Abstract
Background: Improved life expectancy in high HIV prevalence populations has been observed since antiretroviral therapy (ART) scale-up. However, it is unclear if the benefits are sustained, and the mortality among HIV-positive individuals not (yet) on ART is not well described. We assessed temporal change in mortality over 9 years in rural Malawi. Methods: Within a demographic surveillance site in northern rural Malawi, we combined demographic, HIV and ART uptake data. We calculated life expectancy using Kaplan-Meier estimates, and compared mortality rates and rate ratios using Poisson regression, by period of ART availability (July 2005–June 2008, July 2008–June 2011 and July 2011–June 2014). Results: Among 32 664 individuals there were 1424 deaths; 1930 individuals were known HIV-positive, of whom 1382 started ART. Overall, life expectancy at age 15 years increased by 10 years within 5 years of ART introduction, and plateaued. Age-standardized adult mortality rates declined from 11.3/1000 to 7.5/1000 person-years between the first and last time period. In July 2011-June 2014 compared with July 2005–June 2008, mortality declined in HIV-positive individuals on ART (rate ratio adjusted (aRR) for age, sex, location and education, 0.3; 95% confidence interval (CI) 0.2–0.5) and in those not (yet) on ART (aRR 0.3; 95%CI 0.1–0.5) but not in HIV-negative individuals (aRR 1.1; 95%CI 0.7–1.9). Conclusions: Total population adult life expectancy increased toward that of HIV-negative individuals by 2011 and remained raised. The reduction in all-cause and HIV-related mortality in HIV-positive individuals not (yet) on ART suggests ART uptake is occurring at an earlier disease stage, particularly in women.
Highlights
In 2004, Malawi initiated a public health approach to HIV care and treatment services
Of 1930 individuals identified as HIV-positive during follow-up, antiretroviral therapy (ART) uptake was established for 1382 individuals: 1192 (86%) via a clinic register link and 190 (14%) via self-report
Data on World Health Organization (WHO) stage at ART initiation were available for 97% of those with a clinic register link: initiation at WHO stage four declined from 33% in July 2005–June 2008, to 8% in July 2008–June 2011 and to 7% in July 2011–June 2014
Summary
In 2004, Malawi initiated a public health approach to HIV care and treatment services. The programme aimed to deliver antiretroviral therapy (ART) to all eligible HIVpositive individuals presenting to decentralized clinics, with minimal reliance on laboratory support for determining eligibility and for monitoring patients in care.[1,2] Early success of this initiative was evident within the first year of scale-up, with increased survival among those started on treatment[3] and declines in all-cause mortality rates at the population level.[4]. Since the scale-up of ART programmes, substantial reductions in adult mortality 5 and improved life expectancy among HIV-positive individuals on ART6–9 have been observed in other high HIV prevalence sub-Saharan African (SSA) countries. Improved life expectancy in high HIV prevalence populations has been observed since antiretroviral therapy (ART) scale-up It is unclear if the benefits are sustained, and the mortality among HIV-positive individuals not (yet) on ART is not well described. The reduction in all-cause and HIV-related mortality in HIV-positive individuals not (yet) on ART suggests ART uptake is occurring at an earlier disease stage, in women
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