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Mortality trends in the era of antiretroviral therapy: evidence from the Network for Analysing Longitudinal Population based HIV/AIDS data on Africa (ALPHA)

Mortality trends in the era of antiretroviral therapy: evidence from the Network for Analysing Longitudinal Population based HIV/AIDS data on Africa (ALPHA)
Mortality trends in the era of antiretroviral therapy: evidence from the Network for Analysing Longitudinal Population based HIV/AIDS data on Africa (ALPHA)
Background:

The rollout of antiretroviral therapy (ART) is one of the largest public health interventions in Eastern and Southern Africa of recent years. Its impact is well described in clinical cohort studies, but population-based evidence is rare.

Methods:

We use data from seven demographic surveillance sites that also conduct community-based HIV testing and collect information on the uptake of HIV services. We present crude death rates of adults (aged 15–64) for the period 2000–2011 by sex, HIV status, and treatment status. Parametric survival models are used to estimate age-adjusted trends in the mortality rates of people living with HIV (PLHIV) before and after the introduction of ART.

Results:

The pooled ALPHA Network dataset contains 2.4 million person-years of follow-up time, and 39114 deaths (6893 to PLHIV). The mortality rates of PLHIV have been relatively static before the availability of ART. Mortality declined rapidly thereafter, with typical declines between 10 and 20% per annum. Compared with the pre-ART era, the total decline in mortality rates of PLHIV exceeds 58% in all study sites with available data, and amounts to 84% for women in Masaka (Uganda). Mortality declines have been larger for women than for men; a result that is statistically significant in five sites. Apart from the early phase of treatment scale up, when the mortality of PLHIV on ART was often very high, mortality declines have been observed in PLHIV both on and off ART.

Conclusion:

The expansion of treatment has had a large and pervasive effect on adult mortality. Mortality declines have been more pronounced for women, a factor that is often attributed to women's greater engagement with HIV services. Improvements in the timing of ART initiation have contributed to mortality reductions in PLHIV on ART, but also among those who have not (yet) started treatment because they are increasingly selected for early stage disease.
S533-S542
Reniers, Georgesa
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Slaymaker, Emma
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Nakiyingi-Miiro, Jessica
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Nyamukapa, Constance
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Crampin, Amelia Catharine
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Herbst, Kobus
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Urassa, Mark
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Otieno, Fred
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Gregson, Simon
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Sewe, Maquins
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Michael, Denna
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Lutalo, Tom
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Hosegood, Victoria
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Kasamba, Ivan
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Price, Alison
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Nabukalu, Dorean
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Mclean, Estelle
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Zaba, Basia
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Reniers, Georgesa
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Slaymaker, Emma
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Nakiyingi-Miiro, Jessica
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Nyamukapa, Constance
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Crampin, Amelia Catharine
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Herbst, Kobus
fab67269-11ef-4c52-91bc-635b00065504
Urassa, Mark
00e0ab52-c0b3-4067-932e-66b0ea24e672
Otieno, Fred
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Gregson, Simon
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Sewe, Maquins
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Michael, Denna
549d5e34-bf84-4365-8b2b-e2caacafceb6
Lutalo, Tom
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Hosegood, Victoria
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Kasamba, Ivan
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Price, Alison
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Nabukalu, Dorean
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Mclean, Estelle
d26a1af6-e8d1-41dc-a72d-5518c6550592
Zaba, Basia
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Reniers, Georgesa, Slaymaker, Emma, Nakiyingi-Miiro, Jessica, Nyamukapa, Constance, Crampin, Amelia Catharine, Herbst, Kobus, Urassa, Mark, Otieno, Fred, Gregson, Simon, Sewe, Maquins, Michael, Denna, Lutalo, Tom, Hosegood, Victoria, Kasamba, Ivan, Price, Alison, Nabukalu, Dorean, Mclean, Estelle and Zaba, Basia (2014) Mortality trends in the era of antiretroviral therapy: evidence from the Network for Analysing Longitudinal Population based HIV/AIDS data on Africa (ALPHA). [in special issue: The 2013/14 UNAIDS Estimates Methods: Extending The Scope and Granularity of HIV Estimates] AIDS, 28 (4), S533-S542. (doi:10.1097/QAD.0000000000000496). (PMID:24235929)

Record type: Article

Abstract

Background:

The rollout of antiretroviral therapy (ART) is one of the largest public health interventions in Eastern and Southern Africa of recent years. Its impact is well described in clinical cohort studies, but population-based evidence is rare.

Methods:

We use data from seven demographic surveillance sites that also conduct community-based HIV testing and collect information on the uptake of HIV services. We present crude death rates of adults (aged 15–64) for the period 2000–2011 by sex, HIV status, and treatment status. Parametric survival models are used to estimate age-adjusted trends in the mortality rates of people living with HIV (PLHIV) before and after the introduction of ART.

Results:

The pooled ALPHA Network dataset contains 2.4 million person-years of follow-up time, and 39114 deaths (6893 to PLHIV). The mortality rates of PLHIV have been relatively static before the availability of ART. Mortality declined rapidly thereafter, with typical declines between 10 and 20% per annum. Compared with the pre-ART era, the total decline in mortality rates of PLHIV exceeds 58% in all study sites with available data, and amounts to 84% for women in Masaka (Uganda). Mortality declines have been larger for women than for men; a result that is statistically significant in five sites. Apart from the early phase of treatment scale up, when the mortality of PLHIV on ART was often very high, mortality declines have been observed in PLHIV both on and off ART.

Conclusion:

The expansion of treatment has had a large and pervasive effect on adult mortality. Mortality declines have been more pronounced for women, a factor that is often attributed to women's greater engagement with HIV services. Improvements in the timing of ART initiation have contributed to mortality reductions in PLHIV on ART, but also among those who have not (yet) started treatment because they are increasingly selected for early stage disease.

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More information

Accepted/In Press date: 22 September 2014
Published date: November 2014
Organisations: Social Statistics & Demography

Identifiers

Local EPrints ID: 371996
URI: http://eprints.soton.ac.uk/id/eprint/371996
PURE UUID: ae914df1-6b28-44a8-b9c5-61260d2df003
ORCID for Victoria Hosegood: ORCID iD orcid.org/0000-0002-2244-2518

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Date deposited: 21 Nov 2014 16:33
Last modified: 15 Mar 2024 03:37

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Contributors

Author: Georgesa Reniers
Author: Emma Slaymaker
Author: Jessica Nakiyingi-Miiro
Author: Constance Nyamukapa
Author: Amelia Catharine Crampin
Author: Kobus Herbst
Author: Mark Urassa
Author: Fred Otieno
Author: Simon Gregson
Author: Maquins Sewe
Author: Denna Michael
Author: Tom Lutalo
Author: Ivan Kasamba
Author: Alison Price
Author: Dorean Nabukalu
Author: Estelle Mclean
Author: Basia Zaba

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