Background
Women
have better patient outcomes in HIV care and treatment than men in sub-Saharan
Africa. We assessed—at the population level—whether and to what extent mass HIV
treatment is associated with changes in sex disparities in adult life
expectancy, a summary metric of survival capturing mortality across the full
cascade of HIV care. We also determined sex-specific trends in HIV mortality
and the distribution of HIV-related deaths in men and women prior to and at
each stage of the clinical cascade.
Methods and Findings
Data
were collected on all deaths occurring from 2001 to 2011 in a large
population-based surveillance cohort (52,964 women and 45,688 men, ages 15 y
and older) in rural KwaZulu-Natal, South Africa. Cause of death was ascertained
by verbal autopsy (93% response rate). Demographic data were linked at the
individual level to clinical records from the public sector HIV treatment and
care program that serves the region. Annual rates of HIV-related mortality were
assessed for men and women separately, and female-to-male rate ratios were
estimated in exponential hazard models. Sex-specific trends in adult life
expectancy and HIV-cause-deleted adult life expectancy were calculated. The
proportions of HIV deaths that accrued to men and women at different stages in
the HIV cascade of care were estimated annually.
Following
the beginning of HIV treatment scale-up in 2004, HIV mortality declined among
both men and women. Female adult life expectancy increased from 51.3 y (95% CI
49.7, 52.8) in 2003 to 64.5 y (95% CI 62.7, 66.4) in 2011, a gain of 13.2 y.
Male adult life expectancy increased from 46.9 y (95% CI 45.6, 48.2) in 2003 to
55.9 y (95% CI 54.3, 57.5) in 2011, a gain of 9.0 y. The gap between female and
male adult life expectancy doubled, from 4.4 y in 2003 to 8.6 y in 2011, a
difference of 4.3 y (95% CI 0.9, 7.6). For women, HIV mortality declined from
1.60 deaths per 100 person-years (95% CI 1.46, 1.75) in 2003 to 0.56 per 100
person-years (95% CI 0.48, 0.65) in 2011. For men, HIV-related mortality
declined from 1.71 per 100 person-years (95% CI 1.55, 1.88) to 0.76 per 100
person-years (95% CI 0.67, 0.87) in the same period. The female-to-male rate
ratio for HIV mortality declined from 0.93 (95% CI 0.82–1.07) in 2003 to 0.73
(95% CI 0.60–0.89) in 2011, a statistically significant decline (p = 0.046). In 2011, 57% and 41% of HIV-related
deaths occurred among men and women, respectively, who had never sought care
for HIV in spite of the widespread availability of free HIV treatment. The
results presented here come from a poor rural setting in southern Africa with
high HIV prevalence and high HIV treatment coverage; broader generalizability
is unknown. Additionally, factors other than HIV treatment scale-up may have
influenced population mortality trends.
Conclusions
Mass HIV treatment has been accompanied by faster
declines in HIV mortality among women than men and a growing female–male
disparity in adult life expectancy at the population level. In 2011, over half
of male HIV deaths occurred in men who had never sought clinical HIV care.
Interventions to increase HIV testing and linkage to care among men are
urgently needed.
Below: Adult life expectancy and HIV-cause-deleted adult life expectancy,
2001–2011, by sex.
Solid symbols are annual estimates of adult life expectancy;
open symbols are annual estimates of HIV-cause-deleted adult life expectancy.
95% CIs are shown. The black dashed line indicates the beginning of ART
scale-up in 2004.
Below: Female–male difference in adult life expectancy, 2001–2011.
Solid blue circles display annual estimates of the gap
between female and male adult life expectancy. The red dashed line indicates
the gap in HIV-cause-deleted life expectancy observed in 2011. The black dashed
line indicates the beginning of ART scale-up in 2004.
Below: Sex-specific survival curves: 2003, 2011, and
HIV-cause-deleted.
Sex-specific continuous-time Kaplan-Meier survival curves
for 2003 and 2011 are shown. The HIV-cause-deleted survival curves pool
person-time for 2001–2011. These are period (synthetic cohort) survival curves
reflecting age-specific mortality rates in a population in a given period of
time; life expectancy is calculated as the area under the curve. A risk table
showing persons at risk and deaths at each age for each of the six survival
curves is available as S1 Table.
Below: Female-to-male HIV mortality rate ratios by age and calendar
year, 2001–2011.
Age-specific HIV mortality rate ratios for women versus men
were estimated in an exponential hazard regression model that included calendar
year indicators for each age group and interactions for each age and year with
sex. The 45–64 y and 65+ y age groups were combined to improve precision at
older ages. The pooled estimate is from a separate regression model. Mortality
rate ratios declined after 2004 in all age groups.
Below: Distribution of HIV deaths across cascade of care,
2001–2011.
We excluded all deaths that occurred within 3 mo of
migrating into the DSA, as the deceased may not have had the opportunity to
seek HIV care in the local health system.
By:
Jacob Bor, Sydney Rosen
Department of Global Health,
Boston University School of Public Health, Boston, Massachusetts, United States
of America
Jacob Bor, Natsayi Chimbindi, Noah Haber, Kobus Herbst,
Tinofa Mutevedzi, Frank Tanser, Deenan Pillay, Till Bärnighausen
Africa Centre for Population
Health, Mtubatuba, South Africa
Jacob Bor, Sydney Rosen
Health Economics and
Epidemiology Research Office, Department of Internal Medicine, School of
Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand,
Johannesburg, South Africa
Noah Haber, Till Bärnighausen
Department of Global Health and
Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts,
United States of America
Deenan Pillay
Faculty of Medical Sciences,
University College London, London, United Kingdom
