Three Essays on HIV Investments in Sub-Saharan Africa

by Uzaib Saya

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My dissertation examines the HIV-related health decisions and investments that are made by people living with HIV (PLWH) as well as the institutions that serve them, and it assesses their indirect effects. This contributes to evidence on the short and long-term implications of antiretroviral therapy (ART) and related changes in behavior. Such implications can ultimately inform policy changes to improve ART-related outcomes.

In the first two essays, I use quantitative and qualitative data from an urban HIV clinic in Uganda to better understand how and why PLWH invest in their HIV-related health. Using a discrete choice experiment in the first essay, I examine how ART adherence is influenced by interconnected and competing material deprivations of food insecurity, income, sleep, and pain. By randomly and independently varying the levels of these attributes, I assess the causal effect of a change in each attribute and find that food insecurity had the greatest impact on expected adherence. Separately assessing these inter-related factors can guide the design of more effective HIV interventions.

PLWH may also only focus on direct, short-term benefits, potentially resulting in suboptimal health outcomes. To understand whether this is the case in the context of ART adherence, I use qualitative content analysis and examine how PLWH perceive the broader benefits of ART on health and wealth at individual, household, and structural levels. Understanding these perspectives is key for designing interventions that can ultimately change behaviors such as adherence and they can help promote further ART investments.

I continue to assess the indirect impact of HIV investments in the third essay. Using the US President's Emergency Plan for AIDS Relief (PEPFAR) program as a case study and nationally representative survey data from 21 sub-Saharan African countries between 1995-2017, I assess the benefits of ART expansion on child health. I employ quasi-experimental methods to assess impacts of PEPFAR on child morbidity and mortality among samples of children with HIV-positive mothers, children with HIV-negative mothers, and on a population level. While I find significantly decreased rates of orphanhood in countries receiving large amounts of PEPFAR funding (leading me to hypothesize that surviving caregivers' children would have fewer negative health outcomes), I do not observe changes in child health outcomes. Understanding the indirect effects of international aid can inform the design of future programs to better meet the needs of various vulnerable populations.

Table of Contents

  • Chapter One

    A choice experiment to examine the role of material deprivations and ART adherence in Uganda

  • Chapter Two

    Qualitative evidence on health and wealth-related benefits of ART in Uganda

  • Chapter Three

    The impact of PEPFAR financing on child morbidity and mortality in sub-Saharan Africa

Research conducted by

This document was submitted as a dissertation in October 2021 in partial fulfillment of the requirements of the doctoral degree in public policy analysis at the Pardee RAND Graduate School. The faculty committee that supervised and approved the dissertation consisted of Sebastian Linnemayr (Chair), Zachary Wagner, and Gil Shapira (external member).

This report is part of the RAND Corporation Dissertation series. Pardee RAND dissertations are produced by graduate fellows of the Pardee RAND Graduate School, the world's leading producer of Ph.D.'s in policy analysis. The dissertations are supervised, reviewed, and approved by a Pardee RAND faculty committee overseeing each dissertation.

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.