2. The impact of HIV/AIDS on household dynamics and household welfare in rural northern Malawi 19 th July, 2010 Sian Floyd, Angela Baschieri, Aulive Msoma, Albert Dube, Elenaus Mwaiyeghele, Andreas Jahn, Keith Branson, Anna Molesworth, Judith Glynn, Neil French

3. Outline 1.Background 2.Research aim and questions 3.Methods 4.Results 5.Interpretation / Conclusions

4. 1) Background Evidence from prospectively collected longitudinal data on the impact of adult HIV/AIDS deaths on household welfare in Southern and East Africa still relatively limited Overall, evidence suggests: a)Largest impact if deceased was head of household or spouse of head of household (and possibly smaller impact on big households) b)Effect on household material welfare (e.g. land, assets, housing quality) smaller than anticipated early in HIV epidemic

5. 2) Research aim and questions Aim To add to the existing evidence, using data from a demographic surveillance site (DSS) in rural Malawi Questions What is the effect of a young adult (age 15-59 years old) HIV/AIDS death in the household on each of: 1.Rate at which young adults join and leave a household 2.Household dissolution 3.Household migration 4.Household material welfare

6. Setting Karonga district, rural northern Malawi Main livelihood = subsistence farming HIV prevalence in adults 10-14% (2000-2008) DSS established in south of district, baseline census 2002-2004 population ~30,000 Sufficient identifying information so can trace all individuals, plus whole households, over time 65% of young adult (15-59 years old) deaths due to HIV/AIDS (2002-2006)

7. 3) Methods From time household enrolled in baseline census, or subsequent in-migration of whole household: – births and deaths – monthly – individual joining and leaving of households - once a year – verbal autopsies for all deaths (so can distinguish AIDS vs non-AIDS) Household = unit of analysis –Definition: group of people living together who recognise same head Socio-economic data: at baseline 2002-4; for households that moved into the DSS area after baseline; follow-up survey 2007/8 –Housing quality (construction of roof, walls, floor) –Household sources of income –Household assets (list of 10 items identified as of value in this setting) –Crops grown –Land owned and cultivated –Food and nutrition security (2007/8 survey only)

8. 3) Methods (continued) Between 2002-2007, 93% of all HIV/AIDS deaths were among 15-59 year olds, and 85% of HIV/AIDS deaths among 15-59 year olds were in 3 household types, with households categorised according to the age and sex of their members Thus all analysis focused on effect of an HIV/AIDS death of a 15-59 year old in these 3 household types: 1)Young adults (15-59 years old) only (YA) 2)Children (<15 years old) + young female adults + young male adults (CYA) 3)Children + young female adults + young male adults + older adults (CYO) Analysis restricted to households first seen in DSS prior to 31 August 2005 –ensures 2 years of “follow-up” for experience of HIV/AIDS deaths, from the time a household was first seen in the DSS; and –a further 1-3 years until the follow-up socio-economic survey in 2007/8 All analysis compares households in which a young adult (15-59 years old) died of HIV/AIDS during the first 24 months for which the household was followed up in the DSS, with households in which no young adult died of HIV/AIDS during this time period

9. 4) Results

10. Households that experience an HIV/AIDS death also have higher rate of joining and leaving of young adults Joining (%)Leaving (%) Typology (when first seen)12+1 1. Young adults only No AIDS death (n=1240)164143 AIDS death (n=21)2419 5 2. C + Y female + Y male No AIDS death (n=3978)155208 AIDS death (n=102)25142914 3. C + Y female + Y male + O No AIDS death (n=591)27153729 AIDS death (n=31)26 3539 C = Child (<15 years old), Y = Young adult (15-59 years), O = older adult (60+ years)

11. Households that experience an HIV/AIDS death have higher rate of household dissolution, but not migration Dissolved (%) Migrated (%) Typology (when first seen)4 years later 1. Young adults only No AIDS death1425 AIDS death (n=21)6331 2. C + Y female + Y male No AIDS death715 AIDS death (n=102)3115 3. C + Y female + Y male + O No AIDS death43 AIDS death (n=31)160 YA with AIDS death: 90% was death of household head or spouse CYA with AIDS death: 75% was death of household head or spouse CYO with AIDS death: 10% was death of household head or spouse

12. Small negative impact of HIV/AIDS death on number of household possessions* *For young adult only (YA) households with HIV/AIDS death – very few still existed by 2007/8, so not shown Median number of household possessions in 2007/8 Count of household possessions at time first seen No HIV/AIDS death HIV/AIDS death 1. C + Y female + Y male≤232 3-443 5+54 n=2969n=51 2. C + Y female + Y male + Older adults≤22.52 3-434 5+54.5 n=515n=22

13. Apart from household possessions, no or small effect of young adult HIV/AIDS death on household material welfare Measure of material welfareEvidence of negative effect? Housing qualityNo Food and nutrition securityNo Amount of land ownedNo Amount of land cultivatedSuggestion of small fall in amount of land cultivated Household possessions, number and value Yes, but fall in number/value was relatively small Number of household income sourcesSuggestion of increase, i.e. diversification, but small effect

14. Interpretation / Conclusions A common way in which households respond to an HIV/AIDS death is with “replacement” of the lost member and/or departure of surviving adults Household dissolution is a common response to an HIV/AIDS death The apparently relatively small effect of an HIV/AIDS death in the household on material welfare is partly because households are adapting in these ways Our findings are consistent with those from rural Uganda and Tanzania Important to be aware, when designing programmes to help to mitigate social and economic consequences of young adult HIV/AIDS deaths, that households are “adjusting”/ responding in these ways For the future: impact of young adult HIV/AIDS death on the “next generation” - children’s education and anthropometry; and the effect of ART provision -

15. Acknowledgements Funded by Wellcome Trust All the members of the Continuous Registration System (CRS) team, who conducted the field work