Using payroll and employment records from a large tea plantation in Kericho District of Kenya, we examined the employment patterns of 97 HIV-infected workers (56 women and 41 men) receiving ART at their company clinic from two years pre-ART through 12 months post-ART. We found that male index workers were able to maintain a similar pattern of work as the male comparison group until the month they initiated therapy and then returned to a similar work pattern by their 7th month on ART. For women, we found evidence of substantial differences in employment outcomes, mainly through being less productive while plucking, working fewer days plucking tea, and shifting to non-plucking work assignments. Although women in the index group increased the number of days they spent harvesting tea once they initiated ART, they continued to spend fewer days plucking tea in the 12th month on ART. To compensate, they worked substantially more days on other non-plucking tasks than the general female workforce.
There are probably multiple reasons for the differences in the employment outcomes observed between HIV-infected women and men in the pre-ART and post-ART periods. There is little evidence in the literature of gender-related biological differences in either disease progression or the effectiveness of ART, though the available research comes from industrialized country settings [27
]. In some studies in southern Africa, women face a greater risk of ARV-related toxicities, particularly hyperlactatemia and lactic acidosis associated with d4T [28
], though this finding was not replicated in research in Kenya [29
Some of the differences in gender-specific employment outcomes we observed are likely to be associated with socioeconomic factors. Women may experience more HIV-related morbidity and/or fatigue than men in the pre- and post-ART period as a result of the greater household demands on their time. Women typically allocate much of their non-wage earning time to household production activities, such as cooking, cleaning, child care, and care for sick family members. The latter may be particularly important for women in our index population, who may well have HIV-positive children or spouses. Staff at the ART clinic may be more likely to request or recommend that their female patients be assigned to non-plucking days more than their male patients.
In the absence of antiretroviral therapy, HIV-infected individuals eventually develop AIDS and die. While the progression of the disease from HIV-infection to an AIDS diagnosis may be 10 years or more, studies from resource-limited settings suggest a median survival time of 11 months following an AIDS diagnosis [7
]. Thus, if the tea pluckers included in this study had not initiated therapy, some 50% would likely have died by the end of the study period. Instead of dying, however, the results presented in this paper show that HIV-infected workers who accessed ART in this resource limited setting returned to physically demanding, labor intensive activities after starting treatment.
The number and representativeness of the workers in the index group are a potential limitation of this study for a broader generalization to the treated population in this study site. Regarding numbers in the index groups, it is possible that the male index group (n = 41) is too small to detect significant mean differences given the relatively small size of the estimated differences. Future analysis with a large number of workers in the index group and for a longer follow up period is needed to explore this issue further. Regarding representativeness, enrolment in the study began in March of 2006 as patients came to the central ART clinic for regularly scheduled clinic visits. We cannot determine whether the index group constitutes a random sample of the ART-eligible population of tea pluckers, estimated at about 150 total tea pluckers at the time of enrolment. A few potential participants (<5) discussed enrolment with the study nurse but declined to participate. After consenting, no one in the index group died during the time period included in this analysis.
Although this study is being conducted in a plantation setting, the benefits of ART observed in this setting are relevant, at least to some extent, to the general rural population of Kenya. Plucking tea is physically demanding outdoor work. Pluckers walk substantial distances to fields early in the morning, stand for hours with heavy baskets on their backs, push through rows of bushes, carry heavy packs to weighing stations, and repeat numerous times a day the process of reaching, plucking, raising arms, and placing tea leaf in their basket. Many of the characteristics of tea plucking are thus similar to those of other types of labor commonly found in rural Kenya, such as family labor on one's own farm. On a family farm, there are often several types of tasks to be performed on the same day, so that individuals can shift among tasks depending on their health.
Two clear differences exist, however, between the tea estate workers and other rural workers. First, relative to informal sector workers, tea pluckers are not especially poor or malnourished and generally have good access to high quality health care on the plantation. This is clearly not the case for some portion of the rural population. Second, barriers to accessing and adhering to ART within this plantation setting are probably as low as possible. Cash transportation costs to the ART clinic are zero (the company provides transportation) and travel times are modest.