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Population-level effect of HIV on adult mortality and early evidence of reversal after introduction of antiretroviral therapy in Malawi

Population-level effect of HIV on adult mortality and early evidence of reversal after introduction of antiretroviral therapy in Malawi
Population-level effect of HIV on adult mortality and early evidence of reversal after introduction of antiretroviral therapy in Malawi
BACKGROUND: Malawi, which has about 80,000 deaths from AIDS every year, made free antiretroviral therapy available to more than 80 000 patients between 2004 and 2006. We aimed to investigate mortality in a population before and after the introduction of free antiretroviral therapy, and therefore to assess the effects of such programmes on survival at the population level.

METHODS: We used a demographic surveillance system to measure mortality in a population of 32,000 in northern Malawi, from August, 2002, when free antiretroviral therapy was not available in the study district, until February, 2006, 8 months after a clinic opened. Causes of death were established through verbal autopsies (retrospective interviews). Patients who registered for antiretroviral therapy at the clinic were identified and linked to the population under surveillance. Trends in mortality were analysed by age, sex, cause of death, and zone of residence.

FINDINGS: Before antiretroviral therapy became available in June, 2005, mortality in adults (aged 15-59 years) was 9.8 deaths for 1000 person-years of observation (95% CI 8.9-10.9). The probability of dying between the ages of 15 and 60 years was 43% (39-49) for men and 43% (38-47) for women; 229 of 352 deaths (65.1%) were attributed to AIDS. 8 months after the clinic that provided antiretroviral therapy opened, 107 adults from the study population had accessed treatment, out of an estimated 334 in need of treatment. Overall mortality in adults had decreased by 10% from 10.2 to 8.7 deaths for 1000 person-years of observation (adjusted rate ratio 0.90, 95% CI 0.70-1.14). Mortality was reduced by 35% (adjusted rate ratio 0.65, 0.46-0.92) in adults near the main road, where mortality before antiretroviral therapy was highest (from 13.2 to 8.5 deaths per 1000 person-years of observation before and after antiretroviral therapy). Mortality in adults aged 60 years or older did not change.

INTERPRETATION: Our findings of a reduction in mortality in adults aged between 15 and 59 years, with no change in those older than 60 years, suggests that deaths from AIDS were averted by the rapid scale-up of free antiretroviral therapy in rural Malawi, which led to a decline in adult mortality that was detectable at the population level.
0140-6736
1603-1611
Jahn, A.
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Floyd, S.
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Crampin, A.C.
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Mwaungulu, F.
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Mvula, H.
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Munthali, F.
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McGrath, N.
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Mwafilaso, J.
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Mwinuka, V.
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Mangongo, B.
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Fine, P.E.
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Zaba, B.
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Glynn, J.R.
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Jahn, A.
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Floyd, S.
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Crampin, A.C.
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Mwaungulu, F.
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Mvula, H.
eadd559e-f5f2-419f-9eb4-288f41674643
Munthali, F.
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McGrath, N.
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Mwafilaso, J.
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Mwinuka, V.
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Mangongo, B.
caef0121-4310-4743-8517-9142d831aa80
Fine, P.E.
165bb366-2524-48a6-a8aa-49f9c4b3d2ec
Zaba, B.
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Glynn, J.R.
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Jahn, A., Floyd, S., Crampin, A.C., Mwaungulu, F., Mvula, H., Munthali, F., McGrath, N., Mwafilaso, J., Mwinuka, V., Mangongo, B., Fine, P.E., Zaba, B. and Glynn, J.R. (2008) Population-level effect of HIV on adult mortality and early evidence of reversal after introduction of antiretroviral therapy in Malawi. The Lancet, 371 (9624), 1603-1611. (doi:10.1016/S0140-6736(08)60693-5). (PMID:18468544)

Record type: Article

Abstract

BACKGROUND: Malawi, which has about 80,000 deaths from AIDS every year, made free antiretroviral therapy available to more than 80 000 patients between 2004 and 2006. We aimed to investigate mortality in a population before and after the introduction of free antiretroviral therapy, and therefore to assess the effects of such programmes on survival at the population level.

METHODS: We used a demographic surveillance system to measure mortality in a population of 32,000 in northern Malawi, from August, 2002, when free antiretroviral therapy was not available in the study district, until February, 2006, 8 months after a clinic opened. Causes of death were established through verbal autopsies (retrospective interviews). Patients who registered for antiretroviral therapy at the clinic were identified and linked to the population under surveillance. Trends in mortality were analysed by age, sex, cause of death, and zone of residence.

FINDINGS: Before antiretroviral therapy became available in June, 2005, mortality in adults (aged 15-59 years) was 9.8 deaths for 1000 person-years of observation (95% CI 8.9-10.9). The probability of dying between the ages of 15 and 60 years was 43% (39-49) for men and 43% (38-47) for women; 229 of 352 deaths (65.1%) were attributed to AIDS. 8 months after the clinic that provided antiretroviral therapy opened, 107 adults from the study population had accessed treatment, out of an estimated 334 in need of treatment. Overall mortality in adults had decreased by 10% from 10.2 to 8.7 deaths for 1000 person-years of observation (adjusted rate ratio 0.90, 95% CI 0.70-1.14). Mortality was reduced by 35% (adjusted rate ratio 0.65, 0.46-0.92) in adults near the main road, where mortality before antiretroviral therapy was highest (from 13.2 to 8.5 deaths per 1000 person-years of observation before and after antiretroviral therapy). Mortality in adults aged 60 years or older did not change.

INTERPRETATION: Our findings of a reduction in mortality in adults aged between 15 and 59 years, with no change in those older than 60 years, suggests that deaths from AIDS were averted by the rapid scale-up of free antiretroviral therapy in rural Malawi, which led to a decline in adult mortality that was detectable at the population level.

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Published date: 10 May 2008
Organisations: Faculty of Health Sciences

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Local EPrints ID: 350451
URI: http://eprints.soton.ac.uk/id/eprint/350451
ISSN: 0140-6736
PURE UUID: efcee96d-ba00-4d9b-a46c-bac43b865eb9
ORCID for N. McGrath: ORCID iD orcid.org/0000-0002-1039-0159

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Date deposited: 25 Mar 2013 12:26
Last modified: 17 Dec 2019 01:37

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Contributors

Author: A. Jahn
Author: S. Floyd
Author: A.C. Crampin
Author: F. Mwaungulu
Author: H. Mvula
Author: F. Munthali
Author: N. McGrath ORCID iD
Author: J. Mwafilaso
Author: V. Mwinuka
Author: B. Mangongo
Author: P.E. Fine
Author: B. Zaba
Author: J.R. Glynn

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