title: Trends in the burden of HIV mortality after roll-out of antiretroviral therapy in KwaZulu-Natal, South Africa: an observational community cohort study.
abstract: 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.
  
  
  
  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.
  
  
  
  Covering the calendar years 2001 through to 2014, we obtained information on 93 903 adults who jointly contribute 535 42 8 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.
  
  
  
  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.
  
  
  
  Wellcome Trust, the Bill & Melinda Gates Foundation, and the National Institutes of Health.
authors.affiliation: Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa. Electronic address: georges.reniers@lshtm.ac.uk.
authors.forename: Georges
authors.initials: G
authors.lastname: Reniers
authors.affiliation: Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Sylvia
authors.initials: S
authors.lastname: Blom
authors.affiliation: Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Clara
authors.initials: C
authors.lastname: Calvert
authors.affiliation: Instituto Nacional de Cancerología, Mexico City, Mexico.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Martin-Onraet
authors.affiliation: Africa Health Research Institute, Durban, South Africa.
authors.forename: Abraham J
authors.initials: AJ
authors.lastname: Herbst
authors.affiliation: Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Eaton
authors.affiliation: Department of Global Health, Boston University, Boston, MA, USA.
authors.forename: Jacob
authors.initials: J
authors.lastname: Bor
authors.affiliation: Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Emma
authors.initials: E
authors.lastname: Slaymaker
authors.affiliation: Department of Statistics, University of Washington, Seattle, WA, USA.
authors.forename: Zehang R
authors.initials: ZR
authors.lastname: Li
authors.affiliation: School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Department of Sociology, The Ohio State University, Columbus, OH, USA.
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Clark
authors.affiliation: Africa Health Research Institute, Durban, South Africa; Institute of Public Health, University of Heidelberg, Heidelberg, Germany; Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA.
authors.forename: Till
authors.initials: T
authors.lastname: Bärnighausen
authors.affiliation: Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Basia
authors.initials: B
authors.lastname: Zaba
authors.affiliation: Africa Health Research Institute, Durban, South Africa; Social Statistics and Demography, University of Southampton, Southampton, UK.
authors.forename: Victoria
authors.initials: V
authors.lastname: Hosegood
mesh_terms: D000293:Adolescent; D000328:Adult; D015331:Cohort Studies; D017281:Cost of Illness; D058872:Epidemics; D005260:Female; D014943:Global Health; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology / Q000401:mortality* / Q000821:virology; D006801:Humans; D008017:Life Expectancy / Q000639:trends; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D012423:Rural Health / Q000639:trends; D017678:Sex Distribution; D012737:Sex Factors; D013019:South Africa / Q000453:epidemiology; D055815:Young Adult