HIV development assistance and adult mortality in Africa

Abstract

Context: The effect of global health initiatives on population health is uncertain. Between 2003 and 2008, the US President's Emergency Plan for AIDS Relief (PEPFAR), the largest initiative ever devoted to a single disease, operated intensively in 12 African focus countries. The initiative's effect on all-cause adult mortality is unknown.

Objective: To determine whether PEPFAR was associated with relative changes in adult mortality in the countries and districts where it operated most intensively.

Design, setting, and participants: Using person-level data from the Demographic and Health Surveys, we conducted cross-country and within-country analyses of adult mortality (annual probability of death per 1000 adults between 15 and 59 years old) and PEPFAR's activities. Across countries, we compared adult mortality in 9 African focus countries (Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, Tanzania, Uganda, and Zambia) with 18 African nonfocus countries from 1998 to 2008. We performed subnational analyses using information on PEPFAR's programmatic intensity in Tanzania and Rwanda. We employed difference-in-difference analyses with fixed effects for countries and years as well as personal and time-varying area characteristics.

Main outcome measure: Adult all-cause mortality.

Results: We analyzed information on 1 538 612 adults, including 60 303 deaths, from 41 surveys in 27 countries, 9 of them focus countries. In 2003, age-adjusted adult mortality was 8.3 per 1000 adults in the focus countries (95% CI, 8.0-8.6) and 8.5 per 1000 adults (95% CI, 8.3-8.7) in the nonfocus countries. In 2008, mortality was 4.1 per 1000 (95% CI, 3.6-4.6) in the focus countries and 6.9 per 1000 (95% CI, 6.3-7.5) in the nonfocus countries. The adjusted odds ratio of mortality among adults living in focus countries compared with nonfocus countries between 2004 and 2008 was 0.84 (95% CI, 0.72-0.99; P = .03). Within Tanzania and Rwanda, the adjusted odds ratio of mortality for adults living in districts where PEPFAR operated more intensively was 0.83 (95% CI, 0.72-0.97; P = .02) and 0.75 (95% CI, 0.56-0.99; P = .04), respectively, compared with districts where it operated less intensively.

Conclusions: Between 2004 and 2008, all-cause adult mortality declined more in PEPFAR focus countries relative to nonfocus countries. It was not possible to determine whether PEPFAR was associated with mortality effects separate from reductions in HIV-specific deaths.

Figure 1

Average annual development assistance for HIV (and 95% confidence intervals) from the Institute for Health Metrics and Evaluation database to the focus countries (green) and non-focus countries (red) in 2008 USD, 1998–2008. A preferential rise in assistance to the focus countries is seen between 2003 and 2004. The year 2004 was PEPFAR's first year of implementation, indicated by the dashed vertical line.

Figure 2

Age-adjusted adult mortality trends in the study countries, separated by country group, 1998–2008. Each point represents the probability that an adult between 15 and 59 years old died during the year per 1,000 adults alive for any part of the year. UN Population Division age-structured population estimates for each country were used for age-adjustments. Age weights were calculated in 5-year age categories from 15–59 (9 age categories). These weights were then used to adjust the crude mortality for each country-year-age group, and the point estimates represent the adjusted total. The Figure shows mortality declines were greater in the focus countries starting in 2004. A narrow-bandwidth (0.6) lowess curve is used to fit the trend, and 95% confidence interval bars are shown around each annual estimate. Lowess (locally weighted scatterplot smoothing) is a non-parametric method of fitting a curve using local regressions for each point. The dashed vertical line divides the time period into a baseline period prior to PEPFAR, and a period of implementation starting in 2004.

Figure 3

Adult mortality trends within Tanzania, separated by PEPFAR activity from 1998 to 2008. Intensity of PEPFAR's activities is measured as the number of people receiving PEPFAR-supported ART per capita in the region (above and below median ART per capita are represented as More and Less in the figure, respectively). 95% confidence interval bars are shown around each annual estimate. Additional figures showing trends by clinic size (number on ART per clinic) for Tanzania and Rwanda are in the Supplementary Appendix. The dashed vertical line divides the time period into a baseline period prior to PEPFAR, and a period of implementation starting in 2004.