ART has dramatically improved life expectancy for people living with HIV in KwaZulu-Natal, South Africa

Trends in the burden of HIV mortality after roll-out of antiretroviral therapy in KwaZulu-Natal, South Africa: an observational community cohort study.

Reniers G, Blom S, Calvert C, Martin-Onraet A, Herbst AJ, Eaton JW, Bor J, Slaymaker E, Li ZR, Clark SJ, Barnighausen T, Zaba B, Hosegood V Lancet HIV. 2016 Dec 9. pii: S2352-3018(16)30225-9. doi: 10.1016/S2352-3018(16)30225-9

Background: Antiretroviral therapy (ART) substantially decreases morbidity and mortality in people living with HIV. In this study, we describe population-level trends in the adult life expectancy and trends in the residual burden of HIV mortality after the roll-out of a public sector ART programme in KwaZulu-Natal, South Africa, one of the populations with the most severe HIV epidemics in the world.

Methods: Data come from the Africa Centre Demographic Information System (ACDIS), an observational community cohort study in the uMkhanyakude district in northern KwaZulu-Natal, South Africa. We used non-parametric survival analysis methods to estimate gains in the population-wide life expectancy at age 15 years since the introduction of ART, and the shortfall of the population-wide adult life expectancy compared with that of the HIV-negative population (ie, the life expectancy deficit). Life expectancy gains and deficits were further disaggregated by age and cause of death with demographic decomposition methods.

Findings: Covering the calendar years 2001 through to 2014, we obtained information on 93 903 adults who jointly contribute 535 428 person-years of observation to the analyses and 9992 deaths. Since the roll-out of ART in 2004, adult life expectancy increased by 15.2 years for men (95% CI 12.4-17.8) and 17.2 years for women (14.5-20.2). Reductions in pulmonary tuberculosis and HIV-related mortality account for 79.7% of the total life expectancy gains in men (8.4 adult life-years), and 90.7% in women (12.8 adult life-years). For men, 9.5% is the result of a decline in external injuries. By 2014, the life expectancy deficit had decreased to 1.2 years for men (-2.9 to 5.8) and to 5.3 years for women (2.6-7.8). In 2011-14, pulmonary tuberculosis and HIV were responsible for 84.9% of the life expectancy deficit in men and 80.8% in women.

Interpretation: The burden of HIV on adult mortality in this population is rapidly shrinking, but remains large for women, despite their better engagement with HIV-care services. Gains in adult life-years lived as well as the present life expectancy deficit are almost exclusively due to differences in mortality attributed to HIV and pulmonary tuberculosis.

Abstract access [1]

Editor’s notes: Health and demographic surveillance system (HDSS) sites allow for monitoring of population health through the collection of detailed data on tens of thousands of individuals. Such sites in countries with high HIV prevalence have played an important role in measuring the effects of large-scale programmes, such as the global roll-out of antiretroviral therapy (ART). The data presented in this paper, from the Africa Centre Demographic Information System (ACDIS) in KwaZulu-Natal, South Africa, span 13 years (2001–14) and represent over 93 000 individuals living in an area with extremely high HIV prevalence (29% in adults aged 15–49 years in 2011). At least 15 000 of people studied were HIV-positive, of whom at least 2000 died. ART was first made available to people living with HIV (PLHIV) in this area in 2004.

Among adults aged 15–49 years, the authors report an overall reduction in death rate from 2001–14.  This translates into large increases in life expectancy (i.e., the expected number of years lived from age 15) of 15 and 17 years for men and women, respectively, between 2001 and 2014.  The changes in life expectancy are greater in people who were confirmed HIV-positive: 18 and 21 years for men and women, respectively, from 2007–14.  The large difference in life expectancies between the sexes that still exists (31 versus 44 years in HIV-positive men and women, respectively) are consistent with previously published estimates from Rwanda and Uganda. This study, however, illustrates that HIV-positive men are catching up to their HIV-negative counterparts faster than women are. The ‘deficit’ in 2014 - the gap in life expectancies between HIV-positive and HIV-negative individuals, was 1.2 years in men but still 5.3 years in women.

The authors propose that increased access to ART is the primary driver of the gains in life expectancy seen in this cohort. To further support this, they include data from verbal autopsies (VAs), which suggest that reductions in deaths due to HIV and pulmonary tuberculosis were responsible for 80% and 90% of the increases in life expectancy in men and women, respectively. VAs have limitations, however, particularly in areas of high HIV prevalence, but the overall mortality patterns suggested by these findings are likely to be accurate, even if the precise estimates differ.

The dramatic increases in life expectancy, in only seven years, for HIV-positive individuals in this cohort add to the encouraging observations from other low- and middle-income countries that many people receiving ART can expect to live for nearly as long as HIV-negative individuals.  Of course, people with advanced disease starting ART are still at high risk of death and there remain considerable challenges in getting treatment to all people in need of it. 

Africa [11]
South Africa [12]
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