Microfinance opportunities to improve
quality of life and clinical outcomes
among HIV+ patients in Africa
Edward Mills
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
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
Poverty Alleviation Strategies
1.
Microfinance programs
 Definition: provides a wide range of financial services
including training, savings accounts
2.
Microcredit programs
 Definition: small loans to support entrepreneurship,
empower disadvantaged populations
3.
Cash Transfers/Payments
 Definition: provisions of small cash grants.
• Unconditional: without restriction
• Conditional: conditional on some behavioural
requirements
•
•
•
Microfinance
Microcredit
•
Financial Advice
Open Bank Accounts
Possibility for future
investments
Cash Payment
•
Loans
Conditional
Before
After
• Conditions to
qualify for the grant
•
Grants
Unconditional
Given incentives for
meeting specific targets
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
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
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
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 on
attendance 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
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
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
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
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
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
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
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
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
Critiques of Microfinance strategies
•
•
•
•
Sustainability of 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
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
4˚
hi t
le )
NI
KITGUM
ARUA
GULU
PADER
Gulu
Ag
a
go
ctoria Nile
Vi
APAC
N
Lu
K afu
HOIMA
ON
KABA
RO
KAMWENGE
S EM
IGANGA
M PIGI
✈
MBARARA
Entebbe
WAKISO
MASAKA
Damba
Bugala
MUKONO
Sese Is.
Mbarara
RAKAI
KALANGALA
NTUNGAMO
U
KIS O
R
O
Ka
KABALE
g era
Lake Victoria
oi a
KENYA
Sigulu
Kalangala
Bungoma
Nz
Buvuma
Kome
Masaka
Tororo
0˚
Lolui
BUGIRI
RI
NG
GI
KANU
RUKUN
BUSHENYI
ga
Kitale
TORORO
Jinja
MAYUGE
Ibanda
LE
ga
zin l
K a an n e
Ch
Lake
Edward
BA
to n
BU
L. George
Ka
Mbale
Iganga
Kampala KAMPALA
Kapchorwa
KAPCHORWA
MBALE
JINJA
MUBEN DE
Namalu
NAKAPIRIPIRIT
PALLISA
KAMULI
Bombo
Mubende
KYENJOJO
Kasese
0˚
LUWERO
LE
Kumi
Kamuli
✈
IB
ND
BU
KASESE
KIB A A LE
Katakwi
L. Bisina
Soroti
SOROTI
Lake Kyoga
A
Fort
Portal
LA
KIBOGA
2˚
O
UG
M
KUMI
KAYUNG
Se
i
m li k
YO
B
A
ER
ria
cto N i l e
Nkusi
GO
Lothaa
KA TA KWI
AI
KA
AS
M OROTO
SIR ON K
Hoima
AK
e
Vi
Itu r i
Al
go
La
ke
Ok
SIA
be
Bunia
LIRA
Lake
Kwania
Masindi
oto
BU
rt
M ASINDI
or
DO
CONGO
i
(M
Lira
Winam Gulf
n
o
DEMOCRATIC REPUBLIC
OF THE
Moroto
a
r
Acu
w
Okok
NEBBI
Sha r
KOTIDO
Kotido
✈
Arua
Ora
2˚
g
e
Pa
JU
MA
Kitgum
AD
A lb
Kiba
li
le
Ni
th
YO
ert
MO
Ni
ingo
Ar
ule
m
YUMBE
KENYA
Lopodi
Dope
Ni
e
✈
SUDAN
W
el (
National capital
Town, village
Airport
International
boundary
District boundary
Main road
Secondary road
Railroad
a
g
n
fa
M
Study Design
Eligible
Participants
• >18 years
N=2000
Unstructured
Grant
Grant +
Planning
Pure
Control
Control with
Expectation
N=500
N=500
N=500
N=500
Intervention: 350,000 UgX, (~130 USD)
Data collection: Baseline, Midline, Final
• Baseline questionnaire
• Clinical assessment
• Household assessment
• Blood sample
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
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)
Conclusions
• Microfinance interventions have shown mixed results on
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?
Acknowledgements
Collaborators
• Dean Karlan
• Gordon Guyatt
• Julio Montaner
• Monica Taljaard
• Curtis Cooper
• William Cameron
• Lehana Thabane
• Sanni Yaya
• Evan Wood
• Achyuta Advarhyu
• Pamela Jakiela
• Nathan Ford
• Jonathan Wangisi
• Teddy Chimulwa
• Stephen Okoboi
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