The effect of antiretroviral therapy provision on all-cause, AIDS and non-AIDS mortality at the population level--a comparative analysis of data from four settings in Southern and East Africa

Estimation of cause-specific mortality in Rakai, Uganda, using verbal autopsy 1999-2019

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.

Discussing Reproductive Plans with Healthcare Providers by Sexually Active Women Living with HIV in Western Ethiopia

Discussing reproductive plans with healthcare providers by women living with HIV (WLHIV) can assist in promoting safe reproductive health practices, but little research has been undertaken in this area. A cross-sectional survey was conducted in western Ethiopia in 2018 among 475 sexually active WLHIV. One hundred and twenty seven (26.8%) participants reported becoming pregnant in the last 5 years after being aware of their HIV-positive status; 33.6% reported their intention to have children in the future, and 26.9% were ambivalent about having children. WLHIV who reported general and personalized discussions of reproductive plans with healthcare providers were 30.7% and 16.8%, respectively. Unmarried sexually active women and WLHIV accessing health centers for antiretroviral therapy (ART) were less likely to report both general and personalized discussions than married women and women who accessed ART through hospitals, respectively. WLHIV are both having and intending to have children, highlighting discussions with healthcare providers can deliver support that reduces the risk of vertical and horizontal HIV transmission.

"They haven't asked me. I haven't told them either": fertility plan discussions between women living with HIV and healthcare providers in western Ethiopia

Background

Despite the importance of women living with HIV (WLHIV) engaging in fertility plan discussions with their healthcare providers (HCPs), little research exists. This study explored perceptions surrounding fertility plan discussions between WLHIV and their HCPs in western Ethiopia, from the perspectives of both women and providers.

Methods

Thirty-one interviews (27 with WLHIV and 4 with HCPs) were conducted at four healthcare facilities in western Ethiopia in 2018. Data were transcribed verbatim and translated into English. Codes and themes were identified using inductive thematic analysis.

Results

There was a discordance between HCPs and WLHIV’s perception regarding the delivery of fertility plan discussions. Only nine of the 27 WLHIV reported they had discussed their personal fertility plans with their HCPs. When discussions did occur, safer conception and contraceptive use were the primary focus. Referrals to mother support groups, adherence counsellors as well as family planning clinics (where they can access reproductive counselling) facilitated fertility discussions. However, lack of initiating discussions by either HCPs or women, high client load and insufficient staffing, and a poor referral system were barriers to discussing fertility plans. Where discussions did occur, barriers to good quality interactions were: (a) lack of recognizing women’s fertility needs; (b) a lack of time and being overworked; (c) mismatched fertility desire among couples; (d) non-disclosure of HIV-positive status to a partner; (e) poor partner involvement; (f) fear of repercussions of disclosing fertility desires to a HCP; and (g) HCPs fear of seroconversion.

Conclusions

Our findings highlight the need for policies and guidelines to support fertility plan discussions. Training of HCPs, provision of non-judgmental and client-centered fertility counselling, improving integration of services along with increased human resources are crucial to counselling provision. Enhancing partner involvement, and supporting and training mother support groups and adherence counsellors in providing fertility plan discussions are crucial to improving safer conception and effective contraceptive use, which helps in having healthy babies and reducing HIV transmission.

Contraceptive use among sexually active women living with HIV in western Ethiopia

Introduction

Contraception can help to meet family planning goals for women living with HIV (WLHIV) as well as to support the prevention of mother to child transmission of HIV (PMTCT). However, there is little research into the contraceptive practice among sexually active WLHIV in Ethiopia. Therefore, we aimed to examine contraceptive practice among sexually active WLHIV in western Ethiopia and identify the factors that influenced such practice using the Health Belief Model (HBM).

Methods

A facility-based cross-sectional survey of 360 sexually active WLHIV was conducted from 19^th March to 22^nd June 2018 in western Ethiopia. The eligible participants were WLHIV aged between 18 and 49 years who reported being fecund and sexually active within the previous six months but were not pregnant and not wanting to have another child within two years. Modified Poisson regression analyses were conducted to identify factors that influenced contraceptive practice among sexually active WLHIV in western Ethiopia.

Results

Among sexually active WLHIV (n = 360), 75% used contraception with 25% having unmet needs. Of the contraceptive users, 44.8% used injectables, 37.4% used condoms and 28.5% used implants. Among 152 recorded births in the last five years, 17.8% were reported as mistimed and 25.7% as unwanted. Compared to WLHIV having no child after HIV diagnosis, having two or more children after HIV diagnosis (Adjusted Prevalence Ratio [APR] = 1.31; 95%CI 1.09–1.58) was associated with increased risk of contraceptive practice. However, sexually active unmarried WLHIV (APR = 0.69; 95%CI 0.50–0.95) were less likely to use any contraception compared to their sexually active married counterparts. Importantly, high perceived susceptibility (APR = 1.49; 95%CI 1.20–1.86) and medium perceived susceptibility (APR = 1.55; 95%CI 1.28–1.87) towards unintended pregnancy were associated with higher risk of contraceptive use than WLHIV with low perceived susceptibility.

Conclusions

Although contraceptive use amongst sexually active WLHIV was found to be high, our findings highlight the need for strengthening family planning services given the high rate of unintended pregnancies, the high rate of unmet needs for contraception, as well as the lower efficacy with some of the methods. Our findings also suggest that the HBM would be a valuable framework for healthcare providers, programme planners and policymakers to develop guidelines and policies for contraceptive counselling and choices.

HIV-Related Deaths in Nairobi, Kenya: Results From a HIV Mortuary Surveillance Study, 2015

BACKGROUND

Death is an important but often unmeasured endpoint in public health HIV surveillance. We sought to describe HIV among deaths using a novel mortuary-based approach in Nairobi, Kenya.

METHODS

Cadavers aged 15 years and older at death at Kenyatta National Hospital (KNH) and City Mortuaries were screened consecutively from January 29 to March 3, 2015. Cause of death was abstracted from medical files and death notification forms. Cardiac blood was drawn and tested for HIV infection using the national HIV testing algorithm followed by viral load testing of HIV-positive samples.

RESULTS

Of 807 eligible cadavers, 610 (75.6%) had an HIV test result available. Cadavers from KNH had significantly higher HIV positivity at 23.2% (95% CI: 19.3 to 27.7) compared with City Mortuary at 12.6% (95% CI: 8.8 to 17.8), P < 0.001. HIV prevalence was significantly higher among women than men at both City (33.3% vs. 9.2%, P = 0.008) and KNH Mortuary (28.8% vs. 19.0%, P = 0.025). Half (53.3%) of HIV-infected cadavers had no diagnosis before death, and an additional 22.2% were only diagnosed during hospitalization leading to death. Although not statistically significant, 61.9% of males had no previous diagnosis compared with 45.8% of females (P = 0.144). Half (52.3%) of 44 cadavers at KNH with HIV diagnosis before death were on treatment, and 1 in 5 (22.7%) with a previous diagnosis had achieved viral suppression.

CONCLUSIONS

HIV prevalence was high among deaths in Nairobi, especially among women, and previous diagnosis among cadavers was low. Establishing routine mortuary surveillance can contribute to monitoring HIV-associated deaths among cadavers sent to mortuaries.

Decreased HIV-associated mortality rates during scale-up of antiretroviral therapy, 2011-2016

OBJECTIVE

HIV-associated mortality rates in Africa decreased by 10-20% annually in 2003-2011, after the introduction of antiretroviral therapy (ART). We sought to document HIV-associated mortality rates in the general population in Kenya after 2011 in an era of expanded access to ART.

DESIGN

We obtained data on mortality rates and migration from a health and demographic surveillance system (HDSS) in Gem, western Kenya, and data for HDSS residents aged 15-64 years from home-based HIV counseling and testing (HBCT) rounds in 2011, 2012, 2013, and 2016.

METHODS

Mortality trends were determined among a closed cohort of residents who participated in at least the 2011 round of HBCT.

RESULTS

Of 32 467 eligible HDSS residents, 22 688 (70%) participated in the 2011 round and comprised the study cohort. All-cause mortality rates declined from 10.0 [95% confidence interval (CI) 8.4-11.7] per 1000 in 2011 to 7.4 (95% CI 5·7-9·0) in 2016, whereas the mortality rate was stable among HIV-uninfected residents, at 5.7 per 1000 person-years. Among HIV-infected residents, mortality rates declined from 30.5 per 1000 in 2011 to 15.9 per 1000 in 2016 (average decline 6% per year). The HIV-infected group receiving ART had higher mortality rates than the HIV-uninfected group [adjusted rate ratio (aRR) 2.8, 95% CI 2.2-3.4], as did the HIV-infected group who did not receive ART (aRR 5.3, 95% CI 4.5-6.2).

CONCLUSIONS

Mortality rates among HIV-infected individuals declined substantially during ART expansion between 2011 and 2016, though less than during early ART introduction. Mortality trends among HIV-infected populations are critical to understanding epidemic dynamics.

Unintended Pregnancy in Women Living with HIV in Sub-Saharan Africa: A Systematic Review and Meta-analysis

In 2014, about 1.5 million pregnancies occurred among HIV-positive women in low and middle-income countries. To pool magnitude and factors associated with unintended pregnancy in women living with HIV in sub-Saharan Africa, a systematic search of electronic databases was undertaken in November 2016. Pooling the magnitude of unintended pregnancy reported by 14 studies yielded a crude summary prevalence of 55.9%. The magnitude of unwanted pregnancy and mistimed pregnancy in six studies ranged from 14 to 59 and 9 to 47.2%, respectively. Contraceptive failure was an important factor for many unintended pregnancies. The magnitude of unintended pregnancy was significantly higher in HIV-positive women than for HIV-negative women in three out of six studies. The available evidence suggests that there is a high magnitude of unintended pregnancy in this population. Improving effective contraceptive utilization is thus a priority to address unintended pregnancies and to prevent mother to child transmission of HIV. PROSPERO Number: CRD42016051310.

The Burden of HIV/AIDS in Ethiopia from 1990 to 2016: Evidence from the Global Burden of Diseases 2016 Study

Background

The burden of HIV/AIDS in Ethiopia has not been comprehensively assessed over the last two decades. In this study, we used the 2016 Global Burden of Diseases, Injuries and Risk factors (GBD) data to analyze the incidence, prevalence, mortality and Disability-adjusted Life Years Lost (DALY) rates of Human Immunodeficiency Virus / Acquired Immune Deficiency Syndrome (HIV/AIDS) in Ethiopia over the last 26 years.

Methods

The GBD 2016 used a wide range of data source for Ethiopia such as verbal autopsy (VA), surveys, reports of the Federal Ministry of Health and the United Nations (UN) and published scientific articles. The modified United Nations Programme on HIV/AIDS (UNAIDS) Spectrum model was used to estimate the incidence and mortality rates for HIV/AIDS.

Results

In 2016, an estimated 36,990 new HIV infections (95% uncertainty interval [UI]: 8775-80262), 670,906 prevalent HIV cases (95% UI: 568,268–798,970) and 19,999 HIV deaths (95% UI: 16426-24412) occurred in Ethiopia. The HIV/AIDS incidence rate peaked in 1995 and declined by 6.3% annually for both sexes with a total reduction of 77% between 1990 and 2016. The annualized HIV/AIDS mortality rate reduction during 1990 to 2016 for both sexes was 0.4%.

Conclusions

Ethiopia has achieved the 50% reduction of the incidence rate of HIV/AIDS based on the Millennium Development Goals (MDGs) target. However, the decline in HIV/AIDS mortality rate has been comparatively slow. The country should strengthen the HIV/AIDS detection and treatment programs at community level to achieve its targets during the Sustainable Development Program (SDGs)-era.

Ten years of antiretroviral therapy: Incidences, patterns and risk factors of opportunistic infections in an urban Ugandan cohort

BACKGROUND

Despite increased antiretroviral therapy (ART) coverage and the raised CD4 threshold for starting ART, opportunistic infections (OIs) are still one of the leading causes of death in sub-Saharan Africa. There are few studies from resource-limited settings on long-term reporting of OIs other than tuberculosis.

METHODS

Patients starting ART between April 2004 and April 2005 were enrolled and followed-up for 10 years in Kampala, Uganda. We report incidences, patterns and risk factors using Cox proportional hazards models of OIs among all patients and among patients with CD4 cell counts >200 cells/μL.

RESULTS

Of the 559 patients starting ART, 164 patients developed a total of 241 OIs during 10 years of follow-up. The overall incidence was highest for oral candidiasis (25.4, 95% confidence interval (CI): 20.5-31.6 per 1000 person-years of follow-up), followed by tuberculosis (15.3, 95% CI: 11.7-20.1), herpes zoster (12.3, 95% CI: 9.1-16.6) and cryptococcal meningitis (3.0, 95% CI: 1.7-5.5). Incidence rates for all OIs were highest in the first year after ART initiation and decreased with the increase of the current CD4 cell count. Factors independently associated with development of OIs were baseline nevirapine-based regimens, time-varying higher viral load, time-varying lower CD4 cell count and time-varying lower hemoglobin. In patients developing OIs at a current CD4 cell count >200 cells/μL, factors independently associated with OI development were time-varying increase in viral load and time-varying decrease in hemoglobin, whereas a baseline CD4 cell count <50 cells/μL was protective.

CONCLUSION

We report high early incidences of OIs, decreasing with increasing CD4 cell count and time spent on ART. Ongoing HIV replication and anemia were strong predictors for OI development independent of the CD4 cell count. Our findings support the recommendation for early initiation of ART and suggest close monitoring for OIs among patients recently started on ART, with low CD4 cell count, high viral load and anemia.

"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

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.

Sustained 10-year gain in adult life expectancy following antiretroviral therapy roll-out in rural Malawi: July 2005 to June 2014

Background: Improved life expectancy in high HIV prevalence populations has been observed since antiretroviral therapy (ART) scale-up. However, it is unclear if the benefits are sustained, and the mortality among HIV-positive individuals not (yet) on ART is not well described. We assessed temporal change in mortality over 9 years in rural Malawi.

Methods: Within a demographic surveillance site in northern rural Malawi, we combined demographic, HIV and ART uptake data. We calculated life expectancy using Kaplan-Meier estimates, and compared mortality rates and rate ratios using Poisson regression, by period of ART availability (July 2005–June 2008, July 2008–June 2011 and July 2011–June 2014).

Results: Among 32 664 individuals there were 1424 deaths; 1930 individuals were known HIV-positive, of whom 1382 started ART. Overall, life expectancy at age 15 years increased by 10 years within 5 years of ART introduction, and plateaued. Age-standardized adult mortality rates declined from 11.3/1000 to 7.5/1000 person-years between the first and last time period. In July 2011-June 2014 compared with July 2005–June 2008, mortality declined in HIV-positive individuals on ART (rate ratio adjusted (aRR) for age, sex, location and education, 0.3; 95% confidence interval (CI) 0.2–0.5) and in those not (yet) on ART (aRR 0.3; 95%CI 0.1–0.5) but not in HIV-negative individuals (aRR 1.1; 95%CI 0.7–1.9).

Conclusions: Total population adult life expectancy increased toward that of HIV-negative individuals by 2011 and remained raised. The reduction in all-cause and HIV-related mortality in HIV-positive individuals not (yet) on ART suggests ART uptake is occurring at an earlier disease stage, particularly in women.

Effect of age and level of education on neurocognitive impairment in HIV positive Zambian adults

OBJECTIVE

Older age and lower education levels are known to be associated with worse neurocognitive (NC) performance in healthy adults, and individuals with HIV infection may experience accelerated brain/cognition aging. However, higher education may possibly protect against HIV-associated neurocognitive disorders (HAND). The aim of the current cross-sectional study was to assess the effect of age and education in an HIV-1 clade C infected adult population in urban Zambia.

METHOD

Demographically corrected Zambian norms on a neuropsychological (NP) test battery were used to correct for normal age and education effects. The study assessed 286 HIV positive (+) males (37.1%) and females (62.9%) with a mean age of 41.35 (SD = 8.56) and mean years of education = 10.16 (SD = 2.18). A comprehensive NP test battery was used to assess cognitive domains frequently affected by HIV: attention/working memory, learning/and delayed recall, executive function, verbal fluency, processing speed, verbal and visual episodic memory, and fine motor skills.

RESULTS

In younger HIV+ Zambians, higher education evidenced protective effects against NC impairments overall, and for the specific domains of executive functions, learning and speed of information processing. Impairment scores did not support accelerated overall brain aging although the restricted age range and relative youth of our total sample may have precluded detection of such tendencies.

CONCLUSIONS

The present study raises the need to investigate factors that could be implicated in the poor neurocognitive performance among the younger, less educated HIV+ individuals in Zambia. (PsycINFO Database Record

The Demography of Mental Health Among Mature Adults in a Low-Income, High-HIV-Prevalence Context

Very few studies have investigated mental health in sub-Saharan Africa (SSA). Using data from Malawi, this article provides a first picture of the demography of depression and anxiety (DA) among mature adults (aged 45 or older) in a low-income country with high HIV prevalence. DA are more frequent among women than men, and individuals affected by one are often affected by the other. DA are associated with adverse outcomes, such as poorer nutrition intake and reduced work efforts. DA also increase substantially with age, and mature adults can expect to spend a substantial fraction of their remaining lifetime-for instance, 52 % for a 55-year-old woman-affected by DA. The positive age gradients of DA are not due to cohort effects, and they are in sharp contrast to the age pattern of mental health that has been shown in high-income contexts, where older individuals often experience lower levels of DA. Although socioeconomic and risk- or uncertainty-related stressors are strongly associated with DA, they do not explain the positive age gradients and gender gap in DA. Stressors related to physical health, however, do. Hence, our analyses suggest that the general decline of physical health with age is the key driver of the rise of DA with age in this low-income SSA context.

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

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.

The History of the HIV/AIDS Epidemic in Africa

HIV testing of African immigrants in Belgium showed that HIV existed among Africans by 1983. However, the epidemic was recognized much later in most parts of sub-Saharan Africa (SSA) due to stigma and perceived fear of possible negative consequences to the countries' economies. This delay had devastating mortality, morbidity, and social consequences. In countries where earlier recognition occurred, political leadership was vital in mounting a response. The response involved establishment of AIDS control programs and research on the HIV epidemiology and candidate preventive interventions. Over time, the number of effective interventions has grown; the game changer being triple antiretroviral therapy (ART). ART has led to a rapid decline in HIV-related morbidity and mortality in addition to prevention of onward HIV transmission. Other effective interventions include safe male circumcision, pre-exposure prophylaxis, and post-exposure prophylaxis. However, since none of these is sufficient by itself, delivering a combination package of these interventions is important for ending the HIV epidemic as a public health threat.

The population-level impact of public-sector antiretroviral therapy rollout on adult mortality in rural Malawi

BACKGROUND

Recent evidence from health and demographic surveillance sites (HDSS) has shown that increasing access to antiretroviral therapy (ART) is reducing mortality rates in sub-Saharan Africa (SSA). However, due to limited vital statistics registration in many of the countries most affected by the HIV/AIDS epidemic, there is limited evidence of the magnitude of ART’s effect outside of specific HDSS sites. This paper leverages longitudinal household/family roster data from the Malawi Longitudinal Survey of Families and Health (MLSFH) to estimate the effect of ART availability in public clinics on population-level mortality based on a geographically dispersed sample of individuals in rural Malawi.

OBJECTIVE

We seek to provide evidence on the population-level magnitude of the ART-associated mortality decline in rural Malawi and confirm that this population is experiencing similar declines in mortality as those seen in HDSS sites.

METHODS

We analyze longitudinal household/family-roster data from four waves of the MLSFH to estimate mortality change after the introduction of ART to study areas. We analyze life expectancy using the Kaplan–Meier estimator and examine how the mortality hazard changed over time by individual characteristics with Cox regression.

RESULTS

In the four years following rollout of ART, life expectancy at age 15 increased by 3.1 years (95% CI 1.1, 5.1), and median length of life rose by over ten years.

CONTRIBUTION

Our observations show that the increased availability of ART resulted in a substantial and sustained reversal of mortality trends in SSA and assuage concerns that the post-ART reversals in mortality are not occurring at the same magnitude outside of specific HDSSs.

HIV cause-specific deaths, mortality, risk factors, and the combined influence of HAART and late diagnosis in Zhejiang, China, 2006-2013

To examine patterns of human immunodeficiency virus (HIV) cause-specific deaths, risk factors, and the effect of interactions on mortality, we conducted a retrospective cohort study in Zhejiang, China, from 2006 to 2013. All data were downloaded from the acquired immune deficiency syndrome (AIDS) Prevention and Control Information System. The Cox proportional hazards model was used to assess predictors of cause-specific death. The relative excess risk due to interaction and ratio of hazard ratios (RHR) were calculated for correlations between HAART, late diagnosis, and age. A total of 13,812 HIV/AIDS patients were enrolled with 31,553 person-years (PY) of follow-up. The leading causes of death of HIV patients were accidental death and suicide (21.5%), and the leading cause of death for those with AIDS was AIDS-defining disease (76.4%). Both additive and multiplicative scale correlations were found between receiving HAART and late diagnosis, with RERI of 5.624 (95% CI: 1.766-9.482) and RHR of 2.024 (95% CI: 1.167-2.882). The effects of HAART on AIDS-related mortalities were affected by late diagnosis. Early detection of HIV infection and increased uptake of HAART are important for greater benefits in terms of lives saved.

Predictors of immunodeficiency-related death in a cohort of low-income people living with HIV: a competing risks survival analysis

We conducted a survival analysis with competing risks to estimate the mortality rate and predictive factors for immunodeficiency-related death in people living with HIV/AIDS (PLWH) in northeast Brazil. A cohort with 2372 PLWH was enrolled between July 2007 and June 2010 and monitored until 31 December 2012 at two healthcare centres. The event of interest was immunodeficiency-related death, which was defined based on the Coding Causes of Death in HIV Protocol (CoDe). The predictor variables were: sociodemographic characteristics, illicit drugs, tobacco, alcohol, nutritional status, antiretroviral therapy, anaemia and CD4 cell count at baseline; and treatment or chemoprophylaxis for tuberculosis (TB) during follow-up. We used Fine & Gray's model for the survival analyses with competing risks, since we had regarded immunodeficiency-unrelated deaths as a competing event, and we estimated the adjusted sub-distribution hazard ratios (SHRs). In 10 012·6 person-years of observation there were 3·1 deaths/100 person-years (2·3 immunodeficiency-related and 0·8 immunodeficiency-unrelated). TB (SHR 4·01), anaemia (SHR 3·58), CD4 <200 cells/mm3 (SHR 3·33) and being unemployed (SHR 1·56) were risk factors for immunodeficiency-related death. This study discloses a 13% coverage by highly active antiretroviral therapy (HAART) in our state and adds that anaemia at baseline or the incidence of TB may increase the specific risk of dying from HIV-immunodeficiency, regardless of HAART and CD4.

Topical gentian violet compared with nystatin oral suspension for the treatment of oropharyngeal candidiasis in HIV-1-infected participants

OBJECTIVE

Compare the safety and efficacy of topical gentian violet with that of nystatin oral suspension (NYS) for the treatment of oropharyngeal candidiasis in HIV-1-infected adults in resource-limited settings.

DESIGN

Multicenter, open-label, evaluator-blinded, randomized clinical trial at eight international sites, within the AIDS Clinical Trials Group.

STUDY PARTICIPANTS AND INTERVENTION

Adult HIV-infected participants with oropharyngeal candidiasis, stratified by CD4 cell counts and antiretroviral therapy status at study entry, were randomized to receive either gentian violet (0.00165%, BID) or NYS (500 000 units, QID) for 14 days.

MAIN OUTCOME MEASURE(S)

Cure or improvement after 14 days of treatment. Signs and symptoms of oropharyngeal candidiasis were evaluated in an evaluator-blinded manner.

RESULTS

The study was closed early per Data Safety Monitoring Board after enrolling 221 participants (target = 494). Among the 182 participants eligible for efficacy analysis, 63 (68.5%) in the gentian violet arm had cure or improvement of oropharyngeal candidiasis versus 61 (67.8%) in the NYS arm, resulting in a nonsizable difference of 0.007 (95% confidence interval: -0.129, 0.143). There was no sizable difference in cure rates between the two arms (-0.0007; 95% confidence interval: -0.146, 0.131). No gentian violet-related adverse events were noted. No sizable differences were identified in tolerance, adherence, quality of life, or acceptability of study drugs. In gentian violet arm, 61 and 39% of participants reported 'no' and 'mild-to-moderate' staining, respectively. Cost for medication procurement was significantly lower for gentian violet versus NYS (median $2.51 and 19.42, respectively, P = 0.01).

CONCLUSION

Efficacy of gentian violet was not statistically different than NYS, was well tolerated, and its procurement cost was substantially less than NYS.

Antiretroviral Treatment Scale-Up and Tuberculosis Mortality in High TB/HIV Burden Countries: An Econometric Analysis

Introduction

Antiretroviral therapy (ART) reduces mortality in patients with active tuberculosis (TB), but the population-level relationship between ART coverage and TB mortality is untested. We estimated the reduction in population-level TB mortality that can be attributed to increasing ART coverage across 41 high HIV-TB burden countries.

Methods

We compiled TB mortality trends between 1996 and 2011 from two sources: (1) national program-reported TB death notifications, adjusted for annual TB case detection rates, and (2) WHO TB mortality estimates. National coverage with ART, as proportion of HIV-infected people in need, was obtained from UNAIDS. We applied panel linear regressions controlling for HIV prevalence (5-year lagged), coverage of TB interventions (estimated by WHO and UNAIDS), gross domestic product per capita, health spending from domestic sources, urbanization, and country fixed effects.

Results

Models suggest that that increasing ART coverage was followed by reduced TB mortality, across multiple specifications. For death notifications at 2 to 5 years following a given ART scale-up, a 1% increase in ART coverage predicted 0.95% faster mortality rate decline (p = 0.002); resulting in 27% fewer TB deaths in 2011 alone than would have occurred without ART. Based on WHO death estimates, a 1% increase in ART predicted a 1.0% reduced TB death rate (p<0.001), and 31% fewer deaths in 2011. TB mortality was higher at higher HIV prevalence (p<0.001), but not related to coverage of isoniazid preventive therapy, cotrimoxazole preventive therapy, or other covariates.

Conclusion

This econometric analysis supports a substantial impact of ART on population-level TB mortality realized already within the first decade of ART scale-up, that is apparent despite variable-quality mortality data.

HIV policy and implementation: a national policy review and an implementation case study of a rural area of northern Malawi

Malawi is a global leader in the design and implementation of progressive HIV policies. However, there continues to be substantial attrition of people living with HIV across the “cascade” of HIV services from diagnosis to treatment, and program outcomes could improve further. Ability to successfully implement national HIV policy, especially in rural areas, may have an impact on consistency of service uptake. We reviewed Malawian policies and guidelines published between 2003 and 2013 relating to accessibility of adult HIV testing, prevention of mother-to-child transmission and HIV care and treatment services using a policy extraction tool, with gaps completed through key informant interviews. A health facility survey was conducted in six facilities serving the population of a demographic surveillance site in rural northern Malawi to investigate service-level policy implementation. Survey data were analyzed using descriptive statistics. Policy implementation was assessed by comparing policy content and facility practice using pre-defined indicators covering service access: quality of care, service coordination and patient tracking, patient support, and medical management. ART was rolled out in Malawi in 2004 and became available in the study area in 2005. In most areas, practices in the surveyed health facilities complied with or exceeded national policy, including those designed to promote rapid initiation onto treatment, such as free services and task-shifting for treatment initiation. However, policy and/or practice were/was lacking in certain areas, in particular those strategies to promote retention in HIV care (e.g., adherence monitoring and home-based care). In some instances, though, facilities implemented alternative progressive practices aimed at improving quality of care and encouraging adherence. While Malawi has formulated a range of progressive policies aiming to promote rapid initiation onto ART, increased investment in policy implementation strategies and quality service delivery, in particular to promote long-term retention on treatment may improve outcomes further.

Assessment of the nevirapine safety signal using data from the national antiretroviral dispensing database: a retrospective study

BACKGROUND

Clinical trials showed a higher risk of skin- and liver- related adverse reactions when NVP-based antiretroviral therapy (ART) was initiated in female and male patients with baseline CD4 cell counts ≥250 and ≥400, respectively. Some studies reported no difference in risk between the high and low CD4 count groups. Consequently, the use of NVP-based ART in all patients with a CD4 cell count <350, was recommended. In 2011, the Pharmacovigilance Centre detected an increase in reports of grade III and IV reactions. The center was required to determine if there was an increase in NVP-related reactions.

METHODS

Automated dispensing records from January 2008 to November 2011 were accessed from the National Antiretroviral Dispensing Database (NDB). Records of patients who were initiated on NVP-based ART were selected, and records showing a replacement of NVP with protease inhibitor (PI) were identified. The proportions of grade III and IV reactions were calculated per quarter, and Odds Ratios (OR) were calculated, with the confidence interval set at 95 % and a p-value of <0.05.

RESULTS

From 2008 to 2011 a total of 84,741 patients were started on ART. Of these 67,794 were initiated on NVP-containing ART. Of these, 211 females and 79 males were substituted from NVP to a PI. The OR for females was 2.4 (95 % confidence interval [CI] 1.8 - 3.1). For males the OR was 2.4 (OR 2.4; 95 % CI 1.4 - 3.8) which occurred nine months after the change observed in the females. The odds of a NVP-to-PI substitution in females compared to males before the launch of Namibia's 2010 ART guidelines was the same as the odds after the publication of the guidelines (before, OR 1.6; 95 % CI 1.1 - 2.5; after, OR 1.6; 95 % CI 1.2 - 2.2).

CONCLUSIONS

There was an increase in substitutions of NVP with a PI following the increase in the CD4 threshold for initiating NVP-based HAART, meaning that there was an increase in grade III and IV reactions associated with NVP. Therefore the NVP-safety signal was confirmed to be a true signal, which contributed to the Ministry's decision to review the use of NVP.

Adult life expectancy trends in the era of antiretroviral treatment in rural Uganda (1991-2012)

OBJECTIVE

To estimate the impact of antiretroviral therapy (ART) on population-wide adult life expectancy.

STUDY DESIGN

A population-based open cohort study with repeated HIV status measurements and registration of vital events in Southwestern Uganda (1991-2012).

METHODS

Nonparametric survival analysis techniques are used for estimating trends in the adult life expectancy of the general population (aged 15 and above), the adult life expectancy by HIV status, and the adult life expectancy deficit. The life expectancy deficit is estimated as the difference between overall life expectancy and life expectancy of the HIV-negative population. All estimates are disaggregated by sex.

RESULTS

Between 1991-1993 and 2009-2012, population-wide adult life expectancy increased from 39.3 [95% confidence interval (CI): 35.9-42.8] to 56.1 years (95% CI: 54.0-58.5) in women, and from 38.6 (95% CI: 35.4-42.1) to 51.4 years (95% CI: 49.2-53.7) in men. Most of the adult life expectancy gains coincide with the introduction of ART in 2004; as evidenced by an increase in the adult life expectancy of people living with HIV between 2000-2002 and 2009-2012 of 22.9 and 20.0 years for women and men, respectively. Over the whole period of observation, the adult life expectancy deficit associated with HIV decreased from 16.1 (95% CI: 12.7-19.8) to 6.0 years (95% CI: 4.1-7.8) among women, and from 16.0 (95% CI: 12.1-19.9) to 2.8 years (95% CI: 1.2-4.6) among men.

CONCLUSION

Population-wide life expectancy increased substantially, largely driven by reductions in HIV-related mortality. Women have gained more adult life years than men since the introduction of ART, but the burden of HIV in terms of the life years lost is still larger for women than it is for men.

Health & Demographic Surveillance System Profile: The Magu Health and Demographic Surveillance System (Magu HDSS)

The Magu Health and Demographic Surveillance System (Magu HDSS) is part of Kisesa OpenCohort HIV Study located in a rural area of North-Western Tanzania. Since its establishment in 1994, information on pregnancies, births, marriages, migrations and deaths have been monitored and updated between one and three times a year by trained fieldworkers. Other research activities implemented in the cohort include: sero surveys which have been conducted every 2–3 years to collect socioeconomic data, HIV sero status and health knowledge attitude and behaviour in adults aged 15 years or more living in the area; verbal autopsy (VA) interviews conducted to establish cause of death in all deaths encountered in the area; Llnking data collected at health facilities to community-based data; monitoring voluntary counselling and testing (VCT); and assessing uptake of antiretroviral treatment (ART). In addition, within the community, qualitative studies have been conducted to address issues linked to HIV stigma, the perception of ART access and adherence.

In 2014, the population was over 35 000 individuals. Magu HDSS has contributed to Tanzanian estimates of fertility and mortality, and is a member of the INDEPTH network. Demographic data for Magu HDSS are available via the INDEPTH Network’s Sharing and Accessing Repository (iSHARE) and applications to access HDSS data for collaborative analysis are encouraged.

A comparative analysis of national HIV policies in six African countries with generalized epidemics

OBJECTIVE

To compare national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries.

METHODS

We reviewed HIV policies as part of a multi-country study on adult mortality in sub-Saharan Africa. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. We also compared the national policies with World Health Organization (WHO) guidance.

FINDINGS

There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy.

CONCLUSION

Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. Future research should assess the extent of policy implementation and link these findings with HIV outcomes.

Gender, ageing and carework in East and Southern Africa: A review

An estimated 58 million persons aged 60-plus live in sub-Saharan Africa; by 2050 that number will rise sharply to 215 million. Older Africans traditionally get care in their old age from the middle generation. But in East and Southern Africa, HIV has hollowed out that generation, leaving many older persons to provide care for their children's children without someone to care for him or herself in old age. Simultaneously, the burden of disease among older persons is changing in this region. The result is a growing care deficit. This article examines the existing literature on care for and by older persons in this region, highlighting understudied aspects of older persons' experiences of ageing and care--including the positive impacts of carework, variation in the region and the role of resilience and pensions. We advance a conceptual framework of gendered identities--for both men and women--and intergenerational social exchange to help focus and understand the complex interdependent relationships around carework, which are paramount in addressing the needs of older persons in the current care deficit in this region, and the Global South more generally.

Morbidity and mortality according to latest CD4+ cell count among HIV positive individuals in South Africa who enrolled in project Phidisa

BACKGROUND

Short-term morbidity and mortality rates for HIV positive soldiers in the South African National Defence Force (SANDF) would inform decisions about deployment and HIV disease management. Risks were determined according to the latest CD4+ cell count and use of antiretroviral therapy (ART) for HIV positive individuals in the SANDF and their dependents.

METHODS AND FINDINGS

A total of 7,114 participants were enrolled and followed for mortality over a median of 4.7 years (IQR: 1.9, 7.1 years). For a planned subset (5,976), progression of disease (POD) and grade 4, potentially life-threatening events were also ascertained. CD4+ count and viral load were measured every 3 to 6 months. Poisson regression was used to compare event rates by latest CD4+ count (<50, 50-99, 100-199, 200-349, 350-499, 500+) with a focus on upper three strata, and to estimate relative risks (RRs) (ART/no ART). Median entry CD4+ was 207 cells/mm3. During follow-up over 70% were prescribed ART. Over follow-up 1,226 participants died; rates ranged from 57.6 (< 50 cells) to 0.8 (500+ cells) per 100 person years (py). Compared to those with latest CD4+ 200-349 (2.2/100 py), death rates were significantly lower (p<0.001), as expected, for those with 350-499 (0.9/100 py) and with 500+ cells (0.8/100 py). The composite outcome of death, POD or grade 4 events occurred in 2,302 participants (4,045 events); rates were similar in higher CD4+ count strata (9.4 for 350-499 and 7.9 for 500+ cells) and lower than those with counts 200-349 cells (13.5) (p<0.001). For those with latest CD4+ 350+ cells, 63% of the composite outcomes (680 of 1,074) were grade 4 events.

CONCLUSION

Rates of morbidity and mortality are lowest among those with CD4+ count of 350 or higher and rates do not differ for those with counts of 350-499 versus 500+ cells. Grade 4 events are the predominant morbidity for participants with CD4+ counts of 350+ cells.

Comparison of Rates of Death Having any Death-Certificate Mention of Heart, Kidney, or Liver Disease Among Persons Diagnosed with HIV Infection with those in the General US Population, 2009-2011

OBJECTIVE

Compare age-adjusted rates of death due to liver, kidney, and heart diseases during 2009-2011 among US residents diagnosed with HIV infection with those in the general population.

METHODS

Numerators were numbers of records of multiple-cause mortality data from the national vital statistics system with an ICD-10 code for the disease of interest (any mention, not necessarily the underlying cause), divided into those 1) with and 2) without an additional code for HIV infection. Denominators were 1) estimates of persons living with diagnosed HIV infection from national HIV surveillance system data and 2) general population estimates from the US Census Bureau. We compared age-adjusted rates overall (unstratified by sex, race/ethnicity, or region of residence) and stratified by demographic group.

RESULTS

Overall, compared with the general population, persons diagnosed with HIV infection had higher age-adjusted rates of death reported with hepatitis B (rate ratio [RR]=42.6; 95% CI: 34.7-50.7), hepatitis C (RR=19.4; 95% CI: 18.1-20.8), liver disease excluding hepatitis B or C (RR=2.1; 95% CI: 1.8-2.3), kidney disease (RR=2.4; 95% CI: 2.2-2.6), and cardiomyopathy (RR=1.9; 95% CI: 1.6-2.3), but lower rates of death reported with ischemic heart disease (RR=0.6; 95% CI: 0.6-0.7) and heart failure (RR=0.8; 95% CI: 0.6-0.9). However, the differences in rates of death reported with the heart diseases were insignificant in some demographic groups.

CONCLUSION

Persons with HIV infection have a higher risk of death with liver and kidney diseases reported as causes than the general population.

HIV/AIDS-related mortality in Africa and Asia: evidence from INDEPTH health and demographic surveillance system sites

BACKGROUND

As the HIV/AIDS pandemic has evolved over recent decades, Africa has been the most affected region, even though a large proportion of HIV/AIDS deaths have not been documented at the individual level. Systematic application of verbal autopsy (VA) methods in defined populations provides an opportunity to assess the mortality burden of the pandemic from individual data.

OBJECTIVE

To present standardised comparisons of HIV/AIDS-related mortality at sites across Africa and Asia, including closely related causes of death such as pulmonary tuberculosis (PTB) and pneumonia.

DESIGN

Deaths related to HIV/AIDS were extracted from individual demographic and VA data from 22 INDEPTH sites across Africa and Asia. VA data were standardised to WHO 2012 standard causes of death assigned using the InterVA-4 model. Between-site comparisons of mortality rates were standardised using the INDEPTH 2013 standard population.

RESULTS

The dataset covered a total of 10,773 deaths attributed to HIV/AIDS, observed over 12,204,043 person-years. HIV/AIDS-related mortality fractions and mortality rates varied widely across Africa and Asia, with highest burdens in eastern and southern Africa, and lowest burdens in Asia. There was evidence of rapidly declining rates at the sites with the heaviest burdens. HIV/AIDS mortality was also strongly related to PTB mortality. On a country basis, there were strong similarities between HIV/AIDS mortality rates at INDEPTH sites and those derived from modelled estimates.

CONCLUSIONS

Measuring HIV/AIDS-related mortality continues to be a challenging issue, all the more so as anti-retroviral treatment programmes alleviate mortality risks. The congruence between these results and other estimates adds plausibility to both approaches. These data, covering some of the highest mortality observed during the pandemic, will be an important baseline for understanding the future decline of HIV/AIDS.

The impact of the 2013 WHO antiretroviral therapy guidelines on the feasibility of HIV population prevention trials

BACKGROUND

Several cluster-randomized HIV prevention trials aim to demonstrate the population-level preventive impact of antiretroviral therapy (ART). 2013 World Health Organization (WHO) guidelines raising the ART initiation threshold to CD4 <500/µL could attenuate these trials' effect size by increasing ART usage in control clusters.

METHODS

We used a computational model to simulate strategies from a hypothetical cluster-randomized HIV prevention trial. The primary model outcome was the relative reduction in 24-month HIV incidence between control (ART offered with CD4 below threshold) and intervention (ART offered to all) strategies. We assessed this incidence reduction using the revised (CD4 <500/µL) and prior (CD4 <350/µL) control ART initiation thresholds. Additionally, we evaluated changes to trial characteristics that could bolster the incidence reduction.

RESULTS

With a control ART initiation threshold of CD4 <350/µL, 24-month HIV incidence under control and intervention strategies was 2.46/100 person-years (PY) and 1.96/100 PY, a 21% reduction. Raising the threshold to CD4 <500/µL decreased the incidence reduction by more than one-third, to 12%. Using this higher threshold, moving to a 36-month horizon (vs 24-month), yearly control-strategy HIV screening (vs bian-nual), and intervention-strategy screening every 2 months (vs biannual), resulted in a 31% incidence reduction that was similar to effect size projections for ongoing trials. Alternate assumptions regarding cross-cluster contamination had the greatest influence on the incidence reduction.

CONCLUSIONS

Implementing the 2013 WHO HIV treatment threshold could substantially diminish the incidence reduction in HIV population prevention trials. Alternative HIV testing frequencies and trial horizons can bolster this incidence reduction, but they could be logistically and ethically challenging. The feasibility of HIV population prevention trials should be reassessed as the implementation of treatment guidelines evolves.

How have ART treatment programmes changed the patterns of excess mortality in people living with HIV? Estimates from four countries in East and Southern Africa

Background

Substantial falls in the mortality of people living with HIV (PLWH) have been observed since the introduction of antiretroviral therapy (ART) in sub-Saharan Africa. However, access and uptake of ART have been variable in many countries. We report the excess deaths observed in PLWH before and after the introduction of ART. We use data from five longitudinal studies in Malawi, South Africa, Tanzania, and Uganda, members of the network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA).

Methods

Individual data from five demographic surveillance sites that conduct HIV testing were used to estimate mortality attributable to HIV, calculated as the difference between the mortality rates in PLWH and HIV-negative people. Excess deaths in PLWH were standardized for age and sex differences and summarized over periods before and after ART became generally available. An exponential regression model was used to explore differences in the impact of ART over the different sites.

Results

127,585 adults across the five sites contributed a total of 487,242 person years. Before the introduction of ART, HIV-attributable mortality ranged from 45 to 88 deaths per 1,000 person years. Following ART availability, this reduced to 14–46 deaths per 1,000 person years. Exponential regression modeling showed a reduction of more than 50% (HR =0.43, 95% CI: 0.32–0.58), compared to the period before ART was available, in mortality at ages 15–54 across all five sites.

Discussion

Excess mortality in adults living with HIV has reduced by over 50% in five communities in sub-Saharan Africa since the advent of ART. However, mortality rates in adults living with HIV are still 10 times higher than in HIV-negative people, indicating that substantial improvements can be made to reduce mortality further. This analysis shows differences in the impact across the sites, and contrasts with developed countries where mortality among PLWH on ART can be similar to that of the general population. Further research is urgently needed to establish why the different impacts on mortality were observed and how the care and treatment programmes in these countries can be more effective in reducing mortality further.

Monitoring prevention or emergence of HIV drug resistance: results of a population-based foundational survey of early warning indicators in mainland Tanzania

BACKGROUND

In Tanzania, routine individual-level testing for HIV drug resistance (HIVDR) using laboratory genotyping and phenotyping is not feasible due to resource constraints. To monitor the prevention or emergence of HIVDR at a population level, WHO developed generic strategies to be adapted by countries, which include a set of early warning indicators (EWIs).

METHODS

To establish a baseline of EWIs, we conducted a retrospective longitudinal survey of 35 purposively sampled care and treatment clinics in 17 regions of mainland Tanzania. We extracted data relevant for four EWIs (ART prescribing practices, patients lost to follow-up 12 months after ART initiation, retention on first-line ART at 12 months, and ART clinic appointment keeping in the first 12 months) from the patient monitoring system on patients who initiated ART at each respective facility in 2010. We uploaded patient information into WHO HIVResNet excel-based tool to compute national and facility averages of the EWIs and tested for associations between various programmatic factors and EWI performance using Fisher's Exact Test.

RESULTS

All sampled facilities met the WHO EWI target (100%) for ART prescribing practices. However, the national averages for patients lost to follow-up 12 months after ART initiation, retention on first-line ART at 12 months, and ART clinic appointment keeping in the first 12 months fell short, at 26%, 54% and 38%, respectively, compared to the WHO targets ≤ 20%, ≥ 70%, and ≥ 80%. Clinics with fewer patients lost to follow-up 12 months after ART initiation and more patients retained on first-line-ART at 12 months were more likely to have their patients spend the longest time in the facility (including wait-time and time with providers), (p = 0.011 and 0.007, respectively).

CONCLUSION

Tanzania performed very well in EWI 1a, ART prescribing practices. However, its performance in other three EWIs was far below the WHO targets. This study provides a baseline for future monitoring of EWIs in Tanzania and highlights areas for improvement in the management of ART patients in order not only to prevent emergence of HIVDR due to programmatic factors, but also to improve the quality of life for ART patients.

Social geography of AIDS in Brazil: identifying patterns of regional inequalities

The trend towards decline and stabilization of the AIDS epidemic in Brazil should be analyzed carefully, since aggregate data can mask regional or local inequalities in such a large and diverse country. The current study reevaluates the epidemic’s spatial dissemination and the AIDS-related mortality pattern in Brazil. The study considered all AIDS cases diagnosed in individuals over 18 years of age and living in Brazil, as well as AIDS deaths recorded in 1998-2008. Three-year moving average rates were estimated, and a spatial analysis was conducted using a local empirical Bayesian method. The epidemic was only found to be expanding in the North and Northeast regions, while declining in the rest of the country, especially in the Southeast. According to the findings, the apparent stabilization of AIDS mortality tends to mask regional disparities. Social determinants of health and regional disparities should be taken into account in program development and policymaking.

Does the Spectrum model accurately predict trends in adult mortality? Evaluation of model estimates using empirical data from a rural HIV community cohort study in North-Western Tanzania

Introduction

Spectrum epidemiological models are used by UNAIDS to provide global, regional and national HIV estimates and projections, which are then used for evidence-based health planning for HIV services. However, there are no validations of the Spectrum model against empirical serological and mortality data from populations in sub-Saharan Africa.

Methods

Serologic, demographic and verbal autopsy data have been regularly collected among over 30,000 residents in north-western Tanzania since 1994. Five-year age-specific mortality rates (ASMRs) per 1,000 person years and the probability of dying between 15 and 60 years of age (₄₅Q₁₅,) were calculated and compared with the Spectrum model outputs. Mortality trends by HIV status are shown for periods before the introduction of antiretroviral therapy (1994–1999, 2000–2005) and the first 5 years afterwards (2005–2009).

Results

Among 30–34 year olds of both sexes, observed ASMRs per 1,000 person years were 13.33 (95% CI: 10.75–16.52) in the period 1994–1999, 11.03 (95% CI: 8.84–13.77) in 2000–2004, and 6.22 (95% CI; 4.75–8.15) in 2005–2009. Among the same age group, the ASMRs estimated by the Spectrum model were 10.55, 11.13 and 8.15 for the periods 1994–1999, 2000–2004 and 2005–2009, respectively. The cohort data, for both sexes combined, showed that the ₄₅Q₁₅ declined from 39% (95% CI: 27–55%) in 1994 to 22% (95% CI: 17–29%) in 2009, whereas the Spectrum model predicted a decline from 43% in 1994 to 37% in 2009.

Conclusion

From 1994 to 2009, the observed decrease in ASMRs was steeper in younger age groups than that predicted by the Spectrum model, perhaps because the Spectrum model under-estimated the ASMRs in 30–34 year olds in 1994–99. However, the Spectrum model predicted a greater decrease in ₄₅Q₁₅ mortality than observed in the cohort, although the reasons for this over-estimate are unclear.

Deaths due to respiratory tract infections in Africa: a review of autopsy studies

PURPOSE OF REVIEW

According to the WHO, lower respiratory tract infections are one of the most prevalent causes of death in Africa. Estimates based on verbal autopsies are inaccurate compared with the gold standard for determining cause of death, the anatomical postmortem. Here, we review all respiratory postmortem data available from Africa and assess disease prevalence by HIV status in both adults and children.

RECENT FINDINGS

Pulmonary and extrapulmonary tuberculosis was detected in over 50% of HIV-infected adults, four to five-fold more prevalent than in HIV-uninfected cases. Overall tuberculosis was less prevalent in children, but was more prevalent in HIV-uninfected compared with HIV-infected children. Bacterial pneumonia was more prevalent in children than adults and was relatively unaffected by HIV status. Pneumocystis jirovecci and human cytomegalovirus pneumonia were detected almost exclusively in HIV-infected mortalities, twice as prevalent in children as in adults. Coinfections were common and correlation with premortem clinical diagnoses was low.

SUMMARY

Respiratory tract infections are important causes of mortality in Africa. Of the 21 reviewed studies, only four studies (all adults) were undertaken in the last decade. There is hence an urgent need for new postmortem studies to monitor cause of death in new and emerging patient groups, such as those on antiretroviral therapy and HIV exposed uninfected children.

Profile: the Karonga Health and Demographic Surveillance System

The Karonga Health and Demographic Surveillance System (Karonga HDSS) in northern Malawi currently has a population of more than 35 000 individuals under continuous demographic surveillance since completion of a baseline census (2002–2004). The surveillance system collects data on vital events and migration for individuals and for households. It also provides data on cause-specific mortality obtained by verbal autopsy for all age groups, and estimates rates of disease for specific presentations via linkage to clinical facility data. The Karonga HDSS provides a structure for surveys of socio-economic status, HIV sero-prevalence and incidence, sexual behaviour, fertility intentions and a sampling frame for other studies, as well as evaluating the impact of interventions, such as antiretroviral therapy and vaccination programmes. Uniquely, it relies on a network of village informants to report vital events and household moves, and furthermore is linked to an archive of biological samples and data from population surveys and other studies dating back three decades.