Mapping subnational HIV mortality in six Latin American countries with incomplete vital registration systems

Local Burden Of Disease Hiv Collaborators

doi:10.1186/s12916-020-01876-4

Abstract

BackgroundHuman immunodeficiency virus (HIV) remains a public health priority in Latin America. While the burden of HIV is historically concentrated in urban areas and high-risk groups, subnational estimates that cover multiple countries and years are missing. This paucity is partially due to incomplete vital registration (VR) systems and statistical challenges related to estimating mortality rates in areas with low numbers of HIV deaths. In this analysis, we address this gap and provide novel estimates of the HIV mortality rate and the number of HIV deaths by age group, sex, and municipality in Brazil, Colombia, Costa Rica, Ecuador, Guatemala, and Mexico.MethodsWe performed an ecological study using VR data ranging from 2000 to 2017, dependent on individual country data availability. We modeled HIV mortality using a Bayesian spatially explicit mixed-effects regression model that incorporates prior information on VR completeness. We calibrated our results to the Global Burden of Disease Study 2017.ResultsAll countries displayed over a 40-fold difference in HIV mortality between municipalities with the highest and lowest age-standardized HIV mortality rate in the last year of study for men, and over a 20-fold difference for women. Despite decreases in national HIV mortality in all countries—apart from Ecuador—across the period of study, we found broad variation in relative changes in HIV mortality at the municipality level and increasing relative inequality over time in all countries. In all six countries included in this analysis, 50% or more HIV deaths were concentrated in fewer than 10% of municipalities in the latest year of study. In addition, national age patterns reflected shifts in mortality to older age groups—the median age group among decedents ranged from 30 to 45 years of age at the municipality level in Brazil, Colombia, and Mexico in 2017.ConclusionsOur subnational estimates of HIV mortality revealed significant spatial variation and diverging local trends in HIV mortality over time and by age. This analysis provides a framework for incorporating data and uncertainty from incomplete VR systems and can help guide more geographically precise public health intervention to support HIV-related care and reduce HIV-related deaths.

Highlights

Human immunodeficiency virus (HIV) remains a public health priority in Latin America
To resolve the difficulties associated with small numbers of deaths and vital registration (VR) completeness, Schmertmann and Gonzaga proposed a Bayesian model framework for small area life expectancy estimation in countries with incomplete VR systems [31]. This method incorporates a novel functional form for mortality that is informed by prior distributions for VR completeness coverage based on empirical evidence. We address these challenges by utilizing comprehensive cause of death assignment and applying a small area estimation framework that incorporates prior information on VR completeness to produce estimates of HIV mortality and deaths due to HIV by age and sex at the municipality level in six countries in Latin America: Brazil, Mexico, Guatemala, Costa Rica, Colombia, and Ecuador
Our modeling approach leverages information from neighboring areas across space and time to produce estimates across all years of available data. These six countries were selected based on availability of VR data, but not all contained the same range of available years: our analysis extends from 2000 to 2017 in Brazil, Colombia, and Mexico; from 2009 to 2017 in Guatemala; from 2004 to 2014 in Ecuador; and from 2014 to 2016 in Costa Rica

Summary

Introduction

Human immunodeficiency virus (HIV) remains a public health priority in Latin America. While the burden of HIV is historically concentrated in urban areas and high-risk groups, subnational estimates that cover multiple countries and years are missing. This paucity is partially due to incomplete vital registration (VR) systems and statistical challenges related to estimating mortality rates in areas with low numbers of HIV deaths. While the burden of the HIV epidemic is most concentrated in sub-Saharan Africa, HIV remains a public health priority in Latin America. The Joint United Nations Program on HIV/AIDS (UNAIDS) Fast-Track strategy emphasizes the need to reduce HIV-related deaths to less than 500,000 deaths worldwide by 2020—a 75% reduction from deaths in 2010 [3]. Continued efforts are needed to track progress towards meeting the UNAIDS Fast-Track goals with respect to HIV mortality

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