Damien de Walque

Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders.

Objective:There is limited evidence on whether growing mobile phone availability in sub-Saharan Africa can be used to promote high adherence to antiretroviral therapy (ART). This study tested the efficacy of short message service (SMS) reminders on adherence to ART among patients attending a rural clinic in Kenya. Design:A randomized controlled trial of four SMS reminder interventions with 48 weeks of follow-up. Methods:Four hundred and thirty-one adult patients who had initiated ART within 3 months were enrolled and randomly assigned to a control group or one of the four intervention groups. Participants in the intervention groups received SMS reminders that were either short or long and sent at a daily or weekly frequency. Adherence was measured using the medication event monitoring system. The primary outcome was whether adherence exceeded 90% during each 12-week period of analysis and the 48-week study period. The secondary outcome was whether there were treatment interruptions lasting at least 48 h. Results:In intention-to-treat analysis, 53% of participants receiving weekly SMS reminders achieved adherence of at least 90% during the 48 weeks of the study, compared with 40% of participants in the control group (P = 0.03). Participants in groups receiving weekly reminders were also significantly less likely to experience treatment interruptions exceeding 48 h during the 48-week follow-up period than participants in the control group (81 vs. 90%, P = 0.03). Conclusion:These results suggest that SMS reminders may be an important tool to achieve optimal treatment response in resource-limited settings.

How Does the Impact of an HIV/AIDS Information Campaign Vary with Educational Attainment? Evidence from Rural Uganda

The responsiveness to information is thought to be one channel through which education affects health outcomes. The author tests this hypothesis by examining the effectiveness of an information campaign that aims at preventing the HIV/AIDS epidemic in Uganda. Previous studies in the epidemiological literature have generally concluded that, in Africa, there was either a positive association or no association between HIV infection and schooling levels. Using individual level data from a cohort study following the general population of a cluster of villages in rural Uganda over 12 years, the author shows that, after more than a decade of prevention campaigns about the dangers of the epidemic, there has been a substantial evolution in the HIV/education gradient. Early in the epidemic, in 1990, there was no robust relation between HIV/AIDS and education. In 2000, among young individuals, in particular among females, education lowers the risk of being HIV positive. Results on HIV incidence in a duration framework confirm that finding by establishing that, for young individuals, education reduces the probability of seroconversion. These findings reveal that educated individuals have been more responsive to the HIV/AIDS information campaigns. The analysis of sexual behavior reinforces that conclusion: condom use is associated positively with schooling levels.

Incentivising Safe Sex : A Randomised Trial of Conditional Cash Transfers for HIV and Sexually Transmitted Infection Prevention in Rural Tanzania

Objective The authors evaluated the use of conditional cash transfers as an HIV and sexually transmitted infection prevention strategy to incentivise safe sex. Design An unblinded, individually randomised and controlled trial. Setting 10 villages within the Kilombero/Ulanga districts of the Ifakara Health and Demographic Surveillance System in rural south-west Tanzania. Participants The authors enrolled 2399 participants, aged 18–30 years, including adult spouses. Interventions Participants were randomly assigned to either a control arm (n=1124) or one of two intervention arms: low-value conditional cash transfer (eligible for

HIV Status in Discordant Couples in Sub-Saharan Africa : A Systematic Review and Meta-Analysis

10 per testing round, n=660) and high-value conditional cash transfer (eligible for

Who Gets AIDS and How? The Determinants of HIV Infection and Sexual Behaviors in Burkina Faso, Cameroon, Ghana, Kenya, and Tanzania

20 per testing round, n=615). The authors tested participants every 4 months over a 12-month period for the presence of common sexually transmitted infections. In the intervention arms, conditional cash transfer payments were tied to negative sexually transmitted infection test results. Anyone testing positive for a sexually transmitted infection was offered free treatment, and all received counselling. Main outcome measures The primary study end point was combined prevalence of the four sexually transmitted infections, which were tested and reported to subjects every 4 months: Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and Mycoplasma genitalium. The authors also tested for HIV, herpes simplex virus 2 and syphilis at baseline and month 12. Results At the end of the 12-month period, for the combined prevalence of any of the four sexually transmitted infections, which were tested and reported every 4 months (C trachomatis, N gonorrhoeae, T vaginalis and M genitalium), unadjusted RR for the high-value conditional cash transfer arm compared to controls was 0.80 (95% CI 0.54 to 1.06) and the adjusted RR was 0.73 (95% CI 0.47 to 0.99). Unadjusted RR for the high-value conditional cash transfer arm compared to the low-value conditional cash transfer arm was 0.76 (95% CI 0.49 to 1.03) and the adjusted RR was 0.69 (95% CI 0.45 to 0.92). No harm was reported. Conclusions Conditional cash transfers used to incentivise safer sexual practices are a potentially promising new tool in HIV and sexually transmitted infections prevention. Additional larger study would be useful to clarify the effect size, to calibrate the size of the incentive and to determine whether the intervention can be delivered cost effectively. Trial registration number NCT00922038 ClinicalTrials.gov.

The socio-demographic legacy of the Khmer Rouge period in Cambodia

BACKGROUND Most couples affected by HIV/AIDS in sub-Saharan Africa live in discordant relationships. Men are thought to be the index case in most relationships, and most social marketing and awareness campaigns are focused on men. We investigated serodiscordance in stable relationships to establish the gender balance of index-case infections. METHODS We did a systematic review, random-effects meta-analysis, and meta-regression of published and unpublished studies enrolling discordant couples and assessed the proportion of men and women that were index cases. We repeated the analysis with data from demographic and health surveys (DHS) from the 14 countries that have documented the HIV status of couples. Our primary outcome was the total number of HIV discordant couples, including the proportion of HIV-positive women. FINDINGS We included data from 27 cohorts of 13,061 couples and DHS data from 14 countries of 1145 couples. The proportion of HIV-positive women in stable heterosexual serodiscordant relationships was 47% (95% CI 43-52), which shows that women are as likely as men to be the index partner in a discordant couple. DHS data (46%, 41-51) and our sensitivity analysis (47%, 43-52) showed similar findings. Meta-regression showed that urban versus rural residence (odds ratio 0.31, 95% CI 0.22-0.39), latitude (β coefficient 0.02, 0.023-0.034), gender equality (β coefficient -0.42, -0.56 to -0.27), HIV prevalence (β coefficient -0.037, -0.04 to -0.030), and older age (β coefficient 0.20, 0.08-0.32) were associated with the proportion of female index cases. INTERPRETATION Our study shows the need to focus on both sexes in HIV prevention strategies, such as promotion of condom use and mitigation of risk behaviours. FUNDING None.

Education, information, and smoking decisions : evidence from smoking histories, 1940-2000

This paper analyzes the determinants of HIV infection and associated sexual behaviors using data from the first five Demographic and Health Surveys to include HIV testing for a representative sample of the adult population. Emerging from a wealth of country relevant results, four important findings can be generalized. First, married women who engage in extra-marital sex are less likely to use condoms than single women when doing so. Second, having been in successive marriages is a significant risk-factor, as evidenced by the results on HIV infection and on sexual behaviors. Contrary to prima facie evidence, education is not associated positively with HIV status. But schooling is one of the most consistent predictors of behavior and knowledge: education predicts protective behaviors like condom use, use of counseling and testing, discussion among spouses and knowledge, but it also predicts a higher level of infidelity and a lower level of abstinence. Finally, male circumcision and female genital mutilation are often associated with sexual behaviors, practices, and knowledge related to AIDS. This might explain why in the analysis in the five countries there is no significant negative association between male circumcision and HIV status, despite recent evidence from a randomized control trial that male circumcision has a protective effect.

Child Ability and Household Human Capital Investment Decisions in Burkina Faso

The study presented in this paper is an examination of the long-term impact of genocide during the period of the Khmer Rouge regime (1975–79) in Cambodia. The very high and selective mortality of the period had a major impact on the population structure of Cambodia. Fertility and marriage rates were both very low under the Khmer Rouge, but recovered immediately after the regimes collapse. Because of the shortage of eligible men, the age and education differences between partners tended to decline. The period also had a lasting impact on the educational attainment of the population. The school system collapsed during the period and therefore individuals—especially men—who were of school age at the time have a lower educational attainment than those from the preceding and subsequent birth cohorts.The study presented in this paper is an examination of the long-term impact of genocide during the period of the Khmer Rouge regime (1975–79) in Cambodia. The very high and selective mortality of the period had a major impact on the population structure of Cambodia. Fertility and marriage rates were both very low under the Khmer Rouge, but recovered immediately after the regimes collapse. Because of the shortage of eligible men, the age and education differences between partners tended to decline. The period also had a lasting impact on the educational attainment of the population. The school system collapsed during the period and therefore individuals—especially men—who were of school age at the time have a lower educational attainment than those from the preceding and subsequent birth cohorts.

Using provider performance incentives to increase HIV testing and counseling services in Rwanda

The author tests the hypothesis that education improves health and increases peoples life expectancy. Smoking histories-reconstructed from retrospective data in the National Health Interview Surveys in the United States-show that after 1950, when information about the dangers associated with tobacco consumption started to diffuse, the prevalence of smoking declined earlier and most dramatically for college graduates. More educated individuals are also more likely to quit smoking: incidence analysis of smoking cessation shows a strong education effect. The instrumental variable approach, which relies on the fact that during the Vietnam War college attendance provided a strategy to avoid the draft, indicates that education does affect decisions about whether to smoke or stop smoking.

The long-term legacy of the Khmer Rouge period in Cambodia

Using data we collected in Burkina Faso, we explore how child ability influences parents’ decisions to invest in their children’s human capital. We use a direct measure of child ability for all primary school–aged children, regardless of current school enrollment. We explicitly incorporate direct measures of the ability of each child’s siblings (both absolute and relative measures) to show how sibling rivalry exerts an impact on the parents’ decision of whether and how much to invest in their child’s education. We find that children with one standard deviation higher own ability are 16% more likely to be currently enrolled, while having a higher-ability sibling lowers current enrollment by 15% and having two higher-ability siblings lowers enrollment by 30%. Results are robust to addressing the potential reverse causality of schooling influencing child ability measures and using alternative cognitive tests to measure ability.