title: Using health surveillance systems data to assess the impact of AIDS and antiretroviral treatment on adult morbidity and mortality in Botswana.
abstract: BACKGROUND
  Botswana's AIDS response included free antiretroviral treatment (ART) since 2002, achieving 80% coverage of persons with CD4<350 cells/µl by 2009-10. We explored impact on mortality and HIV prevalence, analyzing surveillance and civil registration data.
  
  
  METHODS
  Hospital natural cause admissions and deaths from the Health Statistics Unit (HSU) over 1990-2009, all-cause deaths from Midnight Bed Census (MNC) over 1990-2011, institutional and non-institutional deaths recorded in the Registry of Birth and Deaths (RBD) over 2003-2010, and antenatal sentinel surveillance (ANC) over 1992-2011 were compared to numbers of persons receiving ART. Mortality was adjusted for differential coverage and completeness of institutional and non-institutional deaths, and compared to WHO and UNAIDS Spectrum projections.
  
  
  RESULTS
  HSU deaths per 1000 admissions declined 49% in adults 15-64 years over 2003-2009. RBD mortality declined 44% (807 to 452/100,000 population in adults 15-64 years) over 2003-2010, similarly in males and females. Generally, death rates were higher in males; declines were greater and earlier in younger adults, and in females. In contrast, death rates in adults 65+, particularly females increased over 2003-2006. MNC all-age post-neonatal mortality declined 46% and 63% in primary and secondary level hospitals, over 2003-2011. We estimated RBD captured 80% of adult deaths over 2006-2011. Comparing empirical, completeness-adjusted deaths to Spectrum estimates, declines over 2003-2009 were similar overall (47% vs. 54%); however, Spectrum projected larger and earlier declines particularly in women. Following stabilization and modest decreases over 1998-2002, HIV prevalence in pregnant women 15-24 and 25-29-years declined by >50% and >30% through 2011, while continuing to increase in older women.
  
  
  CONCLUSIONS
  Adult mortality in Botswana fell markedly as ART coverage increased. HIV prevalence declines may reflect ART-associated reductions in sexual transmission. Triangulation of surveillance system data offers a reasonable approach to evaluate impact of HIV/AIDS interventions, complementing cohort approaches that monitor individual-level health outcomes.
authors.affiliation: UNAIDS, Geneva, Switzerland.
authors.forename: Rand
authors.initials: R
authors.lastname: Stoneburner
authors.affiliation: The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland; Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
authors.forename: Eline
authors.initials: E
authors.lastname: Korenromp
authors.affiliation: Yale University School of Nursing, New Haven, Connecticut, United States of America.
authors.forename: Mark
authors.initials: M
authors.lastname: Lazenby
authors.affiliation: World Health Organization, Geneva, Switzerland.
authors.forename: Jean-Michel
authors.initials: JM
authors.lastname: Tassie
authors.affiliation: Republic of Botswana Ministry of Health, Gaborone, Botswana.
authors.forename: Judith
authors.initials: J
authors.lastname: Letebele
authors.affiliation: Republic of Botswana Ministry of Health, Gaborone, Botswana.
authors.forename: Diemo
authors.initials: D
authors.lastname: Motlapele
authors.affiliation: UNAIDS, Geneva, Switzerland.
authors.forename: Reuben
authors.initials: R
authors.lastname: Granich
authors.affiliation: World Health Organization, Geneva, Switzerland.
authors.forename: Ties
authors.initials: T
authors.lastname: Boerma
authors.affiliation: Global Health Program, The Graduate Institute of International and Development Studies, Geneva, Switzerland.
authors.forename: Daniel
authors.initials: D
authors.lastname: Low-Beer
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000188:drug therapy* / Q000453:epidemiology* / Q000401:mortality; D000293:Adolescent; D000328:Adult; D000368:Aged; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D001902:Botswana / Q000453:epidemiology; D005260:Female; D005333:Fetus / Q000821:virology; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D009017:Morbidity; D036801:Parturition; D010343:Patient Admission / Q000706:statistics & numerical data; D011247:Pregnancy; D012042:Registries; D018571:Sentinel Surveillance; D013997:Time Factors; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents