title: Mortality trends in the era of antiretroviral therapy: evidence from the Network for Analysing Longitudinal Population based HIV/AIDS data on Africa (ALPHA).
abstract: BACKGROUND
  The rollout of antiretroviral therapy (ART) is one of the largest public health interventions in Eastern and Southern Africa of recent years. Its impact is well described in clinical cohort studies, but population-based evidence is rare.
  
  
  METHODS
  We use data from seven demographic surveillance sites that also conduct community-based HIV testing and collect information on the uptake of HIV services. We present crude death rates of adults (aged 15-64) for the period 2000-2011 by sex, HIV status, and treatment status. Parametric survival models are used to estimate age-adjusted trends in the mortality rates of people living with HIV (PLHIV) before and after the introduction of ART.
  
  
  RESULTS
  The pooled ALPHA Network dataset contains 2.4 million person-years of follow-up time, and 39114 deaths (6893 to PLHIV). The mortality rates of PLHIV have been relatively static before the availability of ART. Mortality declined rapidly thereafter, with typical declines between 10 and 20% per annum. Compared with the pre-ART era, the total decline in mortality rates of PLHIV exceeds 58% in all study sites with available data, and amounts to 84% for women in Masaka (Uganda). Mortality declines have been larger for women than for men; a result that is statistically significant in five sites. Apart from the early phase of treatment scale up, when the mortality of PLHIV on ART was often very high, mortality declines have been observed in PLHIV both on and off ART.
  
  
  CONCLUSIONS
  The expansion of treatment has had a large and pervasive effect on adult mortality. Mortality declines have been more pronounced for women, a factor that is often attributed to women's greater engagement with HIV services. Improvements in the timing of ART initiation have contributed to mortality reductions in PLHIV on ART, but also among those who have not (yet) started treatment because they are increasingly selected for early stage disease.
authors.affiliation: aDepartment of Population Health, London School of Hygiene and Tropical Medicine, London, UK bResearch Unit on AIDS, Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda cManicaland HIV/STD prevention project, Bio-medical Research and Training Institute, Harare, Zimbabwe dKaronga Prevention Study, London School of Hygiene and Tropical Medicine, Chilumba, Malawi eAfrica Centre for Health and Population Studies, University of KwaZulu Natal, Somkhele, South Africa fTAZAMA project, National Institute for Medical Research, Mwanza, Tanzania gKenya Medical Research Institute / Centers for Disease Control and Prevention, Kisumu, Kenya hSchool of Public Health, Faculty of Medicine, Imperial College, London, UK iRakai Health Sciences Program, Makerere University School of Public Health, Rakai, Uganda jDepartment of Social Statistics and Demography, Southampton University, Southampton, UK.
authors.forename: Georges
authors.initials: G
authors.lastname: Reniers
authors.forename: Emma
authors.initials: E
authors.lastname: Slaymaker
authors.forename: Jessica
authors.initials: J
authors.lastname: Nakiyingi-Miiro
authors.forename: Constance
authors.initials: C
authors.lastname: Nyamukapa
authors.forename: Amelia Catharine
authors.initials: AC
authors.lastname: Crampin
authors.forename: Kobus
authors.initials: K
authors.lastname: Herbst
authors.forename: Mark
authors.initials: M
authors.lastname: Urassa
authors.forename: Fred
authors.initials: F
authors.lastname: Otieno
authors.forename: Simon
authors.initials: S
authors.lastname: Gregson
authors.forename: Maquins
authors.initials: M
authors.lastname: Sewe
authors.forename: Denna
authors.initials: D
authors.lastname: Michael
authors.forename: Tom
authors.initials: T
authors.lastname: Lutalo
authors.forename: Victoria
authors.initials: V
authors.lastname: Hosegood
authors.forename: Ivan
authors.initials: I
authors.lastname: Kasamba
authors.forename: Alison
authors.initials: A
authors.lastname: Price
authors.forename: Dorean
authors.initials: D
authors.lastname: Nabukalu
authors.forename: Estelle
authors.initials: E
authors.lastname: Mclean
authors.forename: Basia
authors.initials: B
authors.lastname: Zaba
mesh_terms: D000293:Adolescent; D000328:Adult; D000349:Africa / Q000453:epidemiology; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D004363:Drug Utilization; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012737:Sex Factors; D016019:Survival Analysis; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents