title: Determinants of the risk of dying of HIV/AIDS in a rural South African community over the period of the decentralised roll-out of antiretroviral therapy: a longitudinal study.
abstract: BACKGROUND
  Antiretroviral treatment (ART) has significantly reduced HIV mortality in South Africa. The benefits have not been experienced by all groups. Here we investigate the factors associated with these inequities.
  
  
  METHODS
  This study was located in a rural South African setting and used data collected from 2007 to 2010, the period when decentralised ART became available. Approximately one-third of the population were of Mozambican origin. There was a pattern of repeated circular migration between urban areas and this community. Survival analysis models were developed to identify demographic, socioeconomic, and spatial risk factors for HIV mortality.
  
  
  RESULTS
  Among the study population of 105,149 individuals, there were 2,890 deaths. The HIV/TB mortality rate decreased by 27% between 2007-2008 and 2009-2010. For other causes of death, the reduction was 10%. Bivariate analysis found that the HIV/TB mortality risk was lower for: those living within 5 km of the Bhubezi Community Health Centre; women; young adults; in-migrants with a longer period of residence; permanent residents; and members of households owning motorised transport, holding higher socioeconomic positions, and with higher levels of education. Multivariate modelling showed, in addition, that those with South Africa as their country of origin had an increased risk of HIV/TB mortality compared to those with Mozambican origins. For males, those of South African origin, and recent in-migrants, the risk of death associated with HIV/TB was significantly greater than that due to other causes.
  
  
  CONCLUSIONS
  In this community, a combination of factors was associated with an increased risk of dying of HIV/TB over the period of the roll-out of ART. There is evidence for the presence of barriers to successful treatment for particular sub-groups in the population, which must be addressed if the recent improvements in population-level mortality are to be maintained.
authors.affiliation: Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Umeå Centre for Global Health Research, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden; Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK; paul.mee@wits.ac.za.
authors.forename: Paul
authors.initials: P
authors.lastname: Mee
authors.affiliation: Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Umeå Centre for Global Health Research, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Collinson
authors.affiliation: Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of African-American Studies, University of Maryland-College Park, College Park, MD, USA.
authors.forename: Sangeetha
authors.initials: S
authors.lastname: Madhavan
authors.affiliation: Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
authors.forename: Chodziwadziwa
authors.initials: C
authors.lastname: Kabudula
authors.affiliation: Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
authors.forename: Francesc Xavier
authors.initials: FX
authors.lastname: Gómez-Olivé
authors.affiliation: Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Umeå Centre for Global Health Research, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Kahn
authors.affiliation: Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Umeå Centre for Global Health Research, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden; International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Tollman
authors.affiliation: Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: James
authors.initials: J
authors.lastname: Hargreaves
authors.affiliation: Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; WHO Collaborating Centre for Verbal Autopsy, Umeå Centre for Global Health Research, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
authors.forename: Peter
authors.initials: P
authors.lastname: Byass
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000401:mortality; D000293:Adolescent; D000328:Adult; D000368:Aged; D003710:Demography; D005260:Female; D015658:HIV Infections / Q000401:mortality*; D006297:Health Services Accessibility; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011159:Population Surveillance; D012306:Risk; D012307:Risk Factors; D012424:Rural Population; D012959:Socioeconomic Factors; D013019:South Africa / Q000453:epidemiology; D016019:Survival Analysis; D014171:Transients and Migrants; D014376:Tuberculosis / Q000401:mortality
keywords: HIV; South Africa; determinants; global health; healthcare access; mortality; population health