“Evaluating Interventions for the Prevention of Mother-to-Child Transmission of HIV:
Evidence from Africa", 2016
(Job market paper)

Abstract: Development assistance from rich countries to poor countries faces challenges to effective implementation. Aid in the form of technical recommendations and funding often fails to reach people in need or has unintended negative consequences when executed on a large scale. In this paper, I evaluate the impact of prevention of mother-to-child transmission of HIV (PMTCT) services, a major contemporary example of development aid for health. PMTCT remains active, yet little is known about the outcomes of these services on a large scale.

A key component of PMTCT efforts by WHO/UNICEF is inducing HIV-positive mothers to wean early to mitigate the risk of postnatal HIV transmission through breastfeeding. I propose a novel method to identify program adherence using survey data on breastfeeding durations and mother's HIV status from 21 African countries. A difference-in-differences estimation strategy finds that HIV-positive mothers who know their status become 15-20 percentage points more likely than HIV-negative mothers to wean by the program benchmark of 6 months post-PMTCT availability, a 300% increase, while HIV-positive mothers who do not know their status do not change their breastfeeding behavior. Despite impressive program reach and adherence, I show that survival rates have not significantly changed for children of HIV-positive mothers after PMTCT. I also find evidence that early weaning increases mortality rates for children without access to piped water, even among children of HIV-positive mothers, indicating that the risk of malnutrition and disease from not breastfeeding in poor environments outweighs the risk of transmission. My work suggests that PMTCT services should be more tailored to reflect heterogeneous conditions on the ground, such as access to clean water.