Article

Population-Level Reduction in Adult Mortality after Extension of Free Anti-Retroviral Therapy Provision into Rural Areas in Northern Malawi

Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
PLoS ONE (Impact Factor: 3.53). 10/2010; 5(10):e13499. DOI: 10.1371/journal.pone.0013499
Source: PubMed

ABSTRACT Four studies from sub-Saharan Africa have found a substantial population-level effect of ART provision on adult mortality. It is important to see if the impact changes with time since the start of treatment scale-up, and as treatment moves to smaller clinics.
During 2002-4 a demographic surveillance site (DSS) was established in Karonga district, northern Malawi. Information on births and deaths is collected monthly, with verbal autopsies conducted for all deaths; migrations are updated annually. We analysed mortality trends by comparing three time periods: pre-ART roll-out in the district (August 2002-June 2005), ART period 1 (July 2005-September 2006) when ART was available only in a town 70 km away, and ART period 2 (October 2006-September 2008), when ART was available at a clinic within the DSS area. HIV prevalence and ART uptake were estimated from a sero-survey conducted in 2007/2008. The all-cause mortality rate among 15-59 year olds was 10.2 per 1000 person-years in the pre-ART period (288 deaths/28285 person-years). It fell by 16% in ART period 1 and by 32% in ART period 2 (95% CI 18%-43%), compared with the pre-ART period. The AIDS mortality rate fell from 6.4 to 4.6 to 2.7 per 1000 person-years in the pre-ART period, period 1 and period 2 respectively (rate ratio for period 2 = 0.43, 95% CI 0.33-0.56). There was little change in non-AIDS mortality. Treatment coverage among individuals eligible to start ART was around 70% in 2008.
ART can have a dramatic effect on mortality in a resource-constrained setting in Africa, at least in the early years of treatment provision. Our findings support the decentralised delivery of ART from peripheral health centres with unsophisticated facilities. Continued funding to maintain and further scale-up treatment provision will bring large benefits in terms of saving lives.

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    • "As none of the studies were randomized trials, none used any method of randomization or concealment of allocation. Only two studies included a form of control group (Bendavid and Bhattacharya 2009; Jia et al. 2010); in neither of these was the control group adequately matched to the intervention group, although the study by Bendavid and Bjattacharya attempted to Table 1 Summary of health outcomes and impact measures reported in included studies Indicator category Indicator Studies reporting indicator Service coverage ART coverage Floyd et al. (2010), Jahn et al. (2008) TB case detection and notification rates Jia et al. (2010), Yumo et al. (2011) % of households owning at least one (long lasting) insecticide treated net Akachi and Atun (2011), Chizema-Kawesha et al. (2010) and Steketee et al. (2008), Flaxman et al. (2010), Noor et al. (2007) % of pregnant women receiving at least two doses of Intermittent Preventive Therapy Chizema-Kawesha et al. (2010) and Steketee et al. (2008) Service utilization % of children under-5 years sleeping under an insecticide-treated bed net Noor et al. (2007), Flaxman et al. (2010), Steketee et al. (2008) ART adherence and loss to follow-up rates Wools-Kaloustian et al. (2009) Health impacts HIV infections averted Ng et al. (2011) HIV prevalence Bendavid and Bhattacharya (2009), Ng et al. (2011) Deaths due to HIV/AIDS Bendavid and Bhattacharya (2009), Floyd et al. (2010) TB treatment outcomes Yumo et al. (2011) Malaria cases Aregawi et al. (2011), Chizema-Kawesha et al. (2010) Anaemia cases Aregawi et al. (2011), Chizema-Kawesha et al. (2010) Malaria-attributed mortality Akachi and Atun (2011), Aregawi et al. (2011), Chizema-Kawesha et al. (2010) All-cause adult mortality Floyd et al. (2010) All-cause under-5 mortality Chizema-Kawesha et al. (2010) Lives saved Akachi and Atun (2011) Table 2 Summary and key findings of included studies "
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    • "In a DSS study in the north of Malawi, declines in the overall mortality rates among adults were observed within 8 months of free ART becoming available, with mortality reduced by 35% (adjusted rate ratio = 0.65; 0.46–0.92) in adults living near the main road, where mortality prior to ART availability had been highest (Jahn et al. 2008). A later study in the same setting detected a decline of 32% in the AIDS-specific mortality rate in the 2 years after the introduction of ART at a clinic in the study area, compared with the 3 years before, with estimated treatment coverage of approximately 70% (Floyd et al. 2010). In a South African cohort study that incorporated DSS data, HIV-related agestandardised mortality declined significantly, from 22.5 to 17.6 per 1000 person-years in women 25–49 years of age (P < 0.001) and from 26.5 to 18.7 per 1000 person-years in men 25–49 years of age (P < 0.001) between 2002 and 2003, before ART availability, and 2004–2006, after ART was introduced (Herbst et al. 2009). "
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