The Socio-demographic Characteristics & Economic Impact of HIV/AIDS Using
Different Econometric Measures in two Gov in Egypt
*Alaa El Din Ghanaam (M.D) , Abeer Barakat, MD**, Soad M. El Sayed ***
*Health and Human Program Director Health Economist & Director of General
Department of policy and Strategies of STSP, MOH
**Assistant Professor of Health Care Management and Health Economics, Public
Health, Department, Faculty of Medicine, Cairo University.
***Public Health Research specialist, International Public Health Consultant.
1. Introduction
HIV’s prevalence in Egypt is considered to be relatively low, with estimates around 0.02 percent
of the general population, which is approximately 9,213 people, suffering from it. But
preconditions for a wider epidemic exist, according to the UNAIDS office in Egypt.
Egypt still faces several challenges in maintaining low prevalence of HIV/AIDS. Egypt also
receives millions of tourists and refugees from countries with high HIV prevalence and/or illicit
drug use rates. In addition, there are pervasive fears and stigmatization of HIV/AIDS and a lack
of effective STI/HIV/AIDS education programs and other preventive measures, such as peer
education and outreach and behavior change communications among at-risk groups, "Health
Profile: Egypt". United States Agency for International Development (March 2008). Accessed
September 7, 2008>]. In addition, an increase in the incidence of HIV-TB co-infection could add
to the complexity of fighting both diseases in Egypt. "Health Profile: Egypt", United States
Agency for International Development (March 2008). Accessed September 7, 2008]. In addition,
there are high risk factors that create an ideal environment for the rapid spread of HIV. These
factors such as Overpopulation, especially in the age bracket of 15–24 who constitute 50
percent of HIV patients, Poverty, Illiteracy in the general population particularly among women,
weak health system despite huge infrastructures, Egypt has a very high level of Hepatitis C
infection, a virus with similar modes of transmission to HIV, Most reported HIV cases are
transmitted through unprotected heterosexual sex , 90% of Egyptian women who live with HIV
were infected within marriage.
Relationship between the Prevalence and Economy
The impact of the HIV/AIDS epidemic on the economy has been a concern since the beginning of
the pandemic. Studies show GNP growth could decrease by more than 1 percentage point for
every 10 per cent HIV prevalence. According to a World Bank study of nine Arab countries, the
current level of response to the epidemic will result in a fall in gross domestic product (GDP) of
30–40% over the coming years, leaving those countries under the poverty line.( 1 Jenkins, C. and
Robalino, D.A., 2003, The Cost of Inaction.)
Others take the view that HIV/AIDS has had little impact on the macro-economy so far. It is
difficult to estimate empirically the effect of HIV/AIDS on economic performance since so many
factors other than HIV/AIDS affect economic growth.
If we add the economic value of health as an aspect of “economic welfare”, which by definition
is not a matter of income alone, Empirical assessments of societies' willingness to pay to avert
an adult death have found values ranging from about 75 to over 180 times per capita GDP
(Jamison, Sachs and Wang, 2001). Therefore, the value attached to actual mortality changes can
be large in relation to the size of conventionally measured trends in GDP. If we add the view of
Egyptian economy and effect of global crisis in donations for Developing Countries, the outcome
will get worse.
1.1 Poverty and Health in Egypt
About one fifth (19.6%) of the Egyptian population lie in poverty, among them 3.8% of the
population are in extreme poverty, Poverty is concentrated in the rural sector and in Upper
Egypt where 77% and 62% of the poor are present, respectively. Out of the poor 55% work in
agriculture and 9% work in construction, studies show that poor spend 2.9% of their total
expenditure on health (LE 213) and 1.96% (LE 196) in education and Their expenditure on food is
54% (LE 3966).
1.2 Four Channels through which HIV/AIDS may Affect the Economy
Authors identified four channels through which HIV/AIDS may affect the economy: the
production channel; the allocation channel; the distribution channel; and the regeneration
channel. The impact of HIV/AIDS on labor force becomes more eminent if it affects hard-toreplace skilled labor and/or if there is no substantial pool of “surplus labor”. Reducing the size of
the working population tends to reduce total output and worsen the dependency ratio.
HIV/AIDS reroutes some of those resources to medical expenses and away from other
productive uses. The medication cost rises by time and differs among countries.
In addition to HIV/AIDS epidemic that increases health expenditures and weakens the income
base, the lowest income groups may fare the worst.
If the HIV/AIDS epidemic compromises the saving capacity and the human capital of the
economy, it will undercut the process of economic development. Foreign and domestic private
investment might also decline if potential investors become convinced that the epidemic is
seriously undermining the rate of return to investment (Theodore, 2001).
Previous Research Concerning Economic Impact of HIV/AIDS in Egypt
World Bank conducted the first attempt to evaluate the risks of an HIV/AIDS epidemic in 9
Middle East and North Africa (MENA) countries (Algeria, Djibouti, Egypt, Iran, Jordan, Lebanon,
Morocco, Tunisia, and Yemen) and its potential economic costs (Robalino et al., 2002).
According to the MENA study, the prevalence rates in Egypt in year 2015 would be between 3.8
percent in 16.1 percent. On average, GDP losses due to the projected prevalence for 2000- 2025
could approximate 44 percent of today's GDP. There, health expenditure on AIDS would
represent 1.3 percent of GDP. Table (9), summarizes the distribution of the output variables of
interest by reporting the mean, standard deviation, and the minimum and maximum values
(Robalino et. al., 2002).
The range of variation of the economic figures between Egypt and the other eight countries
under study is similar (excluding Djibouti). The prevalence of HIV/AIDS in MENA countries in
year 2015 would be between 0.3% and 17% (excluding Djibouti). Across countries, losses in the
present value of GDP per capita could range between close to 2.3% of today's GDP to over 100%
(in Djibouti maximum impacts could be equivalent to 7 times current GDP). Average real GDP
growth rates for the period could be reduced by 0.02% to 2.7% per year. The size of the
population in year 2025 could be reduced by 0.3% to 15%, and HIV/AIDS related expenditures
could increase by 0.1% to 6% of GDP in year 2015 (Robalino etal., 2002).
3. Methodology of the study
3.1. Objectives of the Study
1- Study the socio-demographic profile of PLHA
2- Assess the economic condition of PLHA before and after infection
3- Identify the potential impact of HIV/AIDS at both macro and microeconomic level
3.2. Study Design: This study was a cross sectional study having descriptive and analytical
elements and using both qualitative and quantitative methods.
3.3 Study Setting: This study included cases from Cairo and Alexandria governorates and from
other Lower and Upper Egypt governorates.
3.4. Sample size and sampling technique: A sample of 25% of AIDS population in Egypt was
selected in collaboration with the NAP for participation in the study. Sample selection will be
done according to geographic distribution of cases, to represent rural/urban Upper and Lower
Egypt and largest urban governorates, i.e. Cairo and Alexandria. Participants included PLHA, and
their families, NAP managers and personnel in addition to and policy makers. Desk review was
carried out for gathering data from available documents.
3.5. Study Tools:
1- In-depth interview (23 Questions covered 3 social, cultural and economic aspects) to NAP
managers and personnel
2- In depth interview (27 questions covered economic, cultural, policies, planning and services,
health expenditure) to PLHA and their families
3.6. Data Collection: Data were collected by direct interviewing with the study population. Multiple
interviews, when necessary were organized for building trust and confidence with studied persons
before data collection. Participation was voluntary, confidentiality was guaranteed and the
objectives of the study were discussed.
3.7. Methods of Estimating the Economic Impact of HIV/AIDS
3.7.1 The Macroeconomic Impact
a) Reviewing of literature to identify the mechanisms by which HIV/AIDS can
affect the economy of a country. Economic assessment of some policy
interventions are searched in literature.
b) Estimation of the cost from the perspective of the MOHP/NACP
- Total annual budget of NAP.
- Items of expenditure of NAP budget.
- Cost of case management.
- Share of donors and private sector in covering AIDS expenses.
c) Current output loss due to AIDS deaths: using the labor force percent out of total
population the annual productivity of labor was calculated in LE. This was
multiplied by the number of deaths in 2006. The product is further divided on
2006 GDP to estimate the potential output losses in year 2006.
d) The treatment cost is also estimated.
3.7.2 The Microeconomic Impact
- Pattern of income and expenditure before and after respondents' and spouses'
infection.
- Perceived types of changes in family situation after respondents' and spouses'
infection.
- Source of financing of the medication other than ARV
- The cost of medical treatment from the perspective of the patient:
 Direct cost: is paid by the patient directly to the health care
providers. Monthly cost of medications, special diet and lab
investigations are added to calculate the direct cost.
 Indirect cost: the transportation costs and loss of previously earned
income.
4. Results
4.1 Results related to the socio-demographic characteristic of the group
Distribution of age groups by gender showed a statistically significant relation with a pvalue of 0.016 as shown in Figs. 1&2
Fig. 1. & Fig 2. Distribution of cases defined by sex & Distribution of cases defined by age
group affected
- Marital status by gender, demonstrating that the single status of women is more than men
specially one third of the women are widowed and this doubles the socioeconomic burden on
them.
Table 1. Demonstrates the marital status of both male and female by %
Gender
Marital Status
P Value*
married
never married
divorced
separated
widowed
Total
Male
38.4%
22.4%
5.2%
2.0%
.8%
68.8%
.000
Female
13.6%
.8%
2%
2.4%
12.4%
31.2%
.000
Total
52%
23.2%
7.2%
4.4%
13.2%
100.0%
.000
Table 2 .Demonstrates the literacy status for both males and females
Education
illiterate
read&write,prim,prep
secondary,tec.edu
University &up
Total
P value
Male
8.80%
20.00%
23.20%
16.80%
68.80%
.419
Female
6.40%
8.40%
10.40%
6.00%
31.20%
.433
% of Total
15.20%
28.40%
33.60%
22.80%
100%
.174
Table 3. Demonstrates the Geographical Distribution by gender
Geographical Distributions by gender
Urban
rural
Total
Male
35.60%
33.20%
68.80%
Female
15.60%
15.60%
31.20%
Total
51.20%
48.80%
100.00%
ble : 4. Current Family and Social Condition
“ is your wife live with you”?
Answer
Frequency
%
Yes
126
89.4%
No
15
10.6%
Total
141
100%
Table 5. Did anyone live with you before
having AIDS
Answer
Frequency
%
Yes
232
93%
No
18
7%
Total
250
100%
Flowchart 1: Working status of respondents:
Only 50% of all study participants are working now. Out of the working half 65.6% are at a
professional job. Out of those not currently working 65% were working before. Most of the
latter category left work due to being tired from illness or to stay home to care for an ill parent.
These were mainly females (flowchart 2).
Flowchart 2: Household existence of respondents' family members
About two-thirds of the family members of the respondents are currently living with them.
Those not living with the respondent left because of death which was mainly idiopathic or less
commonly due to disease. Four of family members left for being affected by AIDS. Nine have left
after respondents' disease to live with their families (flowchart 2).
4.2 Findings regarding the macroeconomic impact
a. Financing of MOHP/NACP
About LE50-60 Million are spent every year to cover preventive and curative services adopted by
the MOHP/NACP.
Of all AIDS cases 400 cases need treatment. The average medication cost is about LE3000 per
case per month. This is apart from the medication costs of managing complications that include
opportunistic infections, and from inpatient services expenses. Both costs are not estimated by the
NACP.
Annual analysis of about 1,200,000 blood samples which is done to screen HIV-infected cases
costs about LE70-80 Million. The CD4 count is applied to all AIDS cases every 3 months. It costs
LE250 per person. The NAP budget also covers the annual training of physician's in different
specializations (NAP official, 2009).
Real financial support from the private sector in Egypt is missing. According to the Global Fund
Grants a fund of $11527830 is projected to cover anti-AIDS planned activities along two phases. Less
than half the latter fund has been agreed.
4.3 Output loss due to AIDS
Table 6 .Computing average productivity
Year
Population
Labor force/population%
(mn)
(LE bn)
Annual
productivity of
labour (LE)
GDP
2001-2002
67.9
29.5%
379.0
19856.9
2002-2003
69.2
29.4%
417.5
20521.2
2003-2004
70.5
30.6%
407.0
18866.2
2004-2005
71.9
30.8%
425.2
19200.6
2005-2006
73.6
31.8%
454.3
19410.6
2006-2007
77.5
32.5%
744.3
29550.4
2007-2008
81.7
NA
798.1
NA
Average productivity (2002-2006)
LE 21234.3
Table 7. Potential output losses in LE due to AIDS losses
Average
productivity
LE 21234.3
AIDS deaths in 2006
Potential output losses in 2006
High
estimate
Low
estimate
High estimate
Low estimate
1144
1028
87315441.6
21828860.4
(0.0053% of
GDP)
(0.0048% of
GDP)
Average
(%0.005 of
GDP)
b. Medication Cost
Due to incomplete information we needed to resort to a better proxy of the medication cost
i.e. the medication cost in other developing and comparable countries. Thus, for analytical
purpose the average medication cost of Ethiopia and the Caribbean countries, which is 257 USD
(2185 Birr) and 4000 USD respectively, was taken (Theodore, 2001; Zerfu, 2002).
Table: 8. Medication Cost using the Ethiopian estimation (in USD)
Infected Adult Medication Cost (USD)
Average
cost per
adult
257 USD
Medication cost related to HIV death (USD)
Infected
Adult
Medication
Cost
Output
loss
*Scenario
1
2744
705208
(0.00089
% GDP)
*Scenario
2
10757
2764549
(0.0034%
GDP)
HIV
Death
Medication
Cost
Output
loss
*Scenario
3
1028
264169
(0.00033%
GDP)
*Scenario
4
1144
294008
(0.00037%
% GDP)
* Scenario 1, assuming the NACP prevalence of the HIV (2009): 2744., * Scenario 2, assuming the WHO prevalence of the HIV (2009):
9213-12300 (av10757)., * Scenario 3, assuming the low estimate deaths of the HIV (2006): 1028. , * Scenario 4, assuming the high
estimate deaths of the HIV (2006): 1144
Table 9. Medication Cost using the Caribbean Estimation (in USD)
Infected Adult Medication Cost
Average
cost per
adult
4000 USD
Medication cost related to HIV death
Infected
Adult
Medication
Cost
Output
loss
*Scenario
1
2744
10976000
(0.013%
GDP)
*Scenario
2
10757
43028000
(0.054%
GDP)
HIV
Death
Medication
Cost
Output
loss
*Scenario
3
1028
4112000
(0.0052%
GDP)
*Scenario
4
1144
4576000
(0.0057%
% GDP)
* Scenario 1, assuming the NACP prevalence of the HIV (2009): 2744. , * Scenario 2, assuming the WHO prevalence of the HIV (2009):
9213-12300 (av10757)., * Scenario 3, assuming the low estimate deaths of the HIV (2006): 1028. , * Scenario 4, assuming the high
estimate deaths of the HIV (2006): 1144.
A more intimate estimation would be done by using the NACP figure, namely, LE3000 per case
per month (LE36000/year) (NAP official, 2009).
Table 10. Medication Cost using NACP/WHO prevalence estimation (in LE)
Infected Adult Medication Cost
Average cost per
adult
LE36000/ year
Medication cost related to HIV death
Infected
Adult
Medication
Cost
Output
loss
*Scenario
1
2744
98784000
(0.0216%
GDP)
*Scenario
2
10757
387252000
(0.0852%
GDP)
HIV
Death
Medication Cost
Output loss
*Scenario
3
1028
37008000
(0.00816%
GDP)
*Scenario
4
1144
41184000
(0.00912%
GDP)
* Scenario 1, assuming the NAP prevalence of the HIV (2009): 2744., * Scenario 2, assuming the WHO prevalence of the HIV (2009):
9213-12300 (av10757)., * Scenario 3, assuming the low estimate deaths of the HIV (2006): 1028. , * Scenario 4, assuming the high
estimate deaths of the HIV (2006): 1144.
4.4 Findings regarding the microeconomic impact
Many responses describe the family financial deteriorating situation after respondents'
infection; Level of expenditure reported by respondents after their spouses' infection has
dramatically decreased. That is most likely due to the indicated reduction of both partners' work
and income. This could be explained by decrease in physical ability and /or diverted time to care
for one's ill spouse. In addition the money earned from other new sources of income, including
NGOs, is mainly spent on treatment.
Perceiving a change of family situation after spouse's infection was more evident among male
than female respondents, 62.5% and 53.3%, respectively. However, social changes were more
perceived by male respondents than financial ones, 60% and 20%, respectively. On the other hand,
financial changes were more perceived among Upper Egypt respondents than social ones, 57.1%
and 21.4%, respectively.
Paying for the medication other than ARV was out of pocket in 100% of Upper Egypt, rural and
female respondents. Average monthly cost of medications was LE 681.7+2112.7. The source of
drugs is the pharmacy, the Liver Institute or Caritas NGO in 90.9%, 7.8% and 1.3%, respectively.
About a third of respondents (31%) needed special food with an average monthly cost of LE
503.7+439.5. Some respondents (11.2%) needed to perform lab investigations with an average
monthly cost of LE227.68+252.7. These are done mainly in governmental hospitals (83.6% of
users) followed by private hospitals (7.1% of users).
Table 11. Monthly direct costs of case treatment as reported by respondents
Mean
SD
Median
Inter-quartile range
Min
max
2408.2
4125.8
721
721 (383-1242.5)
240
11799
The values in table (11) were calculated by mere addition of the expenses reported by the
respondents; medications, laboratory investigations and special diet. For three reasons these
figures should be considered cautiously. First, this cost is identified from the patient's
perspective, and not the MOH, the community or the health facility. Second, the statements of
the patients might be underestimated as a trial to get more financial and medical support from
the agencies conducting the interview. Third, some of the cost items were not recorded, e.g. the
physician fee, the hospital admission costs and the transportation costs. Also, indirect costs
related to loss of previously earned income were not thoroughly investigated.
4.5 Economic Assessment of Policy interventions in Literature
Reducing risks (through information and preventive behaviors and services) in those
population groups most likely to contract and spread HIV can be highly cost-effective (Kahn,
1996). Interventions such as reproductive health and HIV/AIDS education in schools, targeted
STD treatment for highly vulnerable groups, and harm reduction for IDUs have also proved to be
cost-effective (Jenkins, 2002).
Expanding condom use and access to clean needles for intravenous drug users GDP losses
during the period 2000-2025 would be significantly reduced, by an equivalent of 27% of 2002
GDP in the case of Egypt. Delaying action for five years can cost, on average, the equivalent of
six percentage points of today's GDP (Robalino et. al., 2002).
Conclusion:
The risk of an increase in the HIV/AIDS prevalence rate in Egypt is real and the expected costs
over the next 25 years could be considerable specially the poor are more exposed to infectious
diseases and complicated with malnutrition, and thus are more vulnerable to the deterioration
of their immune system. They are already face problems of Access to health services as health
systems become financially constrained, these problems can be exacerbated. At the same time,
there are actions that can be implemented to prevent the spread of the epidemic and the costs
of these actions would be more than compensated by the savings they generate; and the time
to act is sooner better than later especially when prevalence rates are still low.
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