Gaydosh, L.

Geubbels, E.

Kante, M.

Levira, F.

Masanja, H.

Mrema, S.

English

Digital Library of the Tanzania Health Community

0
50
100
150
200
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350
Number of 
patients Care and Treatment scale-up
Start 
Health Center 2
Start 
Health Center 1
Start Hospital 2
Start Hospital 1
New  in care
New  on ART
  Population-level AIDS-related adult mortality after  
treatment programs scale-up in rural Tanzania 
 
 
  
 
Studies  in  SSA  find  substantial  population-level  reductions  in  adult  AIDS 
mortality accompanying ART scale-up to district-level hospitals, but there is 
scant evidence to date regarding the impact of scale-up to lower level facilities. 
We  analyze  the  association  between  increased  availability  of  Care  and 
Treatment (C&T) in both district-level and lower-level facilities and population-
level AIDS-related mortality among individuals 15 years and older, in the Rufiji 
Health  and  Demographic  Surveillance  System  (HDSS),  Tanzania.  We  assess 
whether this scale-up led to differences over time in the characteristics of the 
population at highest risk of dying from AIDS.  Finally, as men’s uptake of HIV 
testing and C&T has been reported to lag behind women’s, possibly because of 
perceived gender roles and because women come into contact with PMTCT 
services more often, we investigate gender variation in AIDS-related mortality.  
1Ifakara Health Institute,  Dar es Salaam & Rufiji branches, Tanzania , 2 PhD Candidate, Sociology Department, Princeton University, USA   
 
 
 E. Geubbels1, L. Gaydosh2, F. Levira1, S. Mrema1, M. Kante1, H. Masanja1  
Background  Population and Methods 
Results 
Conclusion   
Demographic surveillance since 1998 
• Data  on  births,  migrations,  unions,  deaths  and  causes  of  death  (by  verbal  autopsy 
method) are collected once every four months 
0
0.5
1
1.5
2
All Women Men
AIDS deaths /
1000 PYAR
1999-2004: pre-Care & Treatment
2005-2007: Care & Treatment in hospitals 
2008-2010: Care & Treatment in hospitals and health centers 
RR 0.80 [0.67-0.96]
RR 0.86 [0.68-1.09]
RR 0.80 [0.63-1.03]
RR 0.83 [0.63-1.08]
RR 0.74 [0.56-0.97]
 
CONTACT Dr Eveline Geubbels: egeubbels@ihi.or.tz, www.ihi.or.tz 
 
HIV Care and Treatment program in the HDSS area 
• Care  CD4 testing, disease staging every 6 months, continuous cotrimoxazol prophylaxis 
• Treatment  initiated if CD4 <200 cells/ml OR if WHO stage 4 OR if WHO stage 3 
and CD4<350 cells/ml 
• Introduced in two hospitals (2005/2006) and in two health  centers (2008/2009). CD4 
testing only available in hospitals 
 
Analysis  
• Relative risk of dying from AIDS-related causes overall and by gender and period: i) pre-
ART (1999-2004), ii) after C&T was introduced in hospitals (2005-2007, 1st scale-up) and iii) 
expanded to health centers (2008-2010, 2nd scale-up), using direct mortality rates 
• Cox Proportional Hazards regression to determine groups at high risk of AIDS mortality 
in each period, by characteristics of  
― individuals: age, sex, educational attainment, work status, marital status 
― household: distance to the main road, distance to nearest Care and Treatment Clinic 
►The scale-up of C&T to lower level health facilities helped to contain population-level AIDS mortality in this district, but did not accelerate mortality reduction. Possibly, roll-out of 
treatment services to lower level health facilities without commensurate roll-out of treatment initiation and monitoring services limits the impact of scale-up 
►Targeted programs to include and retain –especially older- men in C&T should be implemented. Because few  ‘natural’ contacts with the health system exist for men, and because few 
men are formally employed, novel HIV testing programs need to be designed in addition to the existing workplace and health facility based services 
Figure 1  Figure 2 
Model adjusted for work status, distance to main road, distance to nearest CTC and education. The hazard ratios 
for these factors showed little change over time and are not shown in the table. 
 
Table 1a  
► Expansion to health centers accelerated care scale-up, but not treatment scale-up (Fig 1) 
► Population-level AIDS mortality dropped by 20% in 1st scale-up period, and stalled in 
2nd period (Fig 2) 
► Larger mortality decrease in men than women in 1st period, but mortality rose again in 
men in 2nd period (Fig 2) 
► Population-level AIDS  mortality in men and women now equal, despite men having 
half the HIV prevalence of women (Fig 2 & Methods) 
► In 2010, ART coverage (number on ART/ number in need of ART) was 57% in women 
and 34% in men [F. Levira, personal communication; coverage estimated as described in  
Somi et al. Using clinic  and survey data to estimate coverage of HIV care and treatment 
services in Tanzania. 6th IAS conference, Rome 17-20 Jul 2011 ] 
► C&T scale-up associated with increased mortality disparity for divorced / widowed 
women (Table 1a)  
► C&T scale-up associated with increased mortality disparity for older men (Table 1b) 
 
Study population 
• End 2010:  ~40,000 individuals ≥15 years in 33 villages 
• Families living off fishing, farming, day labor and petty trade 
• Adult HIV prevalence in Coast region dropped from 10.5% to 8.4% in women and rose 
from 3.9% to 4.2% in men between the 2003/4 and 2007/8  national HIV indicator surveys 
 
Women  Pre-ART  
(1999-2004) 
1
st C&T period  
(2005-2007) 
2
nd C&T period  
(2008-2010) 
  HR  95% CI  HR  95% CI  HR  95% CI 
Marital status 
Single 
Married 
Divorced/widowed 
Not applicable 
Not known 
 
1 
0.8 
1.2 
1.5 
9.1 
 
 
- 
(0.5-1.4) 
(0.7- 2.2)  
(0.2-11.3) 
(5.3-15.7) 
 
1 
1.1  
 2.3  
  0.6  
 1.0 
 
- 
(0.6-2.0) 
(1.2-4.4) 
(0.1-4.6) 
(0.2-4.6) 
 
1 
2.0 
3.9 
1.3 
- 
 
- 
(0.8-5.0) 
(1.5-10.1) 
(0.2-10.4) 
       
 
Age >= 35 years 
 
1.4  1.1-1.8  1.5  (1.0-2.1)  1.5  (0.9-2.5) 
 
Men  Pre-ART period 
(1999-2004) 
1
st C&T period 
(2005-2007) 
2
nd C&T period 
(2008-2010) 
  HR  95% CI  HR  95% CI  HR  95% CI 
Marital status 
Single 
Married 
Divorced/widowed 
Not applicable 
Not known 
 
1 
0.9 
1.5 
3.2 
11.8 
 
- 
(0.5-1.7) 
(0.7-2.9) 
(0.4- 24.6) 
(6.5-21.6) 
 
 
1 
1.3 
1.9 
3.5 
2.2 
 
- 
(0.6-2.7) 
(0.8-4.4) 
(0.7-16.2) 
(0.4-10.7) 
 
1 
0.5 
0.9 
4.1 
2.2 
 
- 
(0.2-1.2) 
(0.3-2.5) 
(0.8-20.1) 
(0.4-11.9) 
Age >= 35 years 
 
3.9  (2.8- 5.3)  4.6  (2.5-8.4)  7.8  (3.3-18.8) 
  Model adjusted for work status, distance to main road, distance to nearest CTC and education. The hazard ratios 
for these factors showed little change over time and are not shown in the table. 
 
Table 1b  
Dugout canoe crossing the Rufiji river bordering  the HDSS area 

\ud Population-Level AIDS-Related Adult Mortality After Treatment Programs Scale-Up in Rural Tanzania\ud

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