDS in Africa: Gaps in knowledge A development/HIV prevention conflict? Individual social/economic mobility increases HIV risk – Should prevention policy target the better off? Does the poverty-HIV relation change as epidemics mature? Direct effects of wealth vs. structural/community cofounders Dealing with dynamics and simultaneity in estimation: HIV causes household impoverishment—limitations of cross section analysis Can analyze (many of) there issues w/DHS, other surveys

20. Linkages from HIV/AIDS to poverty: Macro level perspectives Pathways: effects on supply of skilled labor, public budgets, firm investment, investments in education => (in theory) reduced growth, increased poverty Cross country regression analysis (data through mid,late 90s) suggest no or ambiguous effects on per capita economic growth. But for longer term impacts: Model results in conflict:  ‘First generation models’: little effect on per capita growth b/c of mortality: GDP falls but so does number of workers  A ‘reduced fertility dividend’? (Young)  But other models (Bell et all.) predict huge falls in per capita growth via collapse of investment in human capital, institutions

21. Effects on income: Reduced labor supply, incomes or farm production, and Health care expenses (S. Africa:1/3 household income); funeral expenses => Reduced consumption Effects on children: Lower investments in schooling due to income, labor stresses Orphanhood => lower schooling:  multicountry analysis by Monasch and Boerma, 2004, Case et al., 2004  Panel analysis for Kenya (Evans & Miguel) finds larger negative effects Linkages from HIV/AIDS to poverty: Micro/household level perspectives

22. Impacts of HIV/AIDS on Poverty: Gaps in knowledge Intergenerational effects: education, health, socialization Can analyze (many of) there issues w/DHS, other surveys But panel data especially valuable Effects on fertility (micro), demographic transition (macro) Modeling to predict long run economic, poverty effects –Depends directly on parameters for behavioral responses (so good micro studies are essential) Coping mechanisms: effects on family/household structure, savings –How robust are family/community safety nets?