AIDS Relief Program Intensity Linked To Lower Death Rates

The May 16 edition of the Global Health themed issue of JAMA reveals a larger drop in all-cause adult mortality in those African countries with more intense operation of the AIDS relief program PEPFAR.

The article’s background information states:

“The effect of global health initiatives on population health is uncertain. Between 2003 and 2008, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the largest initiative ever devoted to a single disease, operated intensively in 12 African focus countries.”

PEPFAR has undertaken a coordinated effort to raise treatment, prevention and care of HIV and increased the delivery of expanded antiretroviral therapy (ART) supporting wide-scale prevention efforts in view of the rapidly increasing HIV epidemic.

Eran Bendavid, M.D., M.S., from California’s Stanford University, and his team decided to assess the association between PEPFAR’s implementation and trends in adult mortality given that the initiative’s impact on all-cause adult mortality is not known.

The team used person-level data from the Demographic and Health Surveys (DHS) to conduct cross-country and within-country analyses of adult mortality defined as the annual probability of death per 1,000 adults between the ages of 15 to 59 years old, and PEPFAR activities. They then compared the adult mortality across 9 African ‘focus countries’, including Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, Tanzania, Uganda and Zambia with the adult mortality in 18 African ‘non-focus countries’ for the duration of one decade, from 1998 to 2008.

The study included data from 41 surveys across 27 countries, between 1998 and 2008, on 1,538,612 African adults. The DHS registered 60,303 deaths during this time period that were included in this study.

A data analysis showed a relatively larger decline in death rates amongst adults in focus countries between 2004 and 2008, namely a decrease from 8.30 per 1,000 adults in 2003 to 4.10 per 1,000 in 2008, whilst the mortality rate in non-focus countries dropped from 8.5 in 2003 to 6.9 in 2008 during the study period.

After adjusting for variables, such as country-level and personal characteristics, the likelihood of all-cause mortality was lower in the focus countries than in the non-focus countries.

The team also analyzed district-level data for Tanzania and Rwanda and even though high and low PEPFAR activity districts counted similar populations, the program intensity was considerably different between both groups. The findings revealed that Tanzanian adults living in regions with above-midpoint PEPFAR intensity had a lower risk of mortality than adults living in regions with below-midpoint intensity, whilst the comparison amongst Rwandan adults was similar, with a lower death risk for adults living in regions with above-midpoint PEPFAR intensity.

The researchers also discovered that a total of 740,914 all-cause adult deaths were averted between 2004 and 2008, due to PEPFAR’s efforts.

The figure was calculated by using the results of each focus country and generalizing it to the size of each country’s adult population. In comparison, PEPFAR was linked to an estimated number of 631,338 averted HIV-specific deaths during the same period.

The researchers write:

“In conclusion, we provide new evidence suggesting that reductions in all- cause adult mortality were greater in PEPFAR’s focus countries relative to the non-focus countries over the time period from 2004 through 2008. Our analysis suggests an association of PEPFAR with these improvements in population health.”