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Nabukalu D, Calazans JA, Marston M, Calvert C, Nakawooya H, Nansereko B, Sekubugu R, Nakigozi G, Serwadda D, Sewankambo N, Kigozi G, Gray RH, Nalugoda F, Makumbi F, Lutalo T, Todd J. Estimation of cause-specific mortality in Rakai, Uganda, using verbal autopsy 1999-2019. Glob Health Action 2024; 17:2338635. [PMID: 38717826 PMCID: PMC11080674 DOI: 10.1080/16549716.2024.2338635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 03/31/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND There are scant data on the causes of adult deaths in sub-Saharan Africa. We estimated the level and trends in adult mortality, overall and by different causes, in rural Rakai, Uganda, by age, sex, and HIV status. OBJECTIVES To estimate and analyse adult cause-specific mortality trends in Rakai, Uganda. METHODOLOGY Mortality information by cause, age, sex, and HIV status was recorded in the Rakai Community Cohort study using verbal autopsy interviews, HIV serosurveys, and residency data. We estimated the average number of years lived in adulthood. Using demographic decomposition methods, we estimated the contribution of each cause of death to adult mortality based on the average number of years lived in adulthood. RESULTS Between 1999 and 2019, 63082 adults (15-60 years) were censused, with 1670 deaths registered. Of these, 1656 (99.2%) had completed cause of death data from verbal autopsy. The crude adult death rate was 5.60 (95% confidence interval (CI): 5.33-5.87) per 1000 person-years of observation (pyo). The crude death rate decreased from 11.41 (95% CI: 10.61-12.28) to 3.27 (95% CI: 2.89-3.68) per 1000 pyo between 1999-2004 and 2015-2019. The average number of years lived in adulthood increased in people living with HIV and decreased in HIV-negative individuals between 2000 and 2019. Communicable diseases, primarily HIV and Malaria, had the biggest decreases, which improved the average number of years lived by approximately extra 12 years of life in females and 6 years in males. There were increases in deaths due to non-communicable diseases and external causes, which reduced the average number of years lived in adulthood by 2.0 years and 1.5 years in females and males, respectively. CONCLUSION There has been a significant decline in overall mortality from 1999 to 2019, with the greatest decline seen in people living with HIV since the availability of antiretroviral therapy in 2004. By 2020, the predominant causes of death among females were non-communicable diseases, with external causes of death dominating in males.
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Affiliation(s)
- Dorean Nabukalu
- Data management, Rakai Health Sciences Program, Rakai, Uganda
- Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Júlia Almeida Calazans
- Centre for Demographic Studies (CED), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Milly Marston
- Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Clara Calvert
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | | | - Robert Sekubugu
- Data management, Rakai Health Sciences Program, Rakai, Uganda
| | | | - David Serwadda
- Data management, Rakai Health Sciences Program, Rakai, Uganda
- Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Nelson Sewankambo
- Data management, Rakai Health Sciences Program, Rakai, Uganda
- College of Health Sciences, Makerere University School of Medicine, Kampala, Uganda
| | - Godfrey Kigozi
- Data management, Rakai Health Sciences Program, Rakai, Uganda
| | - Ronald H Gray
- Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Fred Nalugoda
- Data management, Rakai Health Sciences Program, Rakai, Uganda
| | - Fredrick Makumbi
- Data management, Rakai Health Sciences Program, Rakai, Uganda
- Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Tom Lutalo
- Data management, Rakai Health Sciences Program, Rakai, Uganda
- Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Jim Todd
- Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Houle B, Kabudula C, Mojola SA, Angotti N, Gómez-Olivé FX, Gareta D, Herbst K, Clark SJ, Menken J, Canudas-Romo V. Mortality variability and differentials by age and causes of death in rural South Africa, 1994-2018. BMJ Glob Health 2024; 9:e013539. [PMID: 38589045 PMCID: PMC11015189 DOI: 10.1136/bmjgh-2023-013539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/20/2023] [Indexed: 04/10/2024] Open
Abstract
INTRODUCTION Understanding mortality variability by age and cause is critical to identifying intervention and prevention actions to support disadvantaged populations. We assessed mortality changes in two rural South African populations over 25 years covering pre-AIDS and peak AIDS epidemic and subsequent antiretroviral therapy (ART) availability. METHODS Using population surveillance data from the Agincourt Health and Socio-Demographic Surveillance System (AHDSS; 1994-2018) and Africa Health Research Institute (AHRI; 2000-2018) for 5-year periods, we calculated life expectancy from birth to age 85, mortality age distributions and variation, and life-years lost (LYL) decomposed into four cause-of-death groups. RESULTS The AIDS epidemic shifted the age-at-death distribution to younger ages and increased LYL. For AHDSS, between 1994-1998 and 1999-2003 LYL increased for females from 13.6 years (95% CI 12.7 to 14.4) to 22.1 (95% CI 21.2 to 23.0) and for males from 19.9 (95% CI 18.8 to 20.8) to 27.1 (95% CI 26.2 to 28.0). AHRI LYL in 2000-2003 was extremely high (females=40.7 years (95% CI 39.8 to 41.5), males=44.8 years (95% CI 44.1 to 45.5)). Subsequent widespread ART availability reduced LYL (2014-2018) for women (AHDSS=15.7 (95% CI 15.0 to 16.3); AHRI=22.4 (95% CI 21.7 to 23.1)) and men (AHDSS=21.2 (95% CI 20.5 to 22.0); AHRI=27.4 (95% CI 26.7 to 28.2)), primarily due to reduced HIV/AIDS/TB deaths in mid-life and other communicable disease deaths in children. External causes increased as a proportion of LYL for men (2014-2018: AHRI=25%, AHDSS=17%). The share of AHDSS LYL 2014-2018 due to non-communicable diseases exceeded pre-HIV levels: females=43%; males=40%. CONCLUSIONS Our findings highlight shifting burdens in cause-specific LYL and persistent mortality differentials in two populations experiencing complex epidemiological transitions. Results show high contributions of child deaths to LYL at the height of the AIDS epidemic. Reductions in LYL were primarily driven by lowered HIV/AIDS/TB and other communicable disease mortality during the ART periods. LYL differentials persist despite widespread ART availability, highlighting the contributions of other communicable diseases in children, HIV/AIDS/TB and external causes in mid-life and non-communicable diseases in older ages.
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Affiliation(s)
- Brian Houle
- School of Demography, The Australian National University, Acton, Australian Capital Territory, Australia
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Institute of Behavioral Science, University of Colorado Boulder, Boulder, Colorado, USA
| | - Chodziwadziwa Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Sanyu A Mojola
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Sociology, School of Public and International Affairs, and Office of Population Research, Princeton University, Princeton, New Jersey, USA
| | - Nicole Angotti
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Institute of Behavioral Science, University of Colorado Boulder, Boulder, Colorado, USA
- Department of Sociology, American University, Washington, DC, USA
| | - Francesc Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Dickman Gareta
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Kobus Herbst
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- DSI-MRC South African Population Research Infrastructure Network, Durban, South Africa
| | - Samuel J Clark
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Sociology, The Ohio State University, Columbus, Ohio, USA
| | - Jane Menken
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Institute of Behavioral Science, University of Colorado Boulder, Boulder, Colorado, USA
| | - Vladimir Canudas-Romo
- School of Demography, The Australian National University, Acton, Australian Capital Territory, Australia
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Dye CK, Wu H, Jackson GL, Kidane A, Nkambule R, Lukhele NG, Malinga BP, Chekenyere R, El-Sadr WM, Baccarelli AA, Harris TG. Epigenetic aging in older people living with HIV in Eswatini: a pilot study of HIV and lifestyle factors and epigenetic aging. Clin Epigenetics 2024; 16:32. [PMID: 38403593 PMCID: PMC10895753 DOI: 10.1186/s13148-024-01629-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/12/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND People living with HIV (PLHIV) on effective antiretroviral therapy are living near-normal lives. Although they are less susceptible to AIDS-related complications, they remain highly vulnerable to non-communicable diseases. In this exploratory study of older PLHIV (OPLHIV) in Eswatini, we investigated whether epigenetic aging (i.e., the residual between regressing epigenetic age on chronological age) was associated with HIV-related parameters, and whether lifestyle factors modified these relationships. We calculated epigenetic aging focusing on the Horvath, Hannum, PhenoAge and GrimAge epigenetic clocks, and a pace of biological aging biomarker (DunedinPACE) among 44 OPLHIV in Eswatini. RESULTS Age at HIV diagnosis was associated with Hannum epigenetic age acceleration (EAA) (β-coefficient [95% Confidence Interval]; 0.53 [0.05, 1.00], p = 0.03) and longer duration since HIV diagnosis was associated with slower Hannum EAA (- 0.53 [- 1.00, - 0.05], p = 0.03). The average daily dietary intake of fruits and vegetables was associated with DunedinPACE (0.12 [0.03, 0.22], p = 0.01). The associations of Hannum EAA with the age at HIV diagnosis and duration of time since HIV diagnosis were attenuated when the average daily intake of fruits and vegetables or physical activity were included in our models. Diet and self-perceived quality of life measures modified the relationship between CD4+ T cell counts at participant enrollment and Hannum EAA. CONCLUSIONS Epigenetic age is more advanced in OPLHIV in Eswatini in those diagnosed with HIV at an older age and slowed in those who have lived for a longer time with diagnosed HIV. Lifestyle and quality of life factors may differentially affect epigenetic aging in OPLHIV. To our knowledge, this is the first study to assess epigenetic aging in OPLHIV in Eswatini and one of the few in sub-Saharan Africa.
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Affiliation(s)
- Christian K Dye
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, 630 West 168th St. Room 16-416, New York, NY, 10032, USA.
| | - Haotian Wu
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, 630 West 168th St. Room 16-416, New York, NY, 10032, USA
| | - Gabriela L Jackson
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, 630 West 168th St. Room 16-416, New York, NY, 10032, USA
| | - Altaye Kidane
- ICAP at Columbia University, Mailman School of Public Health, New York, NY, USA
| | | | | | | | | | - Wafaa M El-Sadr
- ICAP at Columbia University, Mailman School of Public Health, New York, NY, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Andrea A Baccarelli
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, 630 West 168th St. Room 16-416, New York, NY, 10032, USA
| | - Tiffany G Harris
- ICAP at Columbia University, Mailman School of Public Health, New York, NY, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
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Ndlovu S, Ross A, Mulondo M. Interventions to improve young men's utilisation of HIV-testing services in KwaZulu-Natal, South Africa: perspectives of young men and health care providers. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2023; 22:316-326. [PMID: 38117741 DOI: 10.2989/16085906.2023.2276897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/01/2023] [Indexed: 12/22/2023]
Abstract
Introduction: HIV-testing services (HTS) are an important point of entry to prevention and treatment of HIV in South Africa. Despite the availability of HTS across the region and in SA, the uptake among men remains low, especially young men residing in rural and peri-urban communities. This study aimed to explore interventions that could improve the uptake of HTS among young men in KwaZulu-Natal.Methods: A descriptive exploratory qualitative study was conducted in which 17 young men and two health care providers in Ladysmith were purposively and conveniently sampled. Data were collected through semi-structured interviews using WhatsApp and landline audio calls between September and December 2021 and thematically analysed.Results: An improvement in the health care provider attitudes and service delivery, establishment of adherence clubs for young people living with HIV, ensuring a diverse and balanced health care provider staff composition at primary health care facilities, and increased demand creation in spaces frequented by men are vital for enhancing access and utilisation of HTS among young men. Additionally, health care providers believe that the presence of male health care providers, investment in health education, prioritising men in the morning at the primary health care facilities, and the establishment of male clinics within communities as key factors in improving the uptake of HTS among young men.Conclusion: To attract and retain young men in HTS and in HIV treatment and care, several improvements at primary health care facilities need to be implemented. These should focus on addressing the specific needs and preferences of young men, ensuring their comfort and engagement in health care.
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Affiliation(s)
- Sithembiso Ndlovu
- Department of Family Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Office of the Dean, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Andrew Ross
- Department of Family Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Mutshidzi Mulondo
- Office of the Dean, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
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Fernandez D, Ali H, Pals S, Alemnji G, Vasireddy V, Siberry GK, Oboho I, Godfrey C. Assessing sex differences in viral load suppression and reported deaths using routinely collected program data from PEPFAR-supported countries in sub-Saharan Africa. BMC Public Health 2023; 23:1941. [PMID: 37805465 PMCID: PMC10559393 DOI: 10.1186/s12889-023-16453-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 08/03/2023] [Indexed: 10/09/2023] Open
Abstract
BACKGROUND In sub-Saharan Africa, more women than men access HIV testing and treatment and may have better viral load suppression (VLS). We utilized routinely reported aggregated HIV program data from 21 sub-Saharan African countries to examine sex differences in VLS and death rates within antiretroviral therapy (ART) programs supported by the United States President's Emergency Plan for AIDS Relief (PEPFAR). METHODS We included VLS and reported death data for persons aged 15 + years on ART from October-December 2020 disaggregated by sex and age for each subnational unit (SNU). We used linear mixed-model regression to estimate VLS proportion and negative binomial mixed-model regression to estimate the rates of death and death plus interruptions in treatment (IIT). All models were weighted for SNU-level ART population size and adjusted for sex, age, HIV/tuberculosis coinfection, country, and SNU; models for reported deaths and deaths plus IIT were also adjusted for SNU-level VLS. RESULTS Mean VLS proportion was higher among women than men (93.0% vs. 92.0%, p-value < 0.0001) and 50 + than 15-49 age group (93.7% vs. 91.2%, p-value < 0.0001). The mean rate of reported deaths was higher among men than women (2.37 vs. 1.51 per 1000 persons, p-value < 0.0001) and 50 + than 15-49 age group (2.39 vs. 1.50 per 1000, p-value < 0.0001); the mean rate of reported deaths plus IIT was higher among men (30.1 in men vs. 26.0 in women per 1000, p-value < 0.0001) and higher among 15-49 than 50 + age group (34.7 vs. 22.6 per 1000, p-value < 0.0001). CONCLUSIONS The mean rate of reported deaths was higher among men in most models despite adjusting for VLS. Further exploration into differences in care-seeking behaviors; coverage of screening, prophylaxis, and/or treatment of opportunistic infections; and more extensive testing options for men to include CD4 is recommended.
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Affiliation(s)
- Danielle Fernandez
- Public Health Institute (PHI), CDC Global Health Fellowship Program, Atlanta, USA.
- Division of Global HIV and Tuberculosis, Center for Global Health, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, USA.
| | - Hammad Ali
- Division of Global HIV and Tuberculosis, Center for Global Health, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, USA
| | - Sherri Pals
- Division of Global HIV and Tuberculosis, Center for Global Health, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, USA
| | - George Alemnji
- Division of Global HIV and Tuberculosis, Center for Global Health, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, USA
| | - Vamsi Vasireddy
- Walter Reed Army Institute of Research, U.S. Department of Defense (DOD), U.S. Embassy, Kampala, Uganda
| | - George K Siberry
- United States Agency for International Development (USAID), Washington, D.C, USA
| | - Ikwo Oboho
- Division of Global HIV and Tuberculosis, Center for Global Health, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, USA
| | - Catherine Godfrey
- Office of the Global AIDS Coordinator, U.S. Department of State, Washington, D.C, USA
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Dye CK, Wu H, Jackson GL, Kidane A, Nkambule R, Lukhele NG, Malinga BP, Chekenyere R, El-Sadr WM, Baccarelli AA, Harris TG. Epigenetic aging in older people living with HIV in Eswatini: a pilot study of HIV and lifestyle factors and epigenetic aging. RESEARCH SQUARE 2023:rs.3.rs-3389208. [PMID: 37886587 PMCID: PMC10602087 DOI: 10.21203/rs.3.rs-3389208/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Background People living with HIV (PLHIV) on effective antiretroviral therapy (ART) are living near-normal lives. Although they are less susceptible to AIDS-related complications, they remain highly vulnerable to non-communicable diseases (NCD). In this exploratory study of older PLHIV (OPLHIV) in Eswatini, we investigated whether biological aging (i.e., the difference between epigenetic age and chronological age, termed 'epigenetic age acceleration [EAA]') was associated with HIV-related parameters, and whether lifestyle factors modified these relationships. We calculated EAA focusing on the second-generation epigenetic clocks, PhenoAge and GrimAge, and a pace of aging biomarker (DunedinPACE) among 44 OPLHIV in Eswatini. Results Among participants, the PhenoAge clock showed older epigenetic age (68 years old [63, 77]) but a younger GrimAge epigenetic age (median=56 years old [interquartile range=50, 61]) compared to the chronological age (59 years old [54, 66]). Participants diagnosed with HIV at an older age showed slower DunedinPACE (β-coefficient [95% Confidence Interval]; -0.02 [-0.04, -0.01], p=0.002) and longer duration since HIV diagnosis was associated with faster DunedinPACE (0.02 [0.01, 0.04], p=0.002). The average daily dietary intake of fruits and vegetables was associated with faster DunedinPACE (0.12 [0.03, 0.22], p=0.01) and modified the relationship between HIV status variables (number of years living with HIV since diagnosis, age at HIV diagnosis, CD4+ T cell counts) and PhenoAge EAA, and DunedinPACE. Conclusions Biological age is accelerated in OPLHIV in Eswatini, with those living with HIV for a longer duration at risk for faster biological aging. Lifestyle factors, especially healthier diets, may attenuate biological aging in OPLHIV. To our knowledge, this is the first study to assess biological aging in Eswatini and one of the few in sub-Saharan Africa.
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Affiliation(s)
| | - Haotian Wu
- Columbia University Mailman School of Public Health
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Sifunda S, Mbewu AD, Mabaso M, Manyaapelo T, Sewpaul R, Morgan JW, Harriman NW, Williams DR, Reddy SP. Prevalence and Psychosocial Correlates of Diabetes Mellitus in South Africa: Results from the South African National Health and Nutrition Examination Survey (SANHANES-1). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20105798. [PMID: 37239526 DOI: 10.3390/ijerph20105798] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023]
Abstract
In South Africa, there are a limited number of population estimates of the prevalence of diabetes and its association with psychosocial factors. This study investigates the prevalence of diabetes and its psychosocial correlates in both the general South African population and the Black South African subpopulation using data from the SANHANES-1. Diabetes was defined as a hemoglobin A1c (HbA1c) ≥6.5% or currently on diabetes treatment. Multivariate ordinary least squares and logistic regression models were used to determine factors associated with HbA1c and diabetes, respectively. The prevalence of diabetes was significantly higher among participants who identified as Indian, followed by White and Coloured people, and lowest among Black South Africans. General population models indicated that being Indian, older aged, having a family history of diabetes, and being overweight and obese were associated with HbA1c and diabetes, and crowding was inversely associated with HbA1c and diabetes. HbA1c was inversely associated with being White, having higher education, and residing in areas with higher levels of neighborhood crime and alcohol use. Diabetes was positively associated with psychological distress. The study highlights the importance of addressing the risk factors of psychological distress, as well as traditional risk factors and social determinants of diabetes, in the prevention and control of diabetes at individual and population levels.
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Affiliation(s)
- Sibusiso Sifunda
- Public Health, Societies and Belonging, Human Sciences Research Council, Pretoria 0001, South Africa
| | - Anthony David Mbewu
- School of Medicine, Sefako Makgatho Health Sciences University, Ga-Rankuwa 0208, South Africa
| | - Musawenkosi Mabaso
- Public Health, Societies and Belonging, Human Sciences Research Council, Pretoria 0001, South Africa
| | - Thabang Manyaapelo
- Social Science Core, Africa Health Research Institute, Somkhele 3925, South Africa
| | - Ronel Sewpaul
- Public Health, Societies and Belonging, Human Sciences Research Council, Cape Town 8000, South Africa
| | - Justin Winston Morgan
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Nigel Walsh Harriman
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - David R Williams
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
- Department of African and African American Studies, Harvard University, Cambridge, MA 02138, USA
| | - Sasiragha Priscilla Reddy
- Faculty of Health Sciences, Nelson Mandela University, Port Elizabeth 6031, South Africa
- The Centre for Critical Research on Race and Identity, University of KwaZulu-Natal, Durban 4041, South Africa
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Houle B, Kabudula C, Gareta D, Herbst K, Clark SJ. Household structure, composition and child mortality in the unfolding antiretroviral therapy era in rural South Africa: comparative evidence from population surveillance, 2000-2015. BMJ Open 2023; 13:e070388. [PMID: 36921956 PMCID: PMC10030929 DOI: 10.1136/bmjopen-2022-070388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
OBJECTIVES The structure and composition of the household has important influences on child mortality. However, little is known about these factors in HIV-endemic areas and how associations may change with the introduction and widespread availability of antiretroviral treatment (ART). We use comparative, longitudinal data from two demographic surveillance sites in rural South Africa (2000-2015) on mortality of children younger than 5 years (n=101 105). DESIGN We use multilevel discrete time event history analysis to estimate children's probability of dying by their matrilineal residential arrangements. We also test if associations have changed over time with ART availability. SETTING Rural South Africa. PARTICIPANTS Children younger than 5 years (n=101 105). RESULTS 3603 children died between 2000 and 2015. Mortality risks differed by co-residence patterns along with different types of kin present in the household. Children in nuclear households with both parents had the lowest risk of dying compared with all other household types. Associations with kin and child mortality were moderated by parental status. Having older siblings lowered the probability of dying only for children in a household with both parents (relative risk ratio (RRR)=0.736, 95% CI (0.633 to 0.855)). Only in the later ART period was there evidence that older adult kin lowered the probability of dying for children in single parent households (RRR=0.753, 95% CI (0.664 to 0.853)). CONCLUSIONS Our findings provide comparative evidence of how differential household profiles may place children at higher mortality risk. Formative research is needed to understand the role of other household kin in promoting child well-being, particularly in one-parent households that are increasingly prevalent.
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Affiliation(s)
- Brian Houle
- School of Demography, The Australian National University, Canberra, Australian Capital Territory, Australia
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Acornhoek, South Africa
| | - Chodziwadziwa Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Acornhoek, South Africa
| | - Dickman Gareta
- Africa Health Research Institute, Somkhele, South Africa
| | - Kobus Herbst
- Africa Health Research Institute, Somkhele, South Africa
- DSI-MRC South African Population Research Infrastructure Network (SAPRIN), Durban, South Africa
| | - Samuel J Clark
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Acornhoek, South Africa
- Department of Sociology, The Ohio State University, Columbus, Ohio, USA
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van Heerden A, Szpiro A, Ntinga X, Celum C, van Rooyen H, Essack Z, Barnabas R. A Sequential Multiple Assignment Randomized Trial of scalable interventions for ART delivery in South Africa: the SMART ART study. Trials 2023; 24:32. [PMID: 36647092 PMCID: PMC9842495 DOI: 10.1186/s13063-022-07025-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/15/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Of the 8 million people in South Africa living with HIV, 74% of persons living with HIV are on antiretroviral therapy (ART) and 65% are virally suppressed. Detectable viral load results in HIV-associated morbidity and mortality and HIV transmission. Patient barriers to care, such as missed wages, transport costs, and long wait times for clinic visits and ART refills, are associated with detectable viral load. HIV differentiated service delivery (DSD) has simplified ART delivery for clients who achieve viral suppression and engage in care. However, DSD needs adaptation to serve clients who are not engaged in care. METHODS A Sequential Multiple Assignment Randomized Trial will be undertaken in KwaZulu-Natal, South Africa, to test adaptive ART delivery for persons with detectable viral load and/or who are not engaged in care. The types of differentiated service delivery (DSD) which will be examined in this study are clinic-based incentives, community-based smart lockers, and home delivery. The study plans to enroll up to 900 participants-people living with HIV, eligible for ART, and who are not engaged in care. The study aims to assess the proportion of ART-eligible persons living with HIV who achieve viral suppression at 18 months. The study will also evaluate the preferences of clients and providers for differentiated service delivery and evaluate the cost-effectiveness of adaptive HIV treatment for those who are not engaged in care. DISCUSSION To increase population-level viral suppression, persons with detectable viral load need responsive DSD interventions. A Sequential Multiple Assignment Randomized Trial (SMART) design facilitates the evaluation of a stepped, adaptive approach to achieving viral suppression with "right-sized" interventions for patients most in need of effective and efficient HIV care delivery strategies. TRIAL REGISTRATION ClinicalTrials.gov NCT05090150. Registered on October 22, 2021.
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Affiliation(s)
- Alastair van Heerden
- grid.417715.10000 0001 0071 1142Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa ,grid.11951.3d0000 0004 1937 1135MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Adam Szpiro
- grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA USA
| | - Xolani Ntinga
- grid.417715.10000 0001 0071 1142Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
| | - Connie Celum
- grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA USA
| | - Heidi van Rooyen
- grid.11951.3d0000 0004 1937 1135MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa ,grid.417715.10000 0001 0071 1142Human Sciences Research Council, Pietermaritzburg, South Africa
| | - Zaynab Essack
- grid.417715.10000 0001 0071 1142Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
| | - Ruanne Barnabas
- grid.32224.350000 0004 0386 9924Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
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10
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Population-Based Temporal Trends and Ethnic Disparity in Cervical Cancer Mortality in South Africa (1999-2018): A Join Point and Age-Period-Cohort Regression Analyses. Cancers (Basel) 2022; 14:cancers14246256. [PMID: 36551741 PMCID: PMC9816936 DOI: 10.3390/cancers14246256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/25/2022] [Accepted: 12/04/2022] [Indexed: 12/23/2022] Open
Abstract
Cervical cancer is one of the leading causes of cancer deaths among women in low- and middle-income countries such as South Africa. The current impact of national cervical cancer control and sexual and reproductive health interventions in South Africa reduce its burden. The aim of this study was to assess the trends in cervical cancer mortality and its relation to breast and gynaecological cancers in South Africa from 1999 to 2018. We conducted joinpoint regression analyses of the trends in crude and age-standardised mortality rates (ASMR) for cervical cancer mortality in South Africa from 1999 to 2018. An age−period−cohort regression analysis was also conducted to determine the impact of age, period, and cohort on cervical cancer mortality trends. Analyses were stratified by ethnicity. Cervical cancer (n = 59,190, 43.92%, 95% CI: 43.65−44.18%) was responsible for about 43.9% of breast and gynecological cancer deaths. The mortality rate of cervical cancer (from 11.7 to 14.08 per 100,000) increased at about 0.9% per annum (Average Annual Percent Change (AAPC): 0.9% (AAPC: 0.9%, p-value < 0.001)), and young women aged 25 to 49 years (AAPC: 1.2−3.5%, p-value < 0.001) had increased rates. The risk of cervical cancer mortality increased among successive birth cohorts. In 2018, cervical cancer mortality rate among Blacks (16.74 per 100,000 women) was about twice the rates among Coloureds (8.53 deaths per 100,000 women) and approximately four-fold among Indians/Asians (4.16 deaths per 100,000 women), and Whites (3.06 deaths per 100,000 women). Cervical cancer control efforts should be enhanced in South Africa and targeted at ethnic difference, age, period, and cohort effects.
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11
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Barnabas RV, Szpiro AA, Ntinga X, Mugambi ML, van Rooyen H, Bruce A, Joseph P, Ngubane T, Krows ML, Schaafsma TT, Zhao T, Tanser F, Baeten JM, Celum C, van Heerden A. Fee for home delivery and monitoring of antiretroviral therapy for HIV infection compared with standard clinic-based services in South Africa: a randomised controlled trial. Lancet HIV 2022; 9:e848-e856. [PMID: 36335976 PMCID: PMC9722609 DOI: 10.1016/s2352-3018(22)00254-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 08/24/2022] [Accepted: 09/02/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Home delivery and monitoring of antiretroviral therapy (ART) is convenient, overcomes logistical barriers, and could increase individual ART adherence and viral suppression. With client payment and sufficient health benefits, this strategy could be scalable. The aim of the Deliver Health Study was to test the acceptability and efficacy of a user fee for home ART monitoring and delivery. METHODS We conducted a randomised trial, the Deliver Health Study, of a fee for home delivery of ART compared with free clinic ART delivery in South Africa. People with HIV who were 18 years or older and clinically stable (including CD4 count >100 cells per μL and WHO HIV stage 1-3) were randomly assigned to: (1) fee for home delivery and monitoring of ART, including community ART initiation if needed; or (2) clinic-based ART (standard of care). The one-time fee for home delivery (ZAR 30, 60, and 90; equivalent to US$2, 4, 6) was tiered on the basis of participant income. The primary outcomes were recorded fee payment and acceptability assessed via questionnaire. The key virological secondary outcome was viral suppression with the difference between study groups assessed through robust Poisson regression including participants with viral load measured at exit (modified intention-to-treat analysis). This trial is registered on ClinicalTrials.gov (NCT04027153) and is complete, with analyses ongoing. FINDINGS From Oct 7, 2019, to Jan 30, 2020, 162 participants were enrolled; 82 were randomly assigned to the fee for home delivery group and 80 to the clinic-based group, with similar characteristics at baseline. Overall, 87 (54%) participants were men, 101 (62%) were on ART, and 98 (60%) were unemployed. In the home delivery group, 40 (49%), 33 (40%), and nine (11%) participants qualified for the ZAR 30, 60, and 90 fee, respectively. Median follow-up was 47 weeks (IQR 43-50) with 96% retention. 80 (98%) participants paid the user fee, with high acceptability and willingness to pay. In the modified intention-to-treat analysis of 155 (96%) participants who completed follow-up, fee for home delivery and monitoring statistically significantly increased viral suppression from 74% to 88% overall (RR 1·21, 95% CI 1·02-1·42); and from 64% to 84% among men (1·31, 1·01-1·71). INTERPRETATION Among South African adults with HIV, a fee for home delivery and monitoring of ART significantly increased viral suppression compared with clinic-based ART. Clients' paying a fee for home delivery and monitoring of ART was highly acceptable in the context of low income and high unemployment, and improved health outcomes as a result. Home ART delivery and monitoring, potentially with a user fee to offset costs, should be evaluated as a differentiated service delivery strategy to increase access to care. FUNDING National Institutes of Mental Health.
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Affiliation(s)
- Ruanne V Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Global Health, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA.
| | - Adam A Szpiro
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Xolani Ntinga
- Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa
| | | | - Heidi van Rooyen
- Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa; MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, South Africa
| | - Andrew Bruce
- Department of Statistics, University of Washington, Seattle, WA, USA
| | - Philip Joseph
- Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa
| | - Thulani Ngubane
- Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa
| | - Meighan L Krows
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Torin T Schaafsma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Theodore Zhao
- Department of Applied Mathematics, University of Washington, Seattle, WA, USA
| | - Frank Tanser
- Africa Health Research Institute, Somkhele, South Africa
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Gilead Sciences, Foster City, CA, USA
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Alastair van Heerden
- Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa; MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, South Africa
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12
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Clouse K, Noholoza S, Ngcobo N, Madwayi S, Mrubata M, Camlin CS, Myer L, Phillips TK. Cohort profile: CareConekta: a pilot study of a smartphone application to improve engagement in postpartum HIV care in South Africa. BMJ Open 2022; 12:e064946. [PMID: 36414286 PMCID: PMC9685000 DOI: 10.1136/bmjopen-2022-064946] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Pregnant and postpartum women living with HIV in South Africa are at high risk of dropping out of care, particularly after delivery. Population mobility may contribute to disruptions in HIV care, and postpartum women are known to be especially mobile. To improve engagement in HIV care during the peripartum period, we developed CareConekta, a smartphone application (app) that uses GPS coordinates to characterise mobility and allow for real-time intervention. We conducted a randomised controlled pilot study to assess feasibility, acceptability and initial efficacy of the app intervention to improve engagement in HIV care. This cohort profile describes participant enrolment and follow-up, describes the data collected and provides participant characteristics. PARTICIPANTS We enrolled 200 pregnant women living with HIV attending routine antenatal care at the Gugulethu Midwife Obstetric Unit in Cape Town, South Africa. Eligible women must have owned smartphones that met the app's technical requirements. Seven participants were withdrawn near enrolment, leaving 193 in the cohort. FINDINGS TO DATE Data were collected from detailed participant questionnaires at enrolment and follow-up (6 months after delivery), as well as GPS data from the app, and medical records. Follow-up is complete; initial analyses have explored smartphone ownership, preferences and patterns of use among women screened for eligibility and those enrolled in the study. FUTURE PLANS Additional planned analyses will characterise mobility in the population using the phone GPS data and participant self-reported data. We will assess the impact of mobility on engagement in care for the mother and infant. We also will describe the acceptability and feasibility of the study, including operational lessons learnt. By linking this cohort to the National Health Laboratory Service National HIV Cohort in South Africa, we will continue to assess engagement in care and mobility outcomes for years to come. Collaborations are welcome. TRIAL REGISTRATION NUMBER NCT03836625.
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Affiliation(s)
- Kate Clouse
- Vanderbilt University School of Nursing, Nashville, TN, USA
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandisiwe Noholoza
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Nkosinathi Ngcobo
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sindiswa Madwayi
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Megan Mrubata
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
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13
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Payne CF, Houle B, Chinogurei C, Herl CR, Kabudula CW, Kobayashi LC, Salomon JA, Manne-Goehler J. Differences in healthy longevity by HIV status and viral load among older South African adults: an observational cohort modelling study. Lancet HIV 2022; 9:e709-e716. [PMID: 36179754 PMCID: PMC9553125 DOI: 10.1016/s2352-3018(22)00198-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 07/03/2022] [Accepted: 07/06/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The population of people living with HIV in South Africa is rapidly ageing due to increased survivorship attributable to antiretroviral therapy (ART). We sought to understand how the combined effects of HIV and ART have led to differences in healthy longevity by HIV status and viral suppression in this context. METHODS In this observational cohort modelling study we use longitudinal data from the 2015 baseline interview (from Nov 13, 2014, to Nov 30, 2015) and the 2018 longitudinal follow-up interview (from Oct 12, 2018, to Nov 7, 2019) of the population-based study Health and Ageing in Africa: a Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) to estimate life expectancy and disability-free life expectancy (DFLE) of adults aged 40 years and older in rural South Africa. Respondents who consented to HIV testing, responded to survey questions on disability, and who were either interviewed in both surveys or who died between survey waves were included in the analysis. We estimate life expectancy and DFLE by HIV status and viral suppression (defined as <200 copies per mL) using Markov-based microsimulation. FINDINGS Among the 4322 eligible participants from the HAALSI study, we find a clear gradient in remaining life expectancy and DFLE based on HIV serostatus and viral suppression. At age 45 years, the life expectancy of a woman without HIV was 33·2 years (95% CI 32·0-35·0), compared with 31·6 years (29·2-34·1) a woman with virally suppressed HIV, and 26·4 years (23·1-29·1) for a woman with unsuppressed HIV; life expectancy for a 45 year old man without HIV was 27·2 years (25·8-29·1), compared with 24·1 years (20·9-27·2) for a man with virally suppressed HIV, and 17·4 years (15·0-20·3) for a man with unsuppressed HIV. Men and women with viral suppression could expect to live nearly as many years of DFLE as HIV-uninfected individuals at ages 45 years and 65 years. INTERPRETATION These results highlight the tremendous benefits of ART for population health in high-HIV-prevalence contexts and reinforce the need for continued work in making ART treatment accessible to ageing populations. FUNDING National Institutes of Health.
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Affiliation(s)
- Collin F Payne
- School of Demography, Research School of Social Sciences, The Australian National University, Canberra, ACT, Australia; Center for Population and Development Studies, Harvard T H Chan School of Public Health, Cambridge, MA, USA.
| | - Brian Houle
- School of Demography, Research School of Social Sciences, The Australian National University, Canberra, ACT, Australia; MRC/Wits Rural Public Health and Heath Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Chido Chinogurei
- Centre for Infectious Diseases and Epidemiology Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Chodziwadziwa Whiteson Kabudula
- MRC/Wits Rural Public Health and Heath Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Lindsay C Kobayashi
- Center for Social Epidemiology and Population Health, Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Joshua A Salomon
- Center for Primary Care and Outcomes Research, Stanford University, Palo Alto, CA, USA
| | - Jennifer Manne-Goehler
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA; Center for Population and Development Studies, Harvard T H Chan School of Public Health, Cambridge, MA, USA
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14
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Baisley K, Orne-Gliemann J, Larmarange J, Plazy M, Collier D, Dreyer J, Mngomezulu T, Herbst K, Hanekom W, Dabis F, Siedner MJ, Iwuji C. Early HIV treatment and survival over six years of observation in the ANRS 12249 Treatment as Prevention Trial. HIV Med 2022; 23:922-928. [PMID: 35218300 PMCID: PMC9545558 DOI: 10.1111/hiv.13263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 01/09/2022] [Accepted: 01/18/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Population-based universal test and treat (UTT) trials have shown an impact on population-level virological suppression. We followed the ANRS 12249 TasP trial population for 6 years to determine whether the intervention had longer-term survival benefits. METHODS The TasP trial was a cluster-randomized trial in South Africa from 2012 to 2016. All households were offered 6-monthly home-based HIV testing. Immediate antiretroviral therapy (ART) was offered through trial clinics to all people living with HIV (PLHIV) in intervention clusters and according to national guidelines in control clusters. After the trial, individuals attending the trial clinics were transferred to the public ART programme. Deaths were ascertained through annual demographic surveillance. Random-effects Poisson regression was used to estimate the effect of trial arm on mortality among (i) all PLHIV; (ii) PLHIV aware of their status and not on ART at trial entry; and (iii) PHLIV who started ART during the trial. RESULTS Mortality rates among PLHIV were 9.3/1000 and 10.4/1000 person-years in the control and intervention arms, respectively. There was no evidence that the intervention decreased mortality among all PLHIV [adjusted rate ratio (aRR) = 1.10, 95% confidence interval (CI) = 0.85-1.43, p = 0.46] or among PLHIV who were aware of their status but not on ART. Among individuals who initiated ART, the intervention decreased mortality during the trial (aRR = 0.49, 95% CI = 0.28-0.85, p = 0.01), but not after the trial ended. CONCLUSIONS The 'treat all' strategy reduced mortality among individuals who started ART but not among all PLHIV. To achieve maximum benefit of immediate ART, barriers to ART uptake and retention in care need to be addressed.
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Affiliation(s)
- Kathy Baisley
- Africa Health Research Institute, Durban, South Africa.,Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Joanna Orne-Gliemann
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France
| | - Joseph Larmarange
- Centre Population et Développement (Ceped), Institut de Recherche pour le Développement (IRD), Université de Paris, Inserm, Paris, France
| | - Melanie Plazy
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France
| | - Dami Collier
- Division of Infection and Immunity, University College London, London, UK.,Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Cambridge, UK
| | - Jaco Dreyer
- Africa Health Research Institute, Durban, South Africa
| | | | - Kobus Herbst
- Africa Health Research Institute, Durban, South Africa.,DSI-MRC South African Population Research Infrastructure Network, Durban, South Africa
| | - Willem Hanekom
- Africa Health Research Institute, Durban, South Africa.,Division of Infection and Immunity, University College London, London, UK
| | - Francois Dabis
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France
| | - Mark J Siedner
- Africa Health Research Institute, Durban, South Africa.,Harvard Medical School, Boston, Massachusetts, USA
| | - Collins Iwuji
- Africa Health Research Institute, Durban, South Africa.,Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
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15
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The health impact of free access to antiretroviral therapy in South Africa. Soc Sci Med 2022; 299:114832. [PMID: 35290814 DOI: 10.1016/j.socscimed.2022.114832] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 01/16/2023]
Abstract
Since 2004 the South African government has rolled out free antiretroviral therapy (ART) at public health care facilities nationwide. No prior studies have estimated the impact of the ART rollout on health and survival using a longitudinal household survey with national coverage. We match household member deaths and self-assessed health from a large national longitudinal survey to community-level ART availability in clinics to estimate the reduction in mortality and morbidity attributable to ART availability between 2006 and 2016, using a difference-in-difference model. Our analysis focuses on black Africans aged 25-49 because this demographic group represents more than two-thirds of all South African HIV cases. We find that the rollout of free ART has reduced annual mortality by 27% and decreased the likelihood of reporting poor health by 36% for black Africans aged 25-49. These estimates amount to annual reductions in this demographic category of 31% in annual mortality and 47% in individuals reporting poor health. Our findings confirm that making ART treatment freely available nationwide has had a dramatic impact in terms of both prolonged survival and improved health, with most of these gains concentrated in the high HIV prevalence group of black Africans aged 25-49.
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16
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To what extent were life expectancy gains in South Africa attributable to declines in HIV/AIDS mortality from 2006 to 2017? A life table analysis of age-specific mortality. DEMOGRAPHIC RESEARCH 2022. [DOI: 10.4054/demres.2022.46.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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17
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Spooner E, Reddy T, Mchunu N, Reddy S, Daniels B, Ngomane N, Luthuli N, Kiepiela P, Coutsoudis A. Point-of-care CD4 testing: Differentiated care for the most vulnerable. J Glob Health 2022; 12:04004. [PMID: 35136596 PMCID: PMC8818294 DOI: 10.7189/jogh.12.04004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background South Africa, with the highest burden of HIV infection globally, has made huge strides in its HIV/ART programme, but AIDS deaths have not decreased proportionally to ART uptake. Advanced HIV disease (CD4 < 200 cells/mm3) persists, and CD4 count testing is being overlooked since universal test-and-treat was implemented. Point-of-care CD4 testing could address this gap and assure differentiated care to these vulnerable patients with low CD4 counts. Methods A time randomised implementation trial was conducted, enrolling 603 HIV positive non-ART, not pregnant patients at a primary health care clinic in Durban, South Africa. Weeks were randomised to either point-of-care CD4 testing (n = 305 patients) or standard-of-care central laboratory CD4 testing (n = 298 patients) to assess the proportion initiating ART at 3 months. Cox regression, with robust standard errors adjusting for clustering by week, were used to assess the relationship between treatment initiation and arm. Results Among the 578 (299 point-of-care and 279 standard-of-care) patients eligible for analysis, there was no significant difference in the number of eligible patients initiating ART within 3 months in the point-of-care (73%) and the standard-of-care (68%) groups (P = 0.112). The time-to-treat analysis was not significantly different in patients with CD4 counts of 201-500 cells/mm3 which could have been due to appointment scheduling to cope with the large burden of cases. However, in patients with advanced HIV disease (CD4 < 200cells/mm3) 65% more patients started ART earlier in the point-of-care group (HR 1.65 (95% confidence interval (CI) = 0.99-2.75; P = 0.052) compared to the standard-of-care group. Conclusions Point-of-care testing decreased time-to-treatment in those with advanced HIV disease. With universal test and treat for HIV, rollout of simple point-of-care CD4 testing would ensure early diagnosis of advanced HIV disease and facilitate differentiated care for these vulnerable patients as per the World Health Organisation 2020 target product profile for point-of-care CD4 testing. Trial registration ISRCTN14220457.
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Affiliation(s)
- Elizabeth Spooner
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa
| | - Tarylee Reddy
- South African Medical Research Council, Biostatistics Unit, Durban, South Africa
| | - Nobuhle Mchunu
- South African Medical Research Council, Biostatistics Unit, Durban, South Africa
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | | | - Brodie Daniels
- South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa
| | | | | | | | - Anna Coutsoudis
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
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18
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Etoori D, Kabudula CW, Wringe A, Rice B, Renju J, Gomez-Olive FX, Reniers G. Investigating clinic transfers among HIV patients considered lost to follow-up to improve understanding of the HIV care cascade: Findings from a cohort study in rural north-eastern South Africa. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000296. [PMID: 36962304 PMCID: PMC10022370 DOI: 10.1371/journal.pgph.0000296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 05/02/2022] [Indexed: 11/18/2022]
Abstract
Investigating clinical transfers of HIV patients is important for accurate estimates of retention and informing interventions to support patients. We investigate transfers for adults reported as lost to follow-up (LTFU) from eight HIV care facilities in the Agincourt health and demographic surveillance system (HDSS), South Africa. Using linked clinic and HDSS records, outcomes of adults more than 90 days late for their last scheduled clinic visit were determined through clinic and routine tracing record reviews, HDSS data, and supplementary tracing. Factors associated with transferring to another clinic were determined through Cox regression models. Transfers were graphically and geospatially visualised. Transfers were more common for women, patients living further from the clinic, and patients with higher baseline CD4 cell counts. Transfers to clinics within the HDSS were more likely to be undocumented and were significantly more likely for women pregnant at ART initiation. Transfers outside the HDSS clustered around economic hubs. Patients transferring to health facilities within the HDSS may be shopping for better care, whereas those who transfer out of the HDSS may be migrating for work. Treatment programmes should facilitate transfer processes for patients, ensure continuity of care among those migrating, and improve tracking of undocumented transfers.
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Affiliation(s)
- David Etoori
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chodziwadziwa Whiteson Kabudula
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Alison Wringe
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Brian Rice
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jenny Renju
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Francesc Xavier Gomez-Olive
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Georges Reniers
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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19
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Kabudula CW, Houle B, Ohene-Kwofie D, Mahlangu D, Ng N, Van Minh H, Gómez-Olivé FX, Tollman S, Kahn K. Mortality transition over a quarter century in rural South Africa: findings from population surveillance in Agincourt 1993-2018. Glob Health Action 2021; 14:1990507. [PMID: 35377287 PMCID: PMC8986310 DOI: 10.1080/16549716.2021.1990507] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Mortality burden in South Africa since the mid-1990s has been characterized by a quadruple disease burden: HIV/AIDS and tuberculosis (TB); other communicable diseases (excluding HIV/AIDS and TB), maternal causes, perinatal conditions and nutritional deficiencies; non-communicable diseases (NCDs); and injuries. Causes from these broad groupings have persistently constituted the top 10 causes of death. However, proportions and rankings have varied over time, alongside overall mortality levels. Objective To provide evidence on the contributions of age and cause-of-death to changes in mortality levels in a rural South African population over a quarter century (1993–2018). Methods Using mortality and cause-of-death data from the Agincourt Health and Socio-Demographic Surveillance System (HDSS), we derive estimates of the distribution of deaths by cause, and hazards of death by age, sex, and time period, 1993–2018. We derive estimates of life expectancies at birth and years of life expectancy gained at age 15 if most common causes of death were deleted. We compare mortality indicators and cause-of-death trends from the Agincourt HDSS with South African national indicators generated from publicly available datasets. Results Mortality and cause-of-death transition reveals that overall mortality levels have returned to pre-HIV epidemic levels. In recent years, the concentration of mortality has shifted towards older ages, and the mortality burden from cardiovascular diseases and other chronic NCDs are more prominent as people living with HIV/AIDS access ART and live longer. Changes in life expectancy at birth, distribution of deaths by age, and major cause-of-death categories in the Agincourt population follow a similar pattern to the South African population. Conclusion The Agincourt HDSS provides critical information about general mortality, cause-of-death, and age patterns in rural South Africa. Realigning and strengthening the South African public health and healthcare systems is needed to concurrently cater for the prevention, control, and treatment of multiple disease conditions.
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Affiliation(s)
- Chodziwadziwa Whiteson Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Brian Houle
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,School of Demography, The Australian National University, Canberra, Australia.,CU Population Center, Institute of Behavioral Science, University of Colorado at Boulder, Boulder, Colorado, USA
| | - Daniel Ohene-Kwofie
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniel Mahlangu
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nawi Ng
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.,School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hoang Van Minh
- Center for Population Health Sciences, Hanoi University of Public Health, Ha Noi, Vietnam
| | - Francesc Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephen Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
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20
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Wong EB, Olivier S, Gunda R, Koole O, Surujdeen A, Gareta D, Munatsi D, Modise TH, Dreyer J, Nxumalo S, Smit TK, Ording-Jespersen G, Mpofana IB, Khan K, Sikhosana ZEL, Moodley S, Shen YJ, Khoza T, Mhlongo N, Bucibo S, Nyamande K, Baisley KJ, Cuadros D, Tanser F, Grant AD, Herbst K, Seeley J, Hanekom WA, Ndung'u T, Siedner MJ, Pillay D. Convergence of infectious and non-communicable disease epidemics in rural South Africa: a cross-sectional, population-based multimorbidity study. Lancet Glob Health 2021; 9:e967-e976. [PMID: 34143995 PMCID: PMC8220132 DOI: 10.1016/s2214-109x(21)00176-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND There has been remarkable progress in the treatment of HIV throughout sub-Saharan Africa, but there are few data on the prevalence and overlap of other significant causes of disease in HIV endemic populations. Our aim was to identify the prevalence and overlap of infectious and non-communicable diseases in such a population in rural South Africa. METHODS We did a cross-sectional study of eligible adolescents and adults from the Africa Health Research Institute demographic surveillance area in the uMkhanyakude district of KwaZulu-Natal, South Africa. The participants, who were 15 years or older, were invited to participate at a mobile health camp. Medical history for HIV, tuberculosis, hypertension, and diabetes was established through a questionnaire. Blood pressure measurements, chest x-rays, and tests of blood and sputum were taken to estimate the population prevalence and geospatial distribution of HIV, active and lifetime tuberculosis, elevated blood glucose, elevated blood pressure, and combinations of these. FINDINGS 17 118 adolescents and adults were recruited from May 25, 2018, to Nov 28, 2019, and assessed. Overall, 52·1% (95% CI 51·3-52·9) had at least one active disease. 34·2% (33·5-34·9) had HIV, 1·4% (1·2-1·6) had active tuberculosis, 21·8% (21·2-22·4) had lifetime tuberculosis, 8·5% (8·1-8·9) had elevated blood glucose, and 23·0% (22·4-23·6) had elevated blood pressure. Appropriate treatment and optimal disease control was highest for HIV (78·1%), and lower for elevated blood pressure (42·5%), active tuberculosis (29·6%), and elevated blood glucose (7·1%). Disease prevalence differed notably by sex, across age groups, and geospatially: men had a higher prevalence of active and lifetime tuberculosis, whereas women had a substantially high prevalence of HIV at 30-49 years and an increasing prevalence of multiple and poorly controlled non-communicable diseases when older than 50 years. INTERPRETATION We found a convergence of infectious and non-communicable disease epidemics in a rural South African population, with HIV well treated relative to all other diseases, but tuberculosis, elevated blood glucose, and elevated blood pressure poorly diagnosed and treated. A public health response that expands the successes of the HIV testing and treatment programme to provide multidisease care targeted to specific populations is required to optimise health in such settings in sub-Saharan Africa. FUNDING Wellcome Trust, Bill & Melinda Gates Foundation, the South African Department of Science and Innovation, South African Medical Research Council, and South African Population Research Infrastructure Network. TRANSLATION For the isiZulu translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Emily B Wong
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Diseases, University of Alabama Birmingham, Birmingham, AL, USA; Division of Infection and Immunity, University College London, London, UK.
| | - Stephen Olivier
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | - Resign Gunda
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa; School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Olivier Koole
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa; London School of Hygiene & Tropical Medicine, London, UK
| | - Ashmika Surujdeen
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | - Dickman Gareta
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | - Day Munatsi
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | | | - Jaco Dreyer
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | - Siyabonga Nxumalo
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | - Theresa K Smit
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | | | | | - Khadija Khan
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | | | - Sashen Moodley
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | - Yen-Ju Shen
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | - Thandeka Khoza
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | - Ngcebo Mhlongo
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | - Sanah Bucibo
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | - Kennedy Nyamande
- Department of Pulmonology and Critical Care, Inkosi Albert Luthuli Hospital, Durban, South Africa; Department of Respiratory Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Kathy J Baisley
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa; London School of Hygiene & Tropical Medicine, London, UK
| | - Diego Cuadros
- Department of Geography, University of Cincinnati, USA
| | - Frank Tanser
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa; School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; Lincoln International Institute for Rural Health, University of Lincoln, UK; Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Alison D Grant
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa; School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Kobus Herbst
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa; Department of Science and Innovation, Medical Research Council, South African Population Research Infrastructure, Durban, South Africa
| | - Janet Seeley
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa; London School of Hygiene & Tropical Medicine, London, UK
| | - Willem A Hanekom
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa; Division of Infection and Immunity, University College London, London, UK
| | - Thumbi Ndung'u
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa; Division of Infection and Immunity, University College London, London, UK; HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard Medical School, Cambridge, MA, USA; Max Planck Institute for Infection Biology, Berlin, Germany
| | - Mark J Siedner
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Deenan Pillay
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa; Division of Infection and Immunity, University College London, London, UK
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21
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Harris TG, Flören S, Mantell JE, Nkambule R, Lukhele NG, Malinga BP, Chekenyere R, Kidane A. HIV and aging among adults aged 50 years and older on antiretroviral therapy in Eswatini. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2021; 20:107-115. [PMID: 33685372 DOI: 10.2989/16085906.2021.1887301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: Antiretroviral therapy (ART) has decreased HIV-related morbidity and mortality and increased life expectancy of people living with HIV (PLHIV). Globally, the number of older PLHIV (OPLHIV; ≥50 years) is growing and predicted to increase substantially in coming years. In sub-Saharan Africa, where the majority of OPLHIV reside, there are limited data on the health and well-being of OPLHIV.Methods: We conducted an exploratory descriptive study that included structured interviews with 50 OPLHIV receiving ART at an outpatient HIV clinic in Eswatini and in-depth qualitative interviews (IDIs) with a sub-set of ten participants to elicit their experiences of living with HIV as an older adult, including quality of life, physical health, and mental health. Quantitative analyses were performed to obtain both descriptive statistics and cross-tabulations. A thematic analysis of IDI narratives was conducted based on three levels of the socio-ecological model to identify sub-themes and response patterns.Results: All study participants were virally suppressed. Self-reported non-communicable disease (NCD) risk factors and markers were common, with 40% (n = 20) reporting being current or former smokers, 0% consuming the recommended servings of fruits and vegetables per day, and 57% (n = 28 of 49 reporting screening) reporting having hypertension. However, the majority (88%; 44 of 50) had sufficient physical activity; most of the activity was in the work domain. Slightly more than one-third (38%; 13 of 34 tested) had a high random blood sugar level. Barriers to living with HIV were primarily structural (food insecurity, unemployment, access to transportation and health care).Conclusions: OPLHIV should be screened for NCDs, and services for NCDs should ideally be integrated with HIV services. While all participants had controlled HIV, this study highlights the need for strategies that facilitate OPLHIV's HIV service utilisation. With the increasing numbers of OPLHIV, these issues cannot be ignored.
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Affiliation(s)
| | | | - Joanne E Mantell
- HIV Center for Clinical and Behavioral Studies, Department of Psychiatry, Division of Gender, Sexuality and Health, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, USA
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22
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Knipper M, Sedas AC, Keshavjee S, Abbara A, Almhawish N, Alashawi H, Lecca L, Wilson M, Zumla A, Abubakar I, Orcutt M. The need for protecting and enhancing TB health policies and services for forcibly displaced and migrant populations during the ongoing COVID-19 pandemic. Int J Infect Dis 2021; 113 Suppl 1:S22-S27. [PMID: 33775886 PMCID: PMC8752449 DOI: 10.1016/j.ijid.2021.03.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 11/29/2022] Open
Abstract
Disruption of health services due to the COVID-19 pandemic threatens to derail progress being made in tuberculosis control efforts. Forcibly displaced people and migrant populations face particular vulnerabilities as a result of the COVID-19 pandemic, which leaves them at further risk of developing TB. They inhabit environments where measures such as “physical distancing” are impossible to realize and where facilities like camps and informal temporary settlements can easily become sites of rapid disease transmission. In this viewpoint we utilize three case studies—from Peru, South Africa, and Syria—to illustrate the lived experience of forced migration and mobile populations, and the impact of COVID-19 on TB among these populations. We discuss the dual pandemics of TB and COVID-19 in the context of migration through a syndemic lens, to systematically address the upstream social, economic, structural and political factors that - in often deleterious dynamics - foster increased vulnerabilities and risk. Addressing TB, COVID-19 and migration from a syndemic perspective, not only draws systematic attention to comorbidity and the relevance of social and structural context, but also helps to find solutions: the true reality of syndemic interactions can only be fully understood by considering a particular population and bio- social context, and ensuring that they receive the comprehensive care that they need. It also provides avenues for strengthening and expanding the existing infrastructure for TB care to tackle both COVID-19 and TB in migrants and refugees in an integrated and synergistic manner.
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Affiliation(s)
- Michael Knipper
- Institute for the History of Medicine, University Justus Liebig Giessen, 35392 Giessen, Germany.
| | - Ana Cristina Sedas
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
| | - Salmaan Keshavjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
| | - Aula Abbara
- Imperial College London, Department of Infectious Disease, St Mary's Hospital, London, UK; Syria Public Health Network, Syria.
| | - Naser Almhawish
- Assistance Coordination Unit (ACU), Early Warning Alert and Response Network (EWARN), Gaziantep, Turkey.
| | | | - Leonid Lecca
- Partners in Health, Lima, Peru, and Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
| | | | - Almuddin Zumla
- Department of Infection, Division of Infection and Immunity, University College London NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, UK.
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London WC1N 1EH, UK.
| | - Miriam Orcutt
- Institute for Global Health, University College London, London WC1N 1EH, UK.
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23
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Abstract
Purpose of Review HIV and ageism continue to be key public health challenges in the USA and globally. Older people living with HIV may experience intersectional stigma resulting from HIV and ageism. The current review summarizes the scientific literature and focuses on social isolation and lack of social support as key factors in experiencing HIV-related and aging-related stigma. Recent Findings Social isolation and social support are key social determinants of health, which may have a bidirectional relationship with HIV-related stigma and ageism. Stigmatization may also result in health care providers not paying enough attention to the mental health and sexual health needs of older adults. Summary Current research suggests that the intersection of HIV-related stigma and ageism is a complex issue. Future research should focus on the design and feasibility of implementing stigma reduction interventions addressing HIV-related stigma and ageism.
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Affiliation(s)
- Monique J. Brown
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208 USA
- South Carolina SmartState Center for Healthcare Quality, Arnold School of Public Health, University of South Carolina, Columbia, SC USA
- Rural and Minority Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, SC USA
- Office for the Study on Aging, Arnold School of Public Health, University of South Carolina, Columbia, SC USA
| | - Oluwafemi Adeagbo
- South Carolina SmartState Center for Healthcare Quality, Arnold School of Public Health, University of South Carolina, Columbia, SC USA
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC USA
- Department of Sociology, Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa
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24
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Kleynhans J, Tempia S, Shioda K, von Gottberg A, Weinberger DM, Cohen C. Estimated impact of the pneumococcal conjugate vaccine on pneumonia mortality in South Africa, 1999 through 2016: An ecological modelling study. PLoS Med 2021; 18:e1003537. [PMID: 33591995 PMCID: PMC7924778 DOI: 10.1371/journal.pmed.1003537] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 03/02/2021] [Accepted: 01/12/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Data on the national-level impact of pneumococcal conjugate vaccine (PCV) introduction on mortality are lacking from Africa. PCV was introduced in South Africa in 2009. We estimated the impact of PCV introduction on all-cause pneumonia mortality in South Africa, while controlling for changes in mortality due to other interventions. METHODS AND FINDINGS We used national death registration data in South Africa from 1999 to 2016 to assess the impact of PCV introduction on all-cause pneumonia mortality in all ages, with the exclusion of infants aged <1 month. We created a composite (synthetic) control using Bayesian variable selection of nondiarrheal, nonpneumonia, and nonpneumococcal deaths to estimate the number of expected all-cause pneumonia deaths in the absence of PCV introduction post 2009. We compared all-cause pneumonia deaths from the death registry to the expected deaths in 2012 to 2016. We also estimated the number of prevented deaths during 2009 to 2016. Of the 9,324,638 deaths reported in South Africa from 1999 to 2016, 12·6% were pneumonia-related. Compared to number of deaths expected, we estimated a 33% (95% credible interval (CrI) 26% to 43%), 23% (95%CrI 17% to 29%), 25% (95%CrI 19% to 32%), and 23% (95%CrI 11% to 32%) reduction in pneumonia mortality in children aged 1 to 11 months, 1 to 4 years, 5 to 7 years, and 8 to 18 years in 2012 to 2016, respectively. In total, an estimated 18,422 (95%CrI 12,388 to 26,978) pneumonia-related deaths were prevented from 2009 to 2016 in children aged <19 years. No declines were estimated observed among adults following PCV introduction. This study was mainly limited by coding errors in original data that could have led to a lower impact estimate, and unmeasured factors could also have confounded estimates. CONCLUSIONS This study found that the introduction of PCV was associated with substantial reduction in all-cause pneumonia deaths in children aged 1 month to <19 years. The model predicted an effect of PCV in age groups who were eligible for vaccination (1 months to 4 years), and an indirect effect in those too old (8 to 18 years) to be vaccinated. These findings support sustaining pneumococcal vaccination to reduce pneumonia-related mortality in children.
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Affiliation(s)
- Jackie Kleynhans
- Centre for Respiratory Diseases and Meningitis (CRDM), National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Stefano Tempia
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kayoko Shioda
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Anne von Gottberg
- Centre for Respiratory Diseases and Meningitis (CRDM), National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniel M. Weinberger
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Cheryl Cohen
- Centre for Respiratory Diseases and Meningitis (CRDM), National Institute for Communicable Diseases (NICD) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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25
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Abstract
PURPOSE OF REVIEW Biological and societal influences are different for men and women leading to different HIV outcomes and related infectious and non-infectious complications. This review evaluates sex differences in the epidemiology and immunological response to HIV and looks at major complications and coinfections, as well as care delivery systems focusing on low- and middle-income countries (LMICs) where most people with HIV live. RECENT FINDINGS More women than men access testing and treatment services in LMIC; women are more likely to be virologically suppressed in that environment. There is a growing recognition that the enhanced immunological response to several pathogens including HIV may result in improved outcomes for infectious comorbidities but may result in a greater burden of non-communicable diseases. Men and women have different requirements for HIV care. Attention to these differences may improve outcomes for all.
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26
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Mejia-Pailles G, Berrington A, McGrath N, Hosegood V. Trends in the prevalence and incidence of orphanhood in children and adolescents <20 years in rural KwaZulu-Natal South Africa, 2000-2014. PLoS One 2020; 15:e0238563. [PMID: 33232331 PMCID: PMC7685426 DOI: 10.1371/journal.pone.0238563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 08/19/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In South Africa, large increases in early adult mortality during the 1990s and early 2000s have reversed since public HIV treatment rollout in 2004. In a rural population in KwaZulu-Natal, we investigate trends in parental mortality and orphanhood from 2000-2014. METHODS Using longitudinal demographic surveillance data for a population of approximately 90,000, we calculated annual incidence and prevalence of maternal, paternal and double orphanhood in children and adolescents (<20 years) and, overall and cause-specific mortality of parents by age. RESULTS The proportion of children and adolescents (<20 years) for whom one or both parents had died rose from 26% in 2000 to peak at 36% in 2010, followed by a decline to 32% in 2014. The burden of orphanhood remains high especially in the oldest age group: in 2014, 53% of adolescents 15-19 years had experienced the death of one or both parents. In all age groups and years, paternal orphan prevalence was three-five times higher than maternal orphan prevalence. Maternal and paternal orphan incidence peaked in 2005 at 17 and 27 per 1,000 person years respectively (<20 years) before declining by half through 2014. The leading cause of parental death throughout the period, HIV/AIDS and TB cause-specific mortality rates declined substantially in mothers and fathers from 2007 and 2009 respectively. CONCLUSIONS The survival of parents with children and adolescents <20 years has improved in tandem with earlier initiation and higher coverage of HIV treatment. However, comparatively high levels of parental deaths persist in this rural population in KwaZulu-Natal, particularly among fathers. Community-level surveillance to estimate levels of orphanhood remains important for monitoring and evaluation of targeted state welfare support for orphans and their guardians.
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Affiliation(s)
| | - Ann Berrington
- Department of Social Statistics & Demography, University of Southampton, Southampton, United Kingdom
| | - Nuala McGrath
- Department of Social Statistics & Demography, University of Southampton, Southampton, United Kingdom
- Department of Population Sciences & Primary Care, University of Southampton, Southampton, United Kingdom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Victoria Hosegood
- Department of Social Statistics & Demography, University of Southampton, Southampton, United Kingdom
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27
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Barnabas RV, Szpiro AA, van Rooyen H, Asiimwe S, Pillay D, Ware NC, Schaafsma TT, Krows ML, van Heerden A, Joseph P, Shahmanesh M, Wyatt MA, Sausi K, Turyamureeba B, Sithole N, Morrison S, Shapiro AE, Roberts DA, Thomas KK, Koole O, Bershteyn A, Ehrenkranz P, Baeten JM, Celum C. Community-based antiretroviral therapy versus standard clinic-based services for HIV in South Africa and Uganda (DO ART): a randomised trial. Lancet Glob Health 2020; 8:e1305-e1315. [PMID: 32971053 PMCID: PMC7527697 DOI: 10.1016/s2214-109x(20)30313-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/22/2020] [Accepted: 06/25/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Community-based delivery of antiretroviral therapy (ART) for HIV, including ART initiation, clinical and laboratory monitoring, and refills, could reduce barriers to treatment and improve viral suppression, reducing the gap in access to care for individuals who have detectable HIV viral load, including men who are less likely than women to be virally suppressed. We aimed to test the effect of community-based ART delivery on viral suppression among people living with HIV not on ART. METHODS We did a household-randomised, unblinded trial (DO ART) of delivery of ART in the community compared with the clinic in rural and peri-urban settings in KwaZulu-Natal, South Africa and the Sheema District, Uganda. After community-based HIV testing, people living with HIV were randomly assigned (1:1:1) with mobile phone software to community-based ART initiation with quarterly monitoring and ART refills through mobile vans; ART initiation at the clinic followed by mobile van monitoring and refills (hybrid approach); or standard clinic ART initiation and refills. The primary outcome was HIV viral suppression at 12 months. If the difference in viral suppression was not superior between study groups, an a-priori test for non-inferiority was done to test for a relative risk (RR) of more than 0·95. The cost per person virally suppressed was a co-primary outcome of the study. This study is registered with ClinicalTrials.gov, NCT02929992. FINDINGS Between May 26, 2016, and March 28, 2019, of 2479 assessed for eligibility, 1315 people living with HIV and not on ART with detectable viral load at baseline were randomly assigned; 666 (51%) were men. Retention at the month 12 visit was 95% (n=1253). At 12 months, community-based ART increased viral suppression compared with the clinic group (306 [74%] vs 269 [63%], RR 1·18, 95% CI 1·07-1·29; psuperiority=0·0005) and the hybrid approach was non-inferior (282 [68%] vs 269 [63%], RR 1·08, 0·98-1·19; pnon-inferiority=0·0049). Community-based ART increased viral suppression among men (73%, RR 1·34, 95% CI 1·16-1·55; psuperiority<0·0001) as did the hybrid approach (66%, RR 1·19, 1·02-1·40; psuperiority=0·026), compared with clinic-based ART (54%). Viral suppression was similar for men (n=156 [73%]) and women (n=150 [75%]) in the community-based ART group. With efficient scale-up, community-based ART could cost US$275-452 per person reaching viral suppression. Community-based ART was considered safe, with few adverse events. INTERPRETATION In high and medium HIV prevalence settings in South Africa and Uganda, community-based delivery of ART significantly increased viral suppression compared with clinic-based ART, particularly among men, eliminating disparities in viral suppression by gender. Community-based ART should be implemented and evaluated in different contexts for people with detectable viral load. FUNDING The Bill & Melinda Gates Foundation; the University of Washington and Fred Hutch Center for AIDS Research; the Wellcome Trust; the University of Washington Royalty Research Fund; and the University of Washington King K Holmes Endowed Professorship in STDs and AIDS.
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Affiliation(s)
- Ruanne V Barnabas
- Department of Global Health, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| | - Adam A Szpiro
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Heidi van Rooyen
- Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa; MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Deenan Pillay
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | - Torin T Schaafsma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Meighan L Krows
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Alastair van Heerden
- Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa; MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Philip Joseph
- Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa
| | | | | | - Kombi Sausi
- Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa
| | | | - Nsika Sithole
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Susan Morrison
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Adrienne E Shapiro
- Department of Global Health, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - D Allen Roberts
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | | | - Olivier Koole
- London School of Hygiene & Tropical Medicine, London, UK
| | - Anna Bershteyn
- New York University School of Medicine, New York, NY, USA
| | | | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Connie Celum
- Department of Global Health, University of Washington, Seattle, WA, USA; Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
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Berner-Rodoreda A, Geldsetzer P, Bärnighausen K, Hettema A, Bärnighausen T, Matse S, McMahon SA. "It's hard for us men to go to the clinic. We naturally have a fear of hospitals." Men's risk perceptions, experiences and program preferences for PrEP: A mixed methods study in Eswatini. PLoS One 2020; 15:e0237427. [PMID: 32966307 PMCID: PMC7510987 DOI: 10.1371/journal.pone.0237427] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 07/27/2020] [Indexed: 01/10/2023] Open
Abstract
Few studies on HIV Pre-Exposure Prophylaxis (PrEP) have focused on men who have sex with women. We present findings from a mixed-methods study in Eswatini, the country with the highest HIV prevalence in the world (27%). Our findings are based on risk assessments, in-depth interviews and focus-group discussions which describe men’s motivations for taking up or declining PrEP. Quantitatively, men self-reported starting PrEP because they had multiple or sero-discordant partners or did not know the partner’s HIV-status. Men’s self-perception of risk was echoed in the qualitative data, which revealed that the hope of facilitated sexual performance or relations, a preference for pills over condoms and the desire to protect themselves and others also played a role for men to initiate PrEP. Trust and mistrust and being able or unable to speak about PrEP with partner(s) were further considerations for initiating or declining PrEP. Once on PrEP, men’s sexual behavior varied in terms of number of partners and condom use. Men viewed daily pill-taking as an obstacle to starting PrEP. Side-effects were a major reason for men to discontinue PrEP. Men also worried that taking anti-retroviral drugs daily might leave them mistaken for a person living with HIV, and viewed clinic-based PrEP education and initiation processes as a further obstacle. Given that men comprise only 29% of all PrEP users in Eswatini, barriers to men’s uptake of PrEP will need to be addressed, in terms of more male-friendly services as well as trialing community-based PrEP education and service delivery.
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Affiliation(s)
| | - Pascal Geldsetzer
- Institute of Global Health, Ruprecht-Karls-Universität, Heidelberg, Germany
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Kate Bärnighausen
- Institute of Global Health, Ruprecht-Karls-Universität, Heidelberg, Germany
- University of the Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Anita Hettema
- Clinton Health Access Initiative Swaziland, Mbabane, Eswatini
| | - Till Bärnighausen
- Institute of Global Health, Ruprecht-Karls-Universität, Heidelberg, Germany
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Sindy Matse
- Eswatini Ministry of Health, Mbabane, Eswatini
| | - Shannon A. McMahon
- Institute of Global Health, Ruprecht-Karls-Universität, Heidelberg, Germany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
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Keene C, Mohr-Holland E, Cassidy T, Scott V, Nelson A, Furin J, Triviño-Duran L. How COVID-19 could benefit tuberculosis and HIV services in South Africa. THE LANCET RESPIRATORY MEDICINE 2020; 8:844-846. [PMID: 32758439 PMCID: PMC7398675 DOI: 10.1016/s2213-2600(20)30311-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/08/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Claire Keene
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa
| | | | - Tali Cassidy
- Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa
| | - Vera Scott
- School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Aurelie Nelson
- Médecins Sans Frontières, South African Mission, Cape Town, South Africa
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA.
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Osler M, Cornell M, Ford N, Hilderbrand K, Goemaere E, Boulle A. Population-wide differentials in HIV service access and outcomes in the Western Cape for men as compared to women, South Africa: 2008 to 2018: a cohort analysis. J Int AIDS Soc 2020; 23 Suppl 2:e25530. [PMID: 32589367 PMCID: PMC7319137 DOI: 10.1002/jia2.25530] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 04/22/2020] [Accepted: 04/27/2020] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Few studies have systematically described population-level differences comparing men and women across the continuum of routine HIV care. This study quantifies differentials in HIV care, treatment and mortality outcomes for men and women over time in South Africa. METHODS We analysed population-wide linked anonymized data, including vital registration linkage, for the Western Cape Province, from the time of first CD4 count. Three antiretroviral therapy guideline eligibility periods were defined: 1 January 2008 to 31 July 2011 (CD4 cell count <200 cells/µL), 1 August 2011 to 31 December 2014 (<350 cells/µL), 1 January 2015 to 31 August 2016 (<500 cells/µL). We estimated care uptake based on service attendance, and modelled associations for men and women with ART initiation and overall, pre-ART and ART mortality. Separate Cox proportional hazard models were built for each outcome and eligibility period, adjusted for tuberculosis, pregnancy, CD4 count and age. RESULTS Adult men made up 49% of the population and constituted 37% of those living with HIV. In 2009, 46% of men living with HIV attended health services, rising to 67% by 2015 compared to 54% and 77% of women respectively. Men contributed <35% of all CD4 cell counts over 10 years and presented with more advanced disease (39% of all first presentation CD4 cell counts from men were <200 cells/µL compared to 25% in women). ART access was lower in men compared to women (AHR 0.79 (0.77 to 0.80) summarized for Period 2) over the entire study). Mortality was greater in men irrespective of ART (AHR 1.08 (1.01 to 1.16) Period 3) and after ART start (AHR 1.15 (1.05 to 1.20) Period 3) with mortality differences decreasing over time. CONCLUSIONS Compared to women, men presented with more advanced disease, were less likely to attend health care services annually, were less likely to initiate ART and had higher mortality overall and while receiving ART care. People living with HIV were more likely to initiate ART if they had acute reasons to access healthcare beyond HIV, such as being pregnant or being co-infected with tuberculosis. Our findings point to missed opportunities for improving access to and outcomes from interventions for men along the entire HIV cascade.
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Affiliation(s)
- Meg Osler
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- HIV/AIDS Department and Global Hepatitis ProgrammeWorld Health OrganizationGenevaSwitzerland
| | - Katherine Hilderbrand
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Médecins Sans FrontièresSouthern African Medical UnitCape TownSouth Africa
| | - Eric Goemaere
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Médecins Sans FrontièresSouthern African Medical UnitCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Department of HealthProvincial Government of the Western CapeCape TownSouth Africa
- Wellcome Centre for Infectious Diseases Research in AfricaInstitute of Infectious Disease and Molecular MedicineUniversity of Cape TownCape TownSouth Africa
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Luwanda LB, Vyas S, Songo J, Chimukuche RS, McLean E, Hassan F, Schouten E, Todd J, Geubbels E, Wringe A, Renju J. Assessing the implementation of facility-based HIV testing policies in Malawi, South Africa and Tanzania from 2013–2018: Findings from SHAPE-UTT study. Glob Public Health 2020; 16:241-255. [DOI: 10.1080/17441692.2020.1763420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
| | - Seema Vyas
- Department of Population Studies, London School of Hygiene and Tropical Medicine, London, UK
| | - John Songo
- Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
| | | | - Estelle McLean
- Department of Population Studies, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Jim Todd
- Department of Population Studies, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Alison Wringe
- Department of Population Studies, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenny Renju
- Department of Population Studies, London School of Hygiene and Tropical Medicine, London, UK
- Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
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Nabukalu D, Reniers G, Risher KA, Blom S, Slaymaker E, Kabudula C, Zaba B, Nalugoda F, Kigozi G, Makumbi F, Serwadda D, Reynolds SJ, Marston M, Eaton JW, Gray R, Wawer M, Sewankambo N, Lutalo T. Population-level adult mortality following the expansion of antiretroviral therapy in Rakai, Uganda. POPULATION STUDIES 2020; 74:93-102. [PMID: 31117928 PMCID: PMC6891159 DOI: 10.1080/00324728.2019.1595099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 02/01/2019] [Indexed: 12/03/2022]
Abstract
There are limited data on the impact of antiretroviral therapy (ART) on population-level adult mortality in sub-Saharan Africa. We analysed data for 2000-14 from the Rakai Community Cohort Study (RCCS) in Uganda, where free ART was scaled up after 2004. Using non-parametric and parametric (Weibull) survival analysis, we estimated trends in average person-years lived between exact ages 15 and 50, per capita life-years lost to HIV, and the mortality hazards of people living with HIV (PLHIV). Between 2000 and 2014, average adult life-years lived before age 50 increased significantly, from 26.4 to 33.5 years for all women and from 28.6 to 33.8 years for all men. As of 2014, life-years lost to HIV had declined significantly, to 1.3 years among women and 0.4 years among men. Following the roll-out of ART, mortality reductions among PLHIV were initially larger in women than men, but this is no longer the case.
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Affiliation(s)
| | - Georges Reniers
- London School of Hygiene and Tropical Medicine
- University of the Witwatersrand
| | | | - Sylvia Blom
- London School of Hygiene and Tropical Medicine
| | | | | | - Basia Zaba
- London School of Hygiene and Tropical Medicine
| | | | | | - Fred Makumbi
- Rakai Health Sciences Program
- Makerere University
| | | | - Steven J Reynolds
- National Institutes of Health
- Johns Hopkins Bloomberg School of Public Health
| | | | | | - Ron Gray
- Rakai Health Sciences Program
- Johns Hopkins Bloomberg School of Public Health
| | - Maria Wawer
- Rakai Health Sciences Program
- Johns Hopkins Bloomberg School of Public Health
| | | | - Tom Lutalo
- Rakai Health Sciences Program
- Uganda Virus Research Institute
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Erlandson KM, Karris MY. HIV and Aging: Reconsidering the Approach to Management of Comorbidities. Infect Dis Clin North Am 2019; 33:769-786. [PMID: 31395144 PMCID: PMC6690376 DOI: 10.1016/j.idc.2019.04.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Health care for older adults with human immunodeficiency virus can be highly complex, resource intensive, and carry a high administrative burden. Data from aging longitudinal cohorts and feedback from the human immunodeficiency virus community suggest that the current model is not meeting the needs of these older adults. We introduce the 6 Ms approach, which acknowledges the multicomplexity of older adults with human immunodeficiency virus, simplifies geriatric principles for non-geriatrics-trained providers, and minimizes extensive training and specialized screening tests or tools. Implementing novel approaches to care requires support at local/national levels.
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Affiliation(s)
- Kristine M Erlandson
- University of Colorado, Anschutz Medical Campus, 12700 East 19th Avenue, Mail Stop B168, Aurora, CO 80045, USA.
| | - Maile Y Karris
- University of California San Diego, 200 West Arbor Drive #8208, San Diego, CA 92103-8208, USA
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Ssekubugu R, Renju J, Zaba B, Seeley J, Bukenya D, Ddaaki W, Moshabela M, Wamoyi J, McLean E, Ondenge K, Skovdal M, Wringe A. "He was no longer listening to me": A qualitative study in six Sub-Saharan African countries exploring next-of-kin perspectives on caring following the death of a relative from AIDS. AIDS Care 2018; 31:754-760. [PMID: 30360642 PMCID: PMC6446248 DOI: 10.1080/09540121.2018.1537467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In the era of widespread antiretroviral therapy, few studies have explored the perspectives of the relatives involved in caring for people living with HIV (PLHIV) during periods of ill-health leading up to their demise. In this analysis, we explore the process of care for PLHIV as their death approached, from their relatives’ perspective. We apply Tronto’s care ethics framework that distinguishes between care-receiving among PLHIV on the one hand, and caring about, caring for and care-giving by their relatives on the other. We draw on 44 in-depth interviews conducted with caregivers following the death of their relatives, in seven rural settings in Eastern and Southern Africa. Relatives suggested that prior to the onset of poor health, few of the deceased had disclosed their HIV status and fewer still were relying on anyone for help. This lack of disclosure meant that some caregivers spoke of enduring a long period of worry, and feelings of helplessness as they were unable to translate their concern and “caring about” into “caring for”. This transition often occurred when the deceased became in need of physical, emotional or financial care. The responsibility was often culturally prescribed, rarely questioned and usually fell to women. The move to “care-giving” was characterised by physical acts of providing care for their relative, which lasted until death. Tronto’s conceptualisation of caring relationships highlights how the burden of caring often intensifies as family members’ caring evolves from “caring about”, to “caring for”, and eventually to “giving care” to their relatives. This progression can lead to caregivers experiencing frustration, provoking tensions with their relatives and highlighting the need for interventions to support family members caring for PLHIV. Interventions should also encourage PLHIV to disclose their HIV status and seek early access to HIV care and treatment services.
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Affiliation(s)
| | - Jenny Renju
- b Population Studies Group, Faculty of Epidemiology and Public Health , London School of Hygiene and Tropical Medicine, London, UK.,c Malawi Epidemiology and Intervention Research Unit , Karonga , Malawi
| | - Basia Zaba
- b Population Studies Group, Faculty of Epidemiology and Public Health , London School of Hygiene and Tropical Medicine, London, UK
| | - Janet Seeley
- d Faculty of Public Health and Policy , London School of Hygiene and Tropical Medicine, London, UK.,e MRC/UVRI and LSHTM Uganda Research Unit , Entebbe , Uganda.,f Africa Health Research Institute , South Africa
| | - Dominic Bukenya
- e MRC/UVRI and LSHTM Uganda Research Unit , Entebbe , Uganda
| | | | - Mosa Moshabela
- f Africa Health Research Institute , South Africa.,g University of KwaZulu-Natal , Durban , South Africa
| | - Joyce Wamoyi
- h National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - Estelle McLean
- c Malawi Epidemiology and Intervention Research Unit , Karonga , Malawi
| | - Kenneth Ondenge
- i Kenya Medical Research Institute Center for Global Health Research Kisumu , Kenya
| | - Morten Skovdal
- j Department of Public Health , University of Copenhagen , Copenhagen , Denmark.,k Biomedical Research and Training Institute , Harare , Zimbabwe
| | - Alison Wringe
- b Population Studies Group, Faculty of Epidemiology and Public Health , London School of Hygiene and Tropical Medicine, London, UK
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Nsanzimana S, Forrest JI. Many pathways to ending AIDS by 2030. Lancet HIV 2018; 5:e407-e408. [PMID: 30021701 DOI: 10.1016/s2352-3018(18)30131-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 05/24/2018] [Indexed: 01/09/2023]
Affiliation(s)
- Sabin Nsanzimana
- Institute for HIV Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda; MTEK Sciences, Vancouver, Canada.
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Barré‐Sinoussi F, Abdool Karim SS, Albert J, Bekker L, Beyrer C, Cahn P, Calmy A, Grinsztejn B, Grulich A, Kamarulzaman A, Kumarasamy N, Loutfy MR, El Filali KM, Mboup S, Montaner JSG, Munderi P, Pokrovsky V, Vandamme A, Young B, Godfrey‐Faussett P. Expert consensus statement on the science of HIV in the context of criminal law. J Int AIDS Soc 2018; 21:e25161. [PMID: 30044059 PMCID: PMC6058263 DOI: 10.1002/jia2.25161] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 06/21/2018] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Globally, prosecutions for non-disclosure, exposure or transmission of HIV frequently relate to sexual activity, biting, or spitting. This includes instances in which no harm was intended, HIV transmission did not occur, and HIV transmission was extremely unlikely or not possible. This suggests prosecutions are not always guided by the best available scientific and medical evidence. DISCUSSION Twenty scientists from regions across the world developed this Expert Consensus Statement to address the use of HIV science by the criminal justice system. A detailed analysis of the best available scientific and medical research data on HIV transmission, treatment effectiveness and forensic phylogenetic evidence was performed and described so it may be better understood in criminal law contexts. Description of the possibility of HIV transmission was limited to acts most often at issue in criminal cases. The possibility of HIV transmission during a single, specific act was positioned along a continuum of risk, noting that the possibility of HIV transmission varies according to a range of intersecting factors including viral load, condom use, and other risk reduction practices. Current evidence suggests the possibility of HIV transmission during a single episode of sex, biting or spitting ranges from no possibility to low possibility. Further research considered the positive health impact of modern antiretroviral therapies that have improved the life expectancy of most people living with HIV to a point similar to their HIV-negative counterparts, transforming HIV infection into a chronic, manageable health condition. Lastly, consideration of the use of scientific evidence in court found that phylogenetic analysis alone cannot prove beyond reasonable doubt that one person infected another although it can be used to exonerate a defendant. CONCLUSIONS The application of up-to-date scientific evidence in criminal cases has the potential to limit unjust prosecutions and convictions. The authors recommend that caution be exercised when considering prosecution, and encourage governments and those working in legal and judicial systems to pay close attention to the significant advances in HIV science that have occurred over the last three decades to ensure current scientific knowledge informs application of the law in cases related to HIV.
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Affiliation(s)
| | - Salim S Abdool Karim
- Mailman School of Public HealthColumbia UniversityNew YorkNYUSA
- Centre for the AIDS Program of Research in South AfricaUniversity of KwaZulu‐NatalDurbanSouth Africa
- Weill Medical CollegeCornell UniversityNew YorkNYUSA
| | - Jan Albert
- Department of Microbiology, Tumor and Cell BiologyKarolinska InstitutetStockholmSweden
| | - Linda‐Gail Bekker
- Institute of Infectious Disease and Molecular MedicineUniversity of Cape TownCape TownSouth Africa
| | - Chris Beyrer
- Department of EpidemiologyCenter for AIDS Research and Center for Public Health and Human RightsJohn Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Pedro Cahn
- Infectious Diseases UnitJuan A. Fernandez Hospital Buenos AiresCABAArgentina
- Buenos Aires University Medical SchoolBuenos AiresArgentina
- Fundación HuéspedBuenos AiresArgentina
| | - Alexandra Calmy
- Infectious DiseasesGeneva University HospitalGenevaSwitzerland
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas‐FiocruzFiocruz, Rio de JaneiroBrazil
| | - Andrew Grulich
- Kirby InstituteUniversity of New South WalesSydneyNSWAustralia
| | | | | | - Mona R Loutfy
- Women's College Research InstituteTorontoCanada
- Women's College HospitalTorontoCanada
- Department of MedicineUniversity of TorontoTorontoCanada
| | - Kamal M El Filali
- Infectious Diseases UnitIbn Rochd Universtiy HospitalCasablancaMorocco
| | - Souleymane Mboup
- Institut de Recherche en Santéde Surveillance Epidemiologique et de FormationsDakarSenegal
| | - Julio SG Montaner
- Faculty of MedicineUniversity of British ColumbiaVancouverCanada
- BC Centre for Excellence in HIV/AIDSVancouverCanada
| | - Paula Munderi
- International Association of Providers of AIDS CareKampalaUganda
| | - Vadim Pokrovsky
- Russian Peoples’ Friendship University (RUDN‐ University)MoscowRussian Federation
- Central Research Institute of EpidemiologyFederal Service on Customers’ Rights Protection and Human Well‐being SurveillanceMoscowRussian Federation
| | - Anne‐Mieke Vandamme
- KU LeuvenDepartment of Microbiology and ImmunologyRega Institute for Medical Research, Clinical and Epidemiological VirologyLeuvenBelgium
- Center for Global Health and Tropical MedicineUnidade de MicrobiologiaInstituto de Higiene e Medicina TropicalUniversidade Nova de LisboaLisbonPortugal
| | - Benjamin Young
- International Association of Providers of AIDS CareWashingtonDCUSA
| | - Peter Godfrey‐Faussett
- UNAIDSGenevaSwitzerland
- Department of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonEngland
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Gesesew HA, Ward P, Woldemichael K, Mwanri L. Early mortality among children and adults in antiretroviral therapy programs in Southwest Ethiopia, 2003-15. PLoS One 2018; 13:e0198815. [PMID: 29912974 PMCID: PMC6005574 DOI: 10.1371/journal.pone.0198815] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/27/2018] [Indexed: 12/21/2022] Open
Abstract
Background Several studies reported that the majority of deaths in HIV-infected people are documented in their early antiretroviral therapy (ART) follow-ups. Early mortality refers to death of people on ART for follow up period of below 24 months due to any cause. The current study assessed predictors of early HIV mortality in Southwest Ethiopia. Methods We have conducted a retrospective analysis of 5299 patient records dating from June 2003- March 2015. To estimate survival time and compare the time to event among the different groups of patients, we used a Kaplan Meir curve and log-rank test. To identify mortality predictors, we used a cox regression analysis. We used SPSS-20 for all analyses. Results A total of 326 patients died in the 12 years follow-up period contributing to 6.2% cumulative incidence and 21.7 deaths per 1000 person-year observations incidence rate. Eighty-nine percent of the total deaths were documented in the first two years follow up—an early-term ART follow up. Early HIV mortality rates among adults were 50% less in separated, divorced or widowed patients compared with never married patients, 1.6 times higher in patients with baseline CD4 count <200 cells/μL compared to baseline CD4 count ≥200 cells/μL, 1.5 times higher in patients with baseline WHO clinical stage 3 or 4 compared to baseline WHO clinical stage 1 or 2, 2.1 times higher in patients with immunologic failure compared with no immunologic failure, 60% less in patients with fair or poor compared with good adherence, 2.9 times higher in patients with bedridden functional status compared to working functional status, and 2.7 times higher with patients who had no history of HIV testing before diagnosis compared to those who had history of HIV testing. Most predictors of early mortality remained the same to the predictors of an overall HIV mortality. When discontinuation was assumed as an event, the predictors of an overall HIV mortality included age between 25–50 years, base line CD4 count, developing immunologic failure, bedridden functional status, and no history of HIV testing before diagnosis. Conclusions The great majority of deaths were documented in the first two years of ART, and several predictors of early HIV mortality were also for the overall mortality when discontinuation was assumed as event or censored. Considering the above population, interventions to improve HIV program in the first two years of ART follow up should be improved.
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Affiliation(s)
- Hailay Abrha Gesesew
- Public Health, Flinders University, Adelaide, Australia
- Epidemiology, Jimma University, Jimma, Ethiopia
- * E-mail:
| | - Paul Ward
- Public Health, Flinders University, Adelaide, Australia
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Johnson LF, May MT, Dorrington RE, Cornell M, Boulle A, Egger M, Davies MA. Estimating the impact of antiretroviral treatment on adult mortality trends in South Africa: A mathematical modelling study. PLoS Med 2017; 14:e1002468. [PMID: 29232366 PMCID: PMC5726614 DOI: 10.1371/journal.pmed.1002468] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 11/07/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Substantial reductions in adult mortality have been observed in South Africa since the mid-2000s, but there has been no formal evaluation of how much of this decline is attributable to the scale-up of antiretroviral treatment (ART), as previous models have not been calibrated to vital registration data. We developed a deterministic mathematical model to simulate the mortality trends that would have been expected in the absence of ART, and with earlier introduction of ART. METHODS AND FINDINGS Model estimates of mortality rates in ART patients were obtained from the International Epidemiology Databases to Evaluate AIDS-Southern Africa (IeDEA-SA) collaboration. The model was calibrated to HIV prevalence data (1997-2013) and mortality data from the South African vital registration system (1997-2014), using a Bayesian approach. In the 1985-2014 period, 2.70 million adult HIV-related deaths occurred in South Africa. Adult HIV deaths peaked at 231,000 per annum in 2006 and declined to 95,000 in 2014, a reduction of 74.7% (95% CI: 73.3%-76.1%) compared to the scenario without ART. However, HIV mortality in 2014 was estimated to be 69% (95% CI: 46%-97%) higher in 2014 (161,000) if the model was calibrated only to HIV prevalence data. In the 2000-2014 period, the South African ART programme is estimated to have reduced the cumulative number of HIV deaths in adults by 1.72 million (95% CI: 1.58 million-1.84 million) and to have saved 6.15 million life years in adults (95% CI: 5.52 million-6.69 million). This compares with a potential saving of 8.80 million (95% CI: 7.90 million-9.59 million) life years that might have been achieved if South Africa had moved swiftly to implement WHO guidelines (2004-2013) and had achieved high levels of ART uptake in HIV-diagnosed individuals from 2004 onwards. The model is limited by its reliance on all-cause mortality data, given the lack of reliable cause-of-death reporting, and also does not allow for changes over time in tuberculosis control programmes and ART effectiveness. CONCLUSIONS ART has had a dramatic impact on adult mortality in South Africa, but delays in the rollout of ART, especially in the early stages of the ART programme, have contributed to substantial loss of life. This is the first study to our knowledge to calibrate a model of ART impact to population-level recorded death data in Africa; models that are not calibrated to population-level death data may overestimate HIV-related mortality.
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Affiliation(s)
- Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Margaret T. May
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Rob E. Dorrington
- Centre for Actuarial Research, University of Cape Town, Cape Town, South Africa
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Matthias Egger
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
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Slaymaker E, McLean E, Wringe A, Calvert C, Marston M, Reniers G, Kabudula CW, Crampin A, Price A, Michael D, Urassa M, Kwaro D, Sewe M, Eaton JW, Rhead R, Nakiyingi-Miiro J, Lutalo T, Nabukalu D, Herbst K, Hosegood V, Zaba B. The Network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA): Data on mortality, by HIV status and stage on the HIV care continuum, among the general population in seven longitudinal studies between 1989 and 2014. Gates Open Res 2017. [PMID: 29528045 PMCID: PMC5841576 DOI: 10.12688/gatesopenres.12753.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Timely progression of people living with HIV (PLHIV) from the point of infection through the pathway from diagnosis to treatment is important in ensuring effective care and treatment of HIV and preventing HIV-related deaths and onwards transmission of infection. Reliable, population-based estimates of new infections are difficult to obtain for the generalised epidemics in sub-Saharan Africa. Mortality data indicate disease burden and, if disaggregated along the continuum from diagnosis to treatment, can also reflect the coverage and quality of different HIV services. Neither routine statistics nor observational clinical studies can estimate mortality prior to linkage to care nor following disengagement from care. For this, population-based data are required. The Network for Analysing Longitudinal Population-based HIV/AIDS data on Africa brings together studies in Kenya, Malawi, South Africa, Tanzania, Uganda, and Zimbabwe. Eight studies have the necessary data to estimate mortality by HIV status, and seven can estimate mortality at different stages of the HIV care continuum. This data note describes a harmonised dataset containing anonymised individual-level information on survival by HIV status for adults aged 15 and above. Among PLHIV, the dataset provides information on survival during different periods: prior to diagnosis of infection; following diagnosis but before linkage to care; in pre-antiretroviral treatment (ART) care; in the first six months after ART initiation; among people continuously on ART for 6+ months; and among people who have ever interrupted ART.
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Affiliation(s)
- Emma Slaymaker
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Estelle McLean
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Alison Wringe
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Clara Calvert
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Milly Marston
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Georges Reniers
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,School of Public Health, University of the Witwatersrand, Johannesburg, 2000, South Africa
| | - Chodziwadziwa Whiteson Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2000, South Africa
| | - Amelia Crampin
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Alison Price
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Denna Michael
- National Institute for Medical Research, Mwanza, Tanzania
| | - Mark Urassa
- National Institute for Medical Research, Mwanza, Tanzania
| | | | | | - Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, London, W2 1PG, UK
| | - Rebecca Rhead
- Department of Infectious Disease Epidemiology, Imperial College London, London, W2 1PG, UK
| | | | - Tom Lutalo
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | - Kobus Herbst
- Africa Health Research Institute, Durban, 4001, South Africa
| | - Victoria Hosegood
- Africa Health Research Institute, Durban, 4001, South Africa.,Department of Social Statistics & Demography, University of Southampton, Southhampton, SO17 1BJ, UK
| | - Basia Zaba
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
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Reniers G, Blom S, Lieber J, Herbst AJ, Calvert C, Bor J, Barnighausen T, Zaba B, Li ZR, Clark SJ, Grant AD, Lessells R, Eaton JW, Hosegood V. Tuberculosis mortality and the male survival deficit in rural South Africa: An observational community cohort study. PLoS One 2017; 12:e0185692. [PMID: 29016619 PMCID: PMC5634548 DOI: 10.1371/journal.pone.0185692] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 09/18/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Women live on average five years longer than men, and the sex difference in longevity is typically lower in populations with high mortality. South Africa-a high mortality population with a large sex disparity-is an exception, but the causes of death that contribute to this difference are not well understood. METHODS Using data from a demographic surveillance system in rural KwaZulu-Natal (2000-2014), we estimate differences between male and female adult life expectancy by HIV status. The contribution of causes of death to these life expectancy differences are computed with demographic decomposition techniques. Cause of death information comes from verbal autopsy interviews that are interpreted with the InSilicoVA tool. RESULTS Adult women lived an average of 10.4 years (95% confidence Interval 9.0-11.6) longer than men. Sex differences in adult life expectancy were even larger when disaggregated by HIV status: 13.1 (95% confidence interval 10.7-15.3) and 11.2 (95% confidence interval 7.5-14.8) years among known HIV negatives and positives, respectively. Elevated male mortality from pulmonary tuberculosis (TB) and external injuries were responsible for 43% and 31% of the sex difference in life expectancy among the HIV negative population, and 81% and 16% of the difference among people living with HIV. CONCLUSIONS The sex differences in adult life expectancy in rural KwaZulu-Natal are exceptionally large, atypical for an African population, and largely driven by high male mortality from pulmonary TB and injuries. This is the case for both HIV positive and HIV negative men and women, signalling a need to improve the engagement of men with health services, irrespective of their HIV status.
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Affiliation(s)
- Georges Reniers
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Sylvia Blom
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Charles H. Dyson School of Applied Economics and Management, Cornell University, Ithaca, New York, United States of America
| | - Judith Lieber
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Abraham J. Herbst
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Clara Calvert
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jacob Bor
- Department of Global Health, Boston University, Boston, Massachusetts, United States of America
| | - Till Barnighausen
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Department of Global Health and Population, T. H. Chan School of Public Health, Harvard University, Cambridge, Massachusetts, United States of America
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Basia Zaba
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Zehang R. Li
- Department of Statistics, University of Washington, Seattle, United States of America
| | - Samuel J. Clark
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Sociology, The Ohio State University, Columbus, Ohio
| | - Alison D. Grant
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard Lessells
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jeffrey W. Eaton
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College, London, United Kingdom
| | - Victoria Hosegood
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Social Statistics and Demography, University of Southampton, Southampton, United Kingdom
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Siedner MJ. Aging, Health, and Quality of Life for Older People Living With HIV in Sub-Saharan Africa: A Review and Proposed Conceptual Framework. J Aging Health 2017; 31:109-138. [PMID: 28831864 DOI: 10.1177/0898264317724549] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The number of people living with HIV (PLWH) over 50 years old in sub-Saharan Africa is predicted to triple in the coming decades, to 6-10 million. Yet, there is a paucity of data on the determinants of health and quality of life for older PLWH in the region. METHODS A review was undertaken to describe the impact of HIV infection on aging for PLWH in sub-Saharan Africa. RESULTS We (a) summarize the pathophysiology and epidemiology of aging with HIV in resource-rich settings, and (b) describe how these relationships might differ in sub-Saharan Africa, (c) propose a conceptual framework to describe determinants of quality of life for older PLWH, and (d) suggest priority research areas needed to ensure long-term gains in quality of life for PLWH in the region. CONCLUSIONS Differences in traditional, lifestyle, and envirnomental risk factors, as well as unique features of HIV epidemiology and care delivery appear to substantially alter the contribution of HIV to aging in sub-Saharan Africa. Meanwhile, unique preferences and conceptualizations of quality of life will require novel measurement and intervention tools. An expanded research and public health infrastructure is needed to ensure that gains made in HIV prevention and treamtent are translated into long-term benefits in this region.
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Affiliation(s)
- Mark J Siedner
- 1 Harvard Medical School, Boston, MA, USA.,2 Massachusetts General Hospital, Boston, MA, USA.,3 Mbarara University of Science and Technology, Mbarara, Uganda
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Reduction in extrapulmonary tuberculosis in context of antiretroviral therapy scale-up in rural South Africa. Epidemiol Infect 2017; 145:2500-2509. [PMID: 28748775 DOI: 10.1017/s095026881700156x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Scale-up of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection has reduced the incidence of pulmonary tuberculosis (PTB) in South Africa. Despite the strong association of HIV infection with extrapulmonary tuberculosis (EPTB), the effect of ART on the epidemiology of EPTB remains undocumented. We conducted a retrospective record review of patients initiated on treatment for EPTB in 2009 (ART coverage <5%) and 2013 (ART coverage 41%) at four public hospitals in rural Mopani District, South Africa. Data were obtained from TB registers and patients' clinical records. There was a 13% decrease in overall number of TB cases, which was similar for cases registered as EPTB (n = 399 in 2009 vs. 336 in 2013; P < 0·01) and for PTB (1031 vs. 896; P < 0·01). Among EPTB cases, the proportion of miliary TB and disseminated TB decreased significantly (both P < 0·01), TB meningitis and TB of bones increased significantly (P < 0·01 and P = 0·02, respectively) and TB pleural effusion and lymphadenopathy remained the same. This study shows a reduction of EPTB cases that is similar to that of PTB in the context of the ART scale-up. The changing profile of EPTB warrants attention of healthcare workers.
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De Neve JW, Harling G. Offspring schooling associated with increased parental survival in rural KwaZulu-Natal, South Africa. Soc Sci Med 2017; 176:149-157. [PMID: 28153751 PMCID: PMC5322823 DOI: 10.1016/j.socscimed.2017.01.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 01/09/2017] [Accepted: 01/11/2017] [Indexed: 11/20/2022]
Abstract
Background Investing in offspring's human capital has been suggested as an effective strategy for parents to improve their living conditions at older ages. A few studies have assessed the role of children's schooling in parental survival in high-income countries, but none have considered lower-resource settings with limited public wealth transfers and high adult mortality. Methods We followed 17,789 parents between January 2003 and August 2015 in a large population-based open cohort in rural KwaZulu-Natal, South Africa. We used Cox proportional hazards models to investigate the association between offspring's schooling and time to parental death. We assessed the association separately by parental sex and for four cause of death groups. Results A one year increase in offspring's schooling attainment was associated with a 5% decline in the hazard of maternal death (adjusted Hazard Ratio [aHR]: 0.95, 95%CI: 0.94–0.97) and a 6% decline in the hazard of paternal death (aHR: 0.94, 95%CI: 0.92–0.96), adjusting for a wide range of demographic and socio-economic variables of the parent and their children. Among mothers, the association was strongest for communicable, maternal, perinatal and nutritional conditions (aHR: 0.87, 95%CI: 0.82–0.92) and AIDS and tuberculosis (aHR: 0.92, 95%CI: 0.89–0.96), and weakest for injuries. Among fathers, the association was strongest for injuries (aHR: 0.87, 95%CI: 0.79–0.95) and AIDS and tuberculosis (aHR: 0.92, 95%CI: 0.89–0.96), and weakest for non-communicable diseases. Conclusion Higher levels of schooling in offspring are associated with increased parental survival in rural South Africa, particularly for mothers at risk of communicable disease mortality and fathers at risk of injury mortality. Offspring's human capital may be an important factor for health disparities, particularly in lower-resource settings. Investing in offspring's education may improve parental survival. We follow 17,789 parents over a 13 year period in rural South Africa. Higher offspring schooling is associated with increased parental survival. Strongest association for mothers is for communicable disease mortality. Strongest association for fathers is for injury mortality.
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Affiliation(s)
- Jan-Walter De Neve
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA 02115, United States; Institute of Public Health, Heidelberg University, Im Neuenheimer Feld 130.3, Heidelberg 69120, Germany.
| | - Guy Harling
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA 02115, United States; Research Department of Infection and Population Health, University College London, off Caper Street, London, WC1E 6JB, United Kingdom; Africa Health Research Institute, University of KwaZulu-Natal, Somkhele, 3935, South Africa
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