Higher CD4 count preserves ability to work and educate children

A higher CD4 cell count benefits the household economically and is associated with better educational opportunities for the children in the household, according to findings from a study in Uganda presented last week at the Nineteenth International AIDS Conference in Washington DC.

The findings suggest that earlier diagnosis, and treatment to maintain CD4 cell counts above 350 in order to preserve health, will have economic benefits for households and will allow children to remain in school.

Harsha Thirmurthy was reporting on a survey from a community-wide health campaign in a rural Ugandan parish on behalf of the Gillings School of Global Health at the University of North Carolina and the SEARCH collaboration.

Access to ART has dramatically reduced death and disease. More recently the prevention benefits of starting ART early have been established.

There is growing evidence to demonstrate improved socio-economic outcomes among HIV-positive adults, as well as for their households, after starting ART.

Yet little is understood about the differences in outcomes in this population that includes both those with high CD4 cell counts and those not enrolled in care.

In light of constrained resources understanding these differences and the potential economic benefits (cost-effectiveness) is necessary to inform policy debates on resource allocation and ART scale-up/starting ART early. 

This requires population level data with CD4 cell count information. With this in mind Dr Thirmurthy and colleagues chose to look at the links between high CD4 cell counts and socio-economic outcomes among adults taking part in a community-wide health campaign in the rural Ugandan parish of Kakyerere, near Mbara.

In May 2011 they conducted a one-week community health campaign in this community of 6,000 individuals. HIV testing as well other infectious and non-communicable testing, diagnostic and treatment services were offered.

Community health campaigns, such as these, serve as a means for widespread HIV testing (see also a report on a Kenyan community health campaign presented at AIDS 2012). Dr. Thirmurthy added that these campaigns are an essential part of a ‘test-and-treat’ strategy of the SEARCH collaboration.

The primary objectives were to investigate:

• Over what range of CD4 counts do we observe declining socio-economic status?

• To what extent does poor adult health influence the well-being of children?

Employment data were collected from all participants and a detailed household socio-economic survey conducted among a random subset.

While there were no real differences in occupation distribution (most were farmers) among HIV-positive and HIV-negative participants, there was a significant difference in assets. For example, HIV-negative participants owned more land, had more cows and poultry than those who were HIV-positive.

Of the 74% (2323) of adults from the community who participated in the campaign 7.8% (179) tested positive, of which close to half were newly diagnosed.

Among these HIV-positive adults, those with CD4 cell counts greater than 550 cells/mm³ and those with CD4 cell counts between 350 and 550 worked 5.3 and 4.8 more days, respectively in the preceding month than those with CD4 cell counts under 200 cells/mm³ (p<0.05).

Those with CD4 cell counts equal to or greater than 500 worked nearly one week more than those with CD4 cell counts under 200. In addition their employment level was statistically indistinguishable from those of their HIV-uninfected peers.

There were no differences in work patterns between those with CD4 cell counts between 200 and 350 and those with CD4 cell counts under 200, Dr Thimurthy noted.

The association between work patterns and CD4 cell counts were similar whether participants were on ART or not.

Adult health and productivity in resource-poor settings is known to influence children’s outcomes.

Older children are more likely to be taken away from school so they can contribute to work on the farm or other kinds of work to help support the household.

Not surprisingly there was a stronger association between CD4 cell counts in adults and education among older children (aged 12-18) than younger children (aged 6-11) because the former are more likely to be the ones who provide substitute labour for sick adults who cannot work as much.

In addition to improved work patterns older children in households of adults with CD4 cell counts above 350 cells/mm³ had a 15% higher school enrolment rate than those in households of adults with CD4 cell counts under 350 (p<0.10).

Of significance, Dr Thimurthy added, the socio-economic outcomes of adults with CD4 cell counts over 350 were much the same as the HIV-negative adult participants.

Dr Thimurthy concluded these outcomes suggest that starting ART early could well have immediate as well as long-term economic benefits. Levels of employment and education would be maintained on a par with their HIV negative peers.

Long-term data and randomised controlled design are necessary to further establish these benefits, he added.

Thirumurthy H et al. Improved employment and children’s education outcomes in households of HIV-positive adults with high CD4 counts: evidence from a community-wide health campaign in Uganda. 19^th International AIDS Conference, Washington DC, abstract THAE0102, July 2012.