Estimating adult mortality rates in the context of the AIDS epidemic in sub-Saharan Africa: analysis of DHS sibling histories

Recent efforts to model the demographic effect of the AIDS pandemic in sub-Saharan Africa have far outnumbered empirical studies of adult mortality levels and patterns in AIDS-affected countries of the region. There is still a paucity of population-based data on adult mortality for nearly all countries in the region. Using data from recent Demographic and Health Surveys (DHS) of six countries and one in-depth DHS, this paper examines the use of sibling histories to directly estimate rates of adult mortality. The countries studied include Uganda, Zambia, Central African Republic, Côte d’Ivoire, Zimbabwe, Malawi, and Tanzania. Rates of adult male and female mortality are presented at the national level in comparison to estimates obtained from other published sources, where available, and for subnational areas where cohort and other mortality studies have been recently conducted. The results indicate surprising consistency with external data and, on the whole, underscore the expected but hitherto only sparsely documented association between residence in high HIV-prevalence areas and sharply elevated mortality risk during the relevant adult ages. The cases of Zambia and Uganda in particular provide clear evidence of very high adult mortality levels among both men and women. In general, the findings of the study demonstrate that DHS-type sibling histories represent a promising, relatively untapped source of data that will add to our understanding of adult mortality dynamics in Africa. The paper discusses some of the advantages and potential limitations of the data and derived mortality estimates

Socioeconomic inequalities in childhood mortality: the 1970s to the 1980s

The last three decades have witnessed substantial reductions in childhood mortality in most developing nations. Despite this encouraging picture, analysis of WFS and DHS survey data shows that socioeconomic disparities in survival chances have not narrowed between the 1970s and 1980s, and in some cases, have widened. Changes in mother’s education and father’s occupation contributed only modestly to secular declines in mortality. In most countries studied, no more than 20 per cent of the national trend could be accounted for by compositional improvements. The median contributions of improvements in mother’s education and father’s occupation were ten and eight per cent, respectively

Childhood Mortality in Kenya: An examination of trends and determinants in the late 1980s to mid 1990s

After Independence in the early 1960s, child mortality in Kenya fell rapidly. Until around 1980, the under 5 mortality rate (U5MR), the probability of dying by age 5, fell at an annual rate of about 4 percent per annum. This rate of decline slowed in the early 1980s, to about 2 per cent per annum. Recent data from the 1998 Kenya Demographic and Health Survey showed that, far from declining, the U5MR increased by as much as 25 percent from the late 1980s to the mid 1990s. This adverse trend coincided with a number of other adverse trends: stagnation in growth of per capita income, declining levels of immunization, falling school enrolment, and the emergence of an HIV/AIDS epidemic. On a more positive note, fertility fell by about 30 percent from the mid 1980s to the mid 1990s. Controversy surrounds the factors responsible for the increase in child mortality in the 1990s, and the objective of this paper is to clarify the situation. Data from the 1993 and 1998 DHSs have been merged into a single data set, and multivariate analysis used to examine the factors associated with mortality risks in childhood. Dummy variables were used to represent different three-year time periods, from 1984-86 to 1996-98. Socioeconomic controls, including mother¹s education, an indicator of household wealth, urban/rural residence, and indicators of health service utilization, plus controls for reproductive dynamics such as age of mother at the birth, birth order, sex and preceding birth interval, were developed. In addition, an indicator of the HIV epidemic, the prevalence of HIV in the district of birth at the time of each child¹s birth, was developed. With no controls, the models confirmed an increase in mortality of about 25 percent. Including socioeconomic and biodemographic controls tended to strengthen the upward trend in mortality; in other words, had there been no changes in these factors, child mortality would have been expected to decline. Introducing controls for health variables immunization, pregnancy and delivery care, prevalence of childhood diseases and maternal and child malnutrition ­ also did not alter the underlying trends substantially. Thus rising child mortality could not be explained by socioeconomic, biodemographic or health status factors. Including the prevalence of HIV in the models, however, changed the underlying trends fundamentally, from sharp increase to monotonic decline. Although models of this sort cannot demonstrate causation, only association, the HIV epidemic appears to be the most probable cause of the recent increases in child mortality in Kenya. Of the health variables, the only one found to be significantly protective was immunization coverage

Recent Patterns in Population-Based HIV Prevalence in Swaziland

Background: The 2011 Swaziland HIV Incidence Measurement Survey (SHIMS) was conducted as part of a national study to evaluate the scale up of key HIV prevention programs. Methods: From a randomly selected sample of all Swazi households, all women and men aged 18-49 were considered eligible, and all consenting adults were enrolled and received HIV testing and counseling. In this analysis, population-based measures of HIV prevalence were produced and compared against similarly measured HIV prevalence estimates from the 2006-7 Swaziland Demographic and Health. Also, measures of HIV service utilization in both HIV infected and uninfected populations were documented and discussed. Results: HIV prevalence among adults aged 18-49 has remained unchanged between 2006-2011 at 31-32%, with substantial differences in current prevalence between women (39%) and men (24%). In both men and women, between since 2006-7 and 2011, prevalence has fallen in the young age groups and risen in the older age groups. Over a third (38%) of the HIV-infected population was unaware of their infection status, and this differed markedly between men (50%) and women (31%). Of those aware of their HIV-positive status, a higher percentage of men (63%) than women (49%) reported ART use. Conclusions: While overall HIV prevalence remains roughly constant, age-specific changes strongly suggest both improved survival of the HIV-infected and a reduction in new HIV infections. Awareness of HIV status and entry into ART services has improved in recent years but remains too low. This study identifies opportunities to improve both HIV preventive and care services in Swaziland

Risk scores for predicting early antiretroviral therapy mortality in sub-Saharan Africa to inform who needs intensification of care: a derivation and external validation cohort study.

BACKGROUND: Clinical scores to determine early (6-month) antiretroviral therapy (ART) mortality risk have not been developed for sub-Saharan Africa (SSA), home to 70% of people living with HIV. In the absence of validated scores, WHO eligibility criteria (EC) for ART care intensification are CD4  37.5 °C (2 points). The same variables plus CD4 < 200/μL (1 point) were included in the CD4-dependent score. Among XPRES enrollees, a CD4-independent score of ≥ 4 would provide 86% sensitivity and 66% specificity, whereas WHO EC would provide 83% sensitivity and 58% specificity. If WHO stage alone was used, sensitivity was 48% and specificity 89%. Among TBFT enrollees, the CD4-independent score of ≥ 4 would provide 95% sensitivity and 27% specificity, whereas WHO EC would provide 100% sensitivity but 0% specificity. Accuracy was similar between CD4-independent and CD4-dependent scores. Categorizing CD4-independent scores into low (< 4), moderate (4-6), and high risk (≥ 7) gave 6-month mortality of 1%, 4%, and 17% for XPRES and 1%, 5%, and 30% for TBFT enrollees. CONCLUSIONS: Sensitivity of the CD4-independent score was nearly twice that of WHO stage in predicting 6-month mortality and could be used in settings lacking CD4 testing to inform ART care intensification. The CD4-dependent score improved specificity versus WHO EC. Both scores should be considered for scale-up in SSA

Derivation and external validation of a risk score for predicting HIV-associated tuberculosis to support case finding and preventive therapy scale-up: A cohort study.

BACKGROUND: Among people living with HIV (PLHIV), more flexible and sensitive tuberculosis (TB) screening tools capable of detecting both symptomatic and subclinical active TB are needed to (1) reduce morbidity and mortality from undiagnosed TB; (2) facilitate scale-up of tuberculosis preventive therapy (TPT) while reducing inappropriate prescription of TPT to PLHIV with subclinical active TB; and (3) allow for differentiated HIV-TB care. METHODS AND FINDINGS: We used Botswana XPRES trial data for adult HIV clinic enrollees collected during 2012 to 2015 to develop a parsimonious multivariable prognostic model for active prevalent TB using both logistic regression and random forest machine learning approaches. A clinical score was derived by rescaling final model coefficients. The clinical score was developed using southern Botswana XPRES data and its accuracy validated internally, using northern Botswana data, and externally using 3 diverse cohorts of antiretroviral therapy (ART)-naive and ART-experienced PLHIV enrolled in XPHACTOR, TB Fast Track (TBFT), and Gugulethu studies from South Africa (SA). Predictive accuracy of the clinical score was compared with the World Health Organization (WHO) 4-symptom TB screen. Among 5,418 XPRES enrollees, 2,771 were included in the derivation dataset; 67% were female, median age was 34 years, median CD4 was 240 cells/μL, 189 (7%) had undiagnosed prevalent TB, and characteristics were similar between internal derivation and validation datasets. Among XPHACTOR, TBFT, and Gugulethu cohorts, median CD4 was 400, 73, and 167 cells/μL, and prevalence of TB was 5%, 10%, and 18%, respectively. Factors predictive of TB in the derivation dataset and selected for the clinical score included male sex (1 point), ≥1 WHO TB symptom (7 points), smoking history (1 point), temperature >37.5°C (6 points), body mass index (BMI) 10) yielded TB prevalence of 1%, 1%, 2%, and 6% in the lowest risk group and 33%, 22%, 26%, and 32% in the highest risk group for XPRES, XPHACTOR, TBFT, and Gugulethu cohorts, respectively. At clinical score ≥2, the number needed to screen (NNS) ranged from 5.0 in Gugulethu to 11.0 in XPHACTOR. Limitations include that the risk score has not been validated in resource-rich settings and needs further evaluation and validation in contemporary cohorts in Africa and other resource-constrained settings. CONCLUSIONS: The simple and feasible clinical score allowed for prioritization of sensitivity and NPV, which could facilitate reductions in mortality from undiagnosed TB and safer administration of TPT during proposed global scale-up efforts. Differentiation of risk by clinical score cutoff allows flexibility in designing differentiated HIV-TB care to maximize impact of available resources

Trends in Prevalence of Advanced HIV Disease at Antiretroviral Therapy Enrollment - 10 Countries, 2004-2015.

Monitoring prevalence of advanced human immunodeficiency virus (HIV) disease (i.e., CD4+ T-cell count <200 cells/μL) among persons starting antiretroviral therapy (ART) is important to understand ART program outcomes, inform HIV prevention strategy, and forecast need for adjunctive therapies.*,†,§ To assess trends in prevalence of advanced disease at ART initiation in 10 high-burden countries during 2004-2015, records of 694,138 ART enrollees aged ≥15 years from 797 ART facilities were analyzed. Availability of national electronic medical record systems allowed up-to-date evaluation of trends in Haiti (2004-2015), Mozambique (2004-2014), and Namibia (2004-2012), where prevalence of advanced disease at ART initiation declined from 75% to 34% (p<0.001), 73% to 37% (p<0.001), and 80% to 41% (p<0.001), respectively. Significant declines in prevalence of advanced disease during 2004-2011 were observed in Nigeria, Swaziland, Uganda, Vietnam, and Zimbabwe. The encouraging declines in prevalence of advanced disease at ART enrollment are likely due to scale-up of testing and treatment services and ART-eligibility guidelines encouraging earlier ART initiation. However, in 2015, approximately a third of new ART patients still initiated ART with advanced HIV disease. To reduce prevalence of advanced disease at ART initiation, adoption of World Health Organization (WHO)-recommended "treat-all" guidelines and strategies to facilitate earlier HIV testing and treatment are needed to reduce HIV-related mortality and HIV incidence

Antiretroviral therapy enrollment characteristics and outcomes among HIV-infected adolescents and young adults compared with older adults--seven African countries, 2004-2013.

Although scale-up of antiretroviral therapy (ART) since 2005 has contributed to declines of about 30% in the global annual number of human immunodeficiency (HIV)-related deaths and declines in global HIV incidence, estimated annual HIV-related deaths among adolescents have increased by about 50% and estimated adolescent HIV incidence has been relatively stable. In 2012, an estimated 2,500 (40%) of all 6,300 daily new HIV infections occurred among persons aged 15-24 years. Difficulty enrolling adolescents and young adults in ART and high rates of loss to follow-up (LTFU) after ART initiation might be contributing to mortality and HIV incidence in this age group, but data are limited. To evaluate age-related ART retention challenges, data from retrospective cohort studies conducted in seven African countries among 16,421 patients, aged ≥15 years at enrollment, who initiated ART during 2004-2012 were analyzed. ART enrollment and outcome data were compared among three groups defined by age at enrollment: adolescents and young adults (aged 15-24 years), middle-aged adults (aged 25-49 years), and older adults (aged ≥50 years). Enrollees aged 15-24 years were predominantly female (81%-92%), commonly pregnant (3%-32% of females), unmarried (54%-73%), and, in four countries with employment data, unemployed (53%-86%). In comparison, older adults were more likely to be male (p<0.001), employed (p<0.001), and married, (p<0.05 in five countries). Compared with older adults, adolescents and young adults had higher LTFU rates in all seven countries, reaching statistical significance in three countries in crude and multivariable analyses. Evidence-based interventions to reduce LTFU for adolescent and young adult ART enrollees could help reduce mortality and HIV incidence in this age group