Adult mortality and antiretroviral treatment roll-out in rural KwaZulu-Natal, South Africa

Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa.
Bulletin of the World Health Organisation (Impact Factor: 5.11). 10/2009; 87(10):754-62. DOI: 10.2471/BLT.08.058982
Source: PubMed

ABSTRACT To investigate trends in adult mortality in a population serviced by a public-sector antiretroviral therapy (ART) programme in rural South Africa using a demographic surveillance system.
Verbal autopsies were conducted for all 7930 deaths observed between January 2000 and December 2006 in a demographic surveillance population of 74,500 in the Umkhanyakude district of northern KwaZulu-Natal province, South Africa. Age-standardized mortality rate ratios (SMRRs) were calculated for adults aged 25 to 49 years, the group most affected by HIV, for the 2 years before 2004 and the 3 subsequent years, during which ART had been available.
Between 2002-2003 (the period before ART) and 2004-2006 (the period after ART), HIV-related age-standardized mortality declined significantly, from 22.52 to 17.58 per 1000 person-years in women 25-49 years of age (P < 0.001; SMRR: 0.780; 95% confidence interval, CI: 0.691-0.881), and from 26.46 to 18.68 per 1000 person-years in men 25-49 years of age (P < 0.001; SMRR: 0.706; 95% CI: 0.615-0.811). On sensitivity analysis the results were robust to the possible effect of misclassification of HIV-related deaths.
Overall population mortality and HIV-related adult mortality declined significantly following ART roll-out in a community with a high prevalence of HIV infection. A clear public health message of the benefits of treatment, as revealed by these findings, should be part of a multi-faceted strategy to encourage people to find out their HIV serostatus and seek care.

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    ABSTRACT: In 2011 there were 5.5 million HIV infected people in South Africa and 71% of those requiring antiretroviral therapy (ART) received it. The effective integration of traditional medical practitioners and biomedical providers in HIV prevention and care has been demonstrated. However concerns remain that the use of traditional treatments for HIV-related disease may lead to pharmacokinetic interactions between herbal remedies and ART drugs and delay ART initiation. Here we analyse the changing prevalence and determinants of traditional healthcare use amongst those dying of HIV-related disease, pulmonary tuberculosis and other causes in a rural South African community between 2003 and 2011. ART was made available in this area in the latter part of this period. Data was collected during household visits and verbal autopsy interviews. InterVA-4 was used to assign causes of death. Spatial analyses of the distribution of traditional healthcare use were performed. Logistic regression models were developed to test associations of determinants with traditional healthcare use. There were 5929 deaths in the study population of which 47.7% were caused by HIV-related disease or pulmonary tuberculosis (HIV/AIDS and TB). Traditional healthcare use declined for all deaths, with higher levels throughout for those dying of HIV/AIDS and TB than for those dying of other causes. In 2003-2005, sole use of biomedical treatment was reported for 18.2% of HIV/AIDS and TB deaths and 27.2% of other deaths, by 2008-2011 the figures were 49.9% and 45.3% respectively. In bivariate analyses, higher traditional healthcare use was associated with Mozambican origin, lower education levels, death in 2003-2005 compared to the later time periods, longer illness duration and moderate increases in prior household mortality. In the multivariate model only country of origin, time period and illness duration remained associated. There were large decreases in reported traditional healthcare use and increases in the sole use of biomedical treatment amongst those dying of HIV/AIDS and TB. No associations between socio-economic position, age or gender and the likelihood of traditional healthcare use were seen. Further qualitative and quantitative studies are needed to assess whether these figures reflect trends in healthcare use amongst the entire population and the reasons for the temporal changes identified.
    BMC Complementary and Alternative Medicine 12/2014; 14(1):504. DOI:10.1186/1472-6882-14-504 · 1.88 Impact Factor
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    ABSTRACT: Background For public health purposes, it is important to see whether men and women in different age groups die of the same causes in South Africa. Objective We explored sex- and age-specific patterns of causes of deaths in a rural demographic surveillance site in northern KwaZulu-Natal in South Africa over the period 2000–2011. Design Deaths reported through the demographic surveillance were followed up by a verbal autopsy (VA) interview using a standardised questionnaire. Causes of death were assigned likelihoods using the publicly available tool InterVA-4. Cause-specific mortality fractions were determined by age and sex. Results Over the study period, a total of 5,416 (47%) and 6,081 (53%) deaths were recorded in men and women, respectively. Major causes of death proportionally affecting more women than men were (all p<0.0001): human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (20.1% vs. 13.6%), other and unspecified cardiac disease (5.9% vs. 3.2%), stroke (4.5% vs. 2.7%), reproductive neoplasms (1.7% vs. 0.4%), diabetes (2.4% vs. 1.2%), and breast neoplasms (0.4% vs. 0%). Major causes of deaths proportionally affecting more men than women were (all p<0.0001) assault (6.1% vs. 1.7%), pulmonary tuberculosis (34.5% vs. 30.2%), road traffic accidents (3.0% vs. 1.0%), intentional self-harm (1.3% vs. 0.3%), and respiratory neoplasms (2.5% vs. 1.5%). Causes of death due to communicable diseases predominated in all age groups except in older persons. Conclusions While mortality during the 2000s was dominated by tuberculosis and HIV/AIDS, we found substantial sex-specific differences both for communicable and non-communicable causes of death, some which can be explained by a differing sex-specific age structure. InterVA-4 is likely to be a valuable tool for investigating causes of death patterns in other similar Southern African settings.
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    ABSTRACT: Adherence to Highly Active Antiretroviral Therapy (HAART) is the main prognostic factor associated with HIV disease progression and death. The aim was to evaluate the effectiveness of a psycho-educational program to promote adherence to HAART in HIV patients. A longitudinal study (n = 102) over 9 months in an Infectious Diseases Hospital was carried out. Adherence to HAART was measured with standardized scales and values of viral load. Two groups were defined: adherents and non-adherents. In the latter, a psycho-educational program was implemented and 6 months later measured adherence to HAART. Knowledge about the infection, CD4 T lymphocytes and HIV-ribonucleic acid values were measured before and after this program. The sample was predominantly male (70%), heterosexual (78%), with a mean age of 49 (SD = 12.7) years, and 48% of participants were not adhering to HAART. After the program, non-adherence decreased to 21.6%. Knowledge about the infection increased from 79 to 97%. A significant increase in CD4 T lymphocytes (mean 540-580) and a decrease in viral load (mean 5411-3052) were observed, the latter of statistical significance. This program seems to be feasible and efficient, improving adherence to HAART.
    Frontiers in Psychiatry 01/2015; 5(Article 198):1-8. DOI:10.3389/fpsyt.2014.00198

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