Edward Mills

1. Microfinance opportunities to improve quality of life and clinical outcomes among HIV+ patients in Africa Edward Mills

2. Microfinance as Pathway to Health • Increased income and financial stability has been conceptualized as a primary pathway to improve health • Purchase more and better quality food • Sustainable access to medicines • Structural improvements to home • Increases in educational attendance • Reductions in sexual and physical violence

3. HIV/AIDs and Poverty • Economic impact of HIV/AIDS to both families and societies can be devastating • Estimated that when HIV affects African households, its income can drop between 30-50% • Increased spending on health care • Lost productivity to care-seeking and care-giving • Clients tend to liquidate their assets to cope with financial exigencies • More single parent households • Clear link between HIV/AIDS and increased food insecurity and malnutrition • Reduced school enrollment via ability to pay school fees

4. Poverty Alleviation Strategies • Microfinance programs • Definition: provides a wide range of financial services including training, savings accounts • Microcredit programs • Definition: small loans to support entrepreneurship, empower disadvantaged populations • Cash Transfers/Payments • Definition: provisions of small cash grants. • Unconditional: without restriction • Conditional: conditional on some behavioural requirements

5. Financial Advice • Open Bank Accounts • Possibility for future investments Microfinance Microcredit Cash Payment • Grants • Loans Unconditional Conditional Before After • Conditions to qualify for the grant • Given incentives for meeting specific targets

6. Innovations for Poverty Action • Leading nonprofit organization that designs and evaluates economic programs and brings successful programs to scale in over 35 countries • Project areas • Agriculture • Charitable Giving • Education • Governance & Community Participation • Health • Enterprise • Water & Sanitation

7. Microfinance Interventions • 2 articles on the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) • Site: South Africa • Participants: Women 14-35 years • Intervention: Loans for groups of 5 women with HIV training • Outcomes of Interest • HIV communication, VCT, Sexual Risk • Results: Significantly higher levels of HIV communication, more VCT, less sexual risk • Social capital • Results: Not statistically significant, however qualitative data indicate increased social capital

8. Microcredit Interventions • 1 Study • Site: South Africa • Participants: female and male applicants who had previously been denied loans • Intervention: give loans with 4-month maturity • Outcomes of Interest • Stress Scale, Depression • Results: Significantly higher stress in men and women • Results: Reduced depression – significant in men, not in women

9. Cash Payment - conditional • 4 studies evaluating child health outcomes • Sites: Mexico, Brazil, Honduras, Nicaragua • Participants: Households with Children ≤10 • Interventions: Cash payments to parents conditional onattendance at a pre-existing health program • Successes • Significant reductions in child behaviour problems • Significant increase in vaccine uptake • Significant increase in antenatal care • Null • Anthropometric measurements: BMI, height-to-weight etc • Concerns • In one study, children in the treatment arm lost weight because parents feared that they would be discontinued from the cash payments if child met developmental targets

10. Cash Payment - unconditional • 1 Study • Site: Urban and Rural Ecuador • Participants: youth aged 12-35 years • Intervention: Individuals in treatment group received $15, comparison group received treatment 2 years later • Outcomes of interest • Language skills • Results: Rural children had significantly better language development, non-significant for urban children • Anthropometric scores: height-for-age, hemoglobin concentration • Results: No significant differences

11. Can conditional cash transfers increase testing and decrease risk behaviours? • Randomized trial; Damien de Walque, 2012, BMJ open • Site: Tanzania • Participants: Men and Women aged 18-30 years • Intervention: Participants received cash transfers dependent on negative HIV/STI test results every 4 months (RESPECT) • Low cash value ($10) per HIV/STI test • High cash value ($20) per HIV/STI test • Control • Outcomes of interest • HIV/STI infections • Results • Intervention significantly reduced new infections: • High vs control: aRR=0.73 (95% CI:0.47-0.99) • Low vs control: aRR=0.69 (95% CI: .45-0.92) • Conditional cash transfers to incentivize safer sexual practices are potentially a promising new tool in HIV/STI prevention

12. Can cash transfers conditional on school attendance decrease HIV prevalence? • Cluster randomized trial; Baird et al., 2012, Lancet • Site: Malawi • Participants: Adolescent schoolgirls aged 13-22 years and their parents • Intervention: Young women received $1-5 monthly and parents received $4-10 • Conditional: school attendance • Unconditional • Control • Outcomes of interest • HIV and HSV-2 infections • Results • No difference between conditional and unconditional • Intervention significantly reduced: • HIV (aOR:0.36, 95% CI:0.14-0.91) and • HSV-2 infections (aOR: 0.24, 95% CI: 0.09-0.65) • Structural interventions that do not directly target sexual behaviour change can be important components of HIV prevention

13. Can conditional cash transfers decrease new HIV infections? • Randomized control trial; Kohler, 2011, World Bank Economic Review • Site: Malawi • Participants: Men and Women aged 14-24 years • Intervention: Participants were given a voucher and if they maintained they HIV- status a year later would get the cash • Low cash value ($10) per HIV/STI test • High cash value ($20) per HIV/STI test • Control • Outcomes of interest • HIV/STI infections • Results • Intervention did not reduce number of new HIV infections: • Men receiving cash transfers were more likely to engage in risky sex • Women were less likely to engage in risky sex • Conditional cash transfers to incentivize safer sexual practices are potentially a promising new tool in HIV/STI prevention

14. Can conditional cash transfers improve testing uptake and condom purchase? • Randomized trial; Thornton, 2008, American Economic Review • Site: Malawi • Participants: Adults • Intervention: Participants offered free door-to-door testing given a voucher redeemable after obtaining HIV/STI test available 2-4 months later, also given voucher for condoms • Voucher: $1-3 • Voucher: $0 • Outcomes of interest • Getting HIV test results • Among HIV+ buying condoms with voucher • Results • Treatment arm more likely to go and pick up test results • Receiving HIV diagnosis in the study was associated with increased condom purchase

15. Uganda, Wagner et al. • Glenn Wagner at RAND performed a randomized trial of 192 ART receiving patients in Kampala and Soroti • Seminar to teach about microfinance opportunities • Low uptake

16. Uganda, Thirumurthy • Transportation assistance • Behavioral Outcomes. medication event monitored system (MEMS) defined treatment interruptions. Mean adherence, ARV drug possession ratio, and missed/late clinical encounters will be secondary outcomes. • Biologic Outcomes. HIV viral load. • Economic Outcomes. Total hours worked per week. Secondary outcomes will be participation in the labor force, household consumption, monetary transfers, hours of school attended per week and hours of child labor per week by children in patients’ households

17. Summary of Outcomes • General health outcomes of interest • Mental health & stress • Intimate partner violence • Nutritional status for recipients children • HIV related outcomes • HIV counseling and testing • Unprotected sex, intergenerational sex • STIs: HSV-2, syphilis, chlamydia, gonorrhea • HIV Incidence • None measure the impact of microfinance interventions on HIV clinical outcomes • Virological Suppression • CD4 count • Adherence

18. Critiques of Microfinance strategies • Sustainabilityof cash transfers • Many studies are short term • Don’t know how they would look in long term • Microcredit • Challenging for poor populations to pay back loan if business fails • Does extra disposable income increase risky behaviour? • Malawi – increased sexual risk among men • Brazil – perceptions that they would be discontinued if children met growth targets • Low control over sexual risk • Programs contingent on maintaining negative status rely on agency • Most at risk would be discontinued from program

19. Empowerment through Positive Living • Objective • To evaluate the effectiveness of microfinance grant opportunities for 2000 people living with HIV in Uganda • Design • Open-label randomized trial with blinded analysis

21. Study Design • >18 years • Intervention: 350,000 UgX, (~130 USD) • Data collection: Baseline, Midline, Final • Baseline questionnaire • Clinical assessment • Household assessment • Blood sample

22. Study Outcomes Primary Outcomes • HIV RNA Viral Load • Treatment Adherence • CD4 T-cell changes • Quality of Life Secondary Outcomes • Food Security • Household income • Savings accumulation • Time allocation • Sexual Behaviour • Child Education Attendance

23. Impact • Study will be the first to evaluate the interaction between socioeconomic wellbeing and health outcomes for HIV patients • Economic Innovations • Unconditional grants to start a business • Cash payment • Cash payment + planning • Waitlist controls who have 1 year to plan • Control • Do grants improve the ability to withstand daily challenges: • HIV specific outcomes • Household economics (e.g. food security)

24. Conclusions • Microfinance interventions have shown mixed resultson the effects on HIV risk including new infections, testing, and sexual behaviour • Many studies have included people living with HIV and how microfinance programs can improve peoples lives • None have focused on clinical outcomes • If we can’t treat our way out of this epidemic, can we buy our way out?

25. Acknowledgements Collaborating Institutions • Innovations for Poverty Alleviation (IPA) • The AIDS Support Organization (TASO) • University of Ottawa • Yale University • University of British Columbia • BC Centre for Excellence in HIV/AIDS • McMaster University • World Health Organization • University of Maryland • University of Michigan Funding • Canadian Institute for Health Research Collaborators • Dean Karlan • Gordon Guyatt • Julio Montaner • Monica Taljaard • Curtis Cooper • William Cameron • LehanaThabane • SanniYaya • Evan Wood • AchyutaAdvarhyu • Pamela Jakiela • Nathan Ford • Jonathan Wangisi • Teddy Chimulwa • Stephen Okoboi