The development of a localised HIV epidemic and the associated excess mortality burden in a rural area of South Africa

Abstract

The human immunodeficiency virus (HIV) epidemic in South Africa rapidly developed into a major pandemic. Here we analyse the development of the epidemic in a rural area of the country. The data used were collected between 1992 and 2013 in a longitudinal population survey, the Agincourt Health and Demographic Surveillance Study, in the northeast of the country. Throughout the period of study mortality rates were similar in all villages, suggesting that there were multiple index cases evenly spread geographically. These were likely to have been returning migrant workers. For those aged below 39 years the HIV mortality rate was higher for women, above this age it was higher for men. This indicates the protective effect of greater access to HIV testing and treatment among older women. The recent convergence of mortality rates for Mozambicans and South Africans indicates that the former refugee population are being assimilated into the host community. More than 60% of the deaths occurring in this community between 1992 and 2013 could be attributed directly or indirectly to HIV. Recently there has been an increasing level of non-HIV mortality which has important implications for local healthcare provision. This study demonstrates how evidence from longitudinal analyses can support healthcare planning.

Keywords: AIDS; Agincourt; HIV; South Africa; epidemic; epidemiology; mortality.

Fig. 1.

Comparison of HIV prevalence for the Agincourt sub-district (2011) [11] and the whole of South Africa (2012) [12]. The overall HIV prevalence in the Agincourt sub-district for those aged over 15 in 2011 was 23.9% for females and 10.6% for males. For the whole of South Africa in 2012 the HIV prevalence in those aged over 15 was 17.8% for females and 11.4% for males.

Fig. 2.

HIV/TB epidemic profiles of mortality for each of the 20 original Agincourt HDSS villages compared with that for the whole study population. The overall mortality rate for all villages is represented as a red dashed line and that for each individual village as a solid blue line.

Fig. 3.

HIV/TB epidemic profiles of mortality (1992–2013) subdivided by age and gender in the Agincourt sub-district, South Africa. The rates for females are represented as a red-dashed line and that for males as a solid blue line.

Fig. 4.

HIV/TB epidemic profiles of mortality for the Agincourt sub-district subdivided by country of origin and gender. The rates for females are represented as a red dashed line and that for males as a solid blue line.

Fig. 5.

Plot showing the estimated numbers of HIV attributable deaths occurring between 1992 and 2013 in the Agincourt sub-district (see online Supplementary Table S1 in the supplementary materials for details of how the estimated were derived).