The population-level impact of public-sector antiretroviral therapy rollout on adult mortality in rural Malawi

Abstract

BACKGROUNDRecent evidence from health and demographic surveillance sites (HDSS) has shown that increasing access to antiretroviral therapy (ART) is reducing mortality rates in sub-Saharan Africa (SSA). However, due to limited vital statistics registration in many of the countries most affected by the HIV/AIDS epidemic, there is limited evidence of the magnitude of ART’s effect outside of specific HDSS sites. This paper leverages longitudinal household/family roster data from the Malawi Longitudinal Survey of Families and Health (MLSFH) to estimate the effect of ART availability in public clinics on population-level mortality based on a geographically dispersed sample of individuals in rural Malawi.OBJECTIVEWe seek to provide evidence on the population-level magnitude of the ART-associated mortality decline in rural Malawi and confirm that this population is experiencing similar declines in mortality as those seen in HDSS sites.METHODSWe analyze longitudinal household/family-roster data from four waves of the MLSFH to estimate mortality change after the introduction of ART to study areas. We analyze life expectancy using the Kaplan–Meier estimator and examine how the mortality hazard changed over time by individual characteristics with Cox regression.RESULTSIn the four years following rollout of ART, life expectancy at age 15 increased by 3.1 years (95% CI 1.1, 5.1), and median length of life rose by over ten years.CONTRIBUTIONOur observations show that the increased availability of ART resulted in a substantial and sustained reversal of mortality trends in SSA and assuage concerns that the post-ART reversals in mortality are not occurring at the same magnitude outside of specific HDSSs.

The Demography of Mental Health Among Mature Adults in a Low-Income, High-HIV-Prevalence Context

“…1, panel a). These recent and projected future improvements in the life expectancy of adults in SSA low-income countries with high HIV prevalence have reversed the previous trend of declines in adult survival caused by the HIV/AIDS epidemic during the 1990s and early 2000s (Bor et al 2013; Floyd et al 2012, Payne and Kohler 2017) (Fig. 1, panel b).…”

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“…This low HIV prevalence is largely due to high HIV-related mortality of these cohorts in early life (Freeman and Anglewicz, 2012). Although HIV prevalence is fairly low at older ages, the HIV epidemic has great contextual importance to this population—older adults in Malawi lived through the peak of a widespread HIV epidemic (Payne and Kohler, 2017), a traumatic process even for the HIV- population. Rural Malawians also live in conditions similar to other rural populations in SSA, characterized by high levels of poverty, episodic malnutrition, poor sanitation, a high prevalence of infectious diseases and endemic parasites, and limited access to health care facilities (Kohler et al, 2015).…”

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“…In 2003, through support of large international donors and governments, the Malawian government started to make ART available for free, and the ART program has been expanding rapidly since. The scale-up of the program, in Malawi and elsewhere in sub-Saharan Africa, is widely regarded as a public health success and has resulted in measured declines in adult mortality (Jahn et al 2008, Floyd et al 2012, and Payne and Kohler 2017.…”