Population-level reduction in adult mortality after extension of free anti-retroviral therapy provision into rural areas in northern Malawi

Floyd, S. et al. (2010) Population-level reduction in adult mortality after extension of free anti-retroviral therapy provision into rural areas in northern Malawi. PLoS ONE, 5(10), e13499. (doi: 10.1371/journal.pone.0013499) (PMID:20976068) (PMCID:PMC2957442)

Abstract

Background: Four studies from sub-Saharan Africa have found a substantial population-level effect of ART provision on adult mortality. It is important to see if the impact changes with time since the start of treatment scale-up, and as treatment moves to smaller clinics. Methods and Findings: During 2002-4 a demographic surveillance site (DSS) was established in Karonga district, northern Malawi. Information on births and deaths is collected monthly, with verbal autopsies conducted for all deaths; migrations are updated annually. We analysed mortality trends by comparing three time periods: pre-ART roll-out in the district (August 2002–June 2005), ART period 1 (July 2005–September 2006) when ART was available only in a town 70 km away, and ART period 2 (October 2006–September 2008), when ART was available at a clinic within the DSS area. HIV prevalence and ART uptake were estimated from a sero-survey conducted in 2007/2008. The all-cause mortality rate among 15–59 year olds was 10.2 per 1000 person-years in the pre-ART period (288 deaths/28285 person-years). It fell by 16% in ART period 1 and by 32% in ART period 2 (95% CI 18%–43%), compared with the pre-ART period. The AIDS mortality rate fell from 6.4 to 4.6 to 2.7 per 1000 person-years in the pre-ART period, period 1 and period 2 respectively (rate ratio for period 2 = 0.43, 95% CI0.33–0.56). There was little change in non-AIDS mortality. Treatment coverage among individuals eligible to start ART was around 70% in 2008. Conclusions: ART can have a dramatic effect on mortality in a resource-constrained setting in Africa, at least in the early years of treatment provision. Our findings support the decentralised delivery of ART from peripheral health centres with unsophisticated facilities.

• Item Type: Articles
• Additional Information: The study was funded by a Wellcome Trust Programme grant (number 079828/Z/06/Z).
• Status: Published
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: Crampin, Professor Mia
• Authors: Floyd, S., Molesworth, A., Dube, A., Banda, E., Jahn, A., Mwafulirwa, C., Ngwira, B., Branson, K., Crampin, A. C., Zaba, B., Glynn, J. R., and French, N.
• College/School: College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > Public Health
• Journal Name: PLoS ONE
• Publisher: Public Library of Science
• ISSN: 1932-6203
• ISSN (Online): 1932-6203
• Copyright Holders: Copyright 2010 Floyd et al.
• First Published: First published in PLoS ONE 5(10):e13499
• Publisher Policy: Reproduced under a Creative Commons license