Antiretroviral therapy coverage associated with increased co-residence between older and working-age adults in Africa

Abstract

The scale-up of ART has likely led to substantial increases in co-residence between older and working-age adults in Africa. Returns to investments in HIV treatment will be too low, if the social benefits from these changes in living arrangements of older adults are not taken into account.

Intergenerational spillover effects of antiretroviral therapy in sub-Saharan Africa: a scoping review and future directions for research

“…The largest study used data on over 200 000 individuals from 28 countries. 52 No studies on spillover effects were identified from several high-burden countries such as Eswatini and Botswana, which have among the world’s highest HIV prevalence. Over 90% of studies included at least some data from rural settings in SSA, such as rural KwaZulu Natal in South Africa.…”

“… 69 71 74 Among the 26 included studies, 16 studies explicitly assessed spillover effects from adults to children (downward spillover effects) 34 35 63 64 68 69 76 77 79–86 and 1 study explicitly assessed spillover effects from working-age adults to older adults (upward spillover effects). 52 Several studies reported spillover effects without fully specifying the recipient of the spillover effect (eg, by grouping together all adult ages in their analytical sample), so that we cannot disentangle the direction of intergenerational spillover effects in those studies. 34 63 68 69 71–75 78 83 85–89 The types of spillover effects that emerged from our analysis were related to (1) wealth and labour market outcomes, (2) health and healthcare utilisation, (3) food security and nutrition, (4) schooling outcomes, (5) caregiving responsibilities, and, lastly, (6) coresidency and relationships.…”

“… 63 76 77 82 For the older generation, the availability of ART was associated with increased coresidence with working-age adults (aged 18–59 years). 52 In a multicountry study in SSA, including individual-level data on over 200 000 older adults aged 60 years or more, an increase in national ART coverage was associated with a higher number of working-age adults living in households with at least one older adult. An increase in ART coverage of 1% was associated with a 0.7 percentage point reduction in the probability of an older adult living without a working-age adult and a 0.2 percentage point reduction in the probability of an older adult living with only dependent children (ie, ‘missing generation’ households).…”

“…For example, about 75% of older adults in SSA live with a working-age adult. 52 In the absence of ART, HIV hollows out the middle generation in households, possibly leaving older household members without care. 53 We, therefore, hypothesised that the scale-up of ART in SSA may have large consequences across generations, including potentially both positive and negative consequences.…”

Causal effect of children’s secondary education on parental health outcomes: findings from a natural experiment in Botswana

“…Our hypothesis was that the role of children’s resources may be more pronounced in households where: (1) children were more likely to be affected by the reform, (2) there was a large intergenerational gap in educational attainment between adult children and their parents, and (3) parents were on average older and thus more likely to be ‘dependent’ on the support of children. 30 To do so, we limited the sample to children with at least 9 years of schooling (ie, those primarily affected by the policy reform). For the subset of households with coresident parents and children, we also limited the sample to households where the difference in educational attainment between parents and children was ≥5.5 years (50th percentile), and stratified our model by parental 10-year age groups.…”