Abstract
ObjectiveTo provide a broad and up-to-date picture of the effect of antiretroviral therapy (ART) provision on population-level mortality in Southern and East Africa.MethodsData on all-cause, AIDS and non-AIDS mortality among 15–59 year olds were analysed from demographic surveillance sites (DSS) in Karonga (Malawi), Kisesa (Tanzania), Masaka (Uganda) and the Africa Centre (South Africa), using Poisson regression. Trends over time from up to 5 years prior to ART roll-out, to 4–6 years afterwards, are presented, overall and by age and sex. For Masaka and Kisesa, trends are analysed separately for HIV-negative and HIV-positive individuals. For Karonga and the Africa Centre, trends in AIDS and non-AIDS mortality are analysed using verbal autopsy data.ResultsFor all-cause mortality, overall rate ratios (RRs) comparing the period 2–6 years following ART roll-out with the pre-ART period were 0.58 (5.9 vs. 10.2 deaths per 1000 person-years) in Karonga, 0.79 (7.2 vs. 9.1 deaths per 1000 person-years) in Kisesa, 0.61 (6.7 compared with 11.0 deaths per 1000 person-years) in Masaka and 0.79 (14.8 compared with 18.6 deaths per 1000 person-years) in the Africa Centre DSS. The mortality decline was seen only in HIV-positive individuals/AIDS mortality, with no decline in HIV-negative individuals/non-AIDS mortality. Less difference was seen in Kisesa where ART uptake was lower.ConclusionsFalls in all-cause mortality are consistent with ART uptake. The largest falls occurred where ART provision has been decentralised or available locally, suggesting that this is important.
Highlights
Adult HIV prevalence has been high across Southern and East Africa since the 1990s, ranging from around 6% to over 20% (UNAIDS & WHO 2009), and recent evidence shows that HIV incidence remains high (Stover et al 2010)
AIDS and non-AIDS deaths can be distinguished by the reviewing clinician, and in the analyses presented here, deaths attributed to TB ⁄ AIDS are included as AIDS mortality
In Karonga and Kisesa, the fall in mortality was smaller in remote rural areas, while in the Africa Centre demographic surveillance sites (DSS), there was no evidence of a fall in mortality in urban areas
Summary
Adult HIV prevalence has been high across Southern and East Africa since the 1990s, ranging from around 6% to over 20% (UNAIDS & WHO 2009), and recent evidence shows that HIV incidence remains high (Stover et al 2010). The impact of HIV on adult mortality has been huge: for example, 63% of all deaths were attributed to AIDS among 15–59 year olds in northern Malawi (Jahn et al 2008) between 2002 and 2005, around half of all. In Karonga district in northern Malawi, all-cause mortality among 15–59 year olds fell by around 30% and mortality attributed to AIDS by around 50% during the third year of ART provision, compared with the years immediately preceding ART roll-out (Floyd et al 2010). In KwaZulu Natal, among adults aged 25–49 years old, mortality attributed to AIDS fell by around 25% averaged over the first 3 years of ART rollout (Herbst et al 2009), and in Masaka district, Uganda all-cause mortality among 15–59 year olds fell by an average of around 40% between 1 and 5 years after the start of free ART provision (Kasamba et al 2012)
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