National Institute for Medical Research, Mwanza, Tanzania; London School of Hygiene and Tropical Medicine, London, UK;
National Institute for Medical Research, Mwanza, Tanzania.
Glob Health Action. 2014 Mar 20;7:21865. doi: 10.3402/gha.v7.21865. eCollection 2014.
The Tanzanian national HIV care and treatment programme has provided free antiretroviral therapy (ART) to HIV-positive persons since 2004. ART has been available to participants of the Kisesa open cohort study since 2005, but data to 2007 showed a slow uptake of ART and a modest impact on mortality. Additional data from the 2010 HIV serological survey provide an opportunity to update the estimated impact of ART in this setting.
The Kisesa Health and Demographic Surveillance Site (HDSS) has collected HIV serological data and demographic data, including verbal autopsy (VA) interviews since 1994. Serological data to the end of 2010 were used to make two estimates of HIV-attributable mortality, the first among HIV positives using the difference in mortality between HIV positives and HIV negatives, and the second in the population using the difference between the observed mortality rate in the whole population and the mortality rate among the HIV negatives. Four time periods (1994-1999, 2000-2004, 2005-2007, and 2008-2010) were used and HIV-attributable mortality estimates were analysed in detail for trends over time. A computer algorithm, InterVA-4, was applied to VA data to estimate the HIV-attributable mortality for the population, and this was compared to the estimates from the serological survey data.
Among HIV-positive adults aged 45-59 years, high mortality rates were observed across all time periods in both males and females. In HIV-positive men, the HIV-attributable mortality was 91.6% (95% confidence interval (CI): 84.6%-95.3%) in 2000-2004 and 86.3% (95% CI: 71.1%-93.3%) in 2008-2010, while among women, the HIV-attributable mortality was 87.8% (95% CI: 71.1%-94.3%) in 2000-2004 and 85.8% (95% CI: 59.6%-94.4%) in 2008-2010. In the whole population, using the serological data, the HIV-attributable mortality among men aged 30-44 years decreased from 57.2% (95% CI: 46.9%-65.3%) in 2000-2004 to 36.5% (95% CI: 18.8%-50.1%) in 2008-2010, while among women the corresponding decrease was from 57.3% (95% CI: 49.7%-63.6%) to 38.7% (95% CI: 27.4%-48.2%). The HIV-attributable mortality in the population using estimates from the InterVA model was lower than that from HIV sero-status data in the period prior to ART, but slightly higher once ART became available.
In the Kisesa HDSS, ART availability corresponds with a decline in adult overall mortality, although not as large as expected. Using InterVA to estimate HIV-attributable mortality showed smaller changes in HIV-related mortality following ART availability than the serological results.
坦桑尼亚国家艾滋病毒护理和治疗方案自 2004 年以来向艾滋病毒阳性者提供免费抗逆转录病毒疗法（ART）。自 2005 年以来，基塞萨开放队列研究的参与者就可以获得 ART，但截至 2007 年的数据显示，ART 的采用速度缓慢，对死亡率的影响也不大。2010 年 HIV 血清学调查的额外数据提供了更新这一背景下 ART 估计影响的机会。
基塞萨健康和人口监测站点（HDSS）自 1994 年以来一直在收集 HIV 血清学数据和人口数据，包括尸检访谈。截至 2010 年底的血清学数据用于进行两次 HIV 归因死亡率估计，第一次是在 HIV 阳性者中，使用 HIV 阳性者和 HIV 阴性者之间的死亡率差异，第二次是在整个人口中，使用整个人口的观察死亡率和 HIV 阴性者的死亡率之间的差异。使用了四个时期（1994-1999 年、2000-2004 年、2005-2007 年和 2008-2010 年），并详细分析了随时间变化的 HIV 归因死亡率趋势。使用 InterVA-4 计算机算法对 VA 数据进行分析，以估计整个人口的 HIV 归因死亡率，并将其与血清学调查数据的估计值进行比较。
在 45-59 岁的 HIV 阳性成年人中，男性和女性在所有时期的死亡率都很高。在 HIV 阳性男性中，2000-2004 年 HIV 归因死亡率为 91.6%（95%置信区间[CI]：84.6%-95.3%），2008-2010 年为 86.3%（95% CI：71.1%-93.3%），而女性在 2000-2004 年的 HIV 归因死亡率为 87.8%（95% CI：71.1%-94.3%），在 2008-2010 年为 85.8%（95% CI：59.6%-94.4%）。在整个人口中，使用血清学数据，30-44 岁男性的 HIV 归因死亡率从 2000-2004 年的 57.2%（95% CI：46.9%-65.3%）下降到 2008-2010 年的 36.5%（95% CI：18.8%-50.1%），而女性相应的下降从 57.3%（95% CI：49.7%-63.6%）降至 38.7%（95% CI：27.4%-48.2%）。使用 InterVA 模型估计的人口 HIV 归因死亡率低于 ART 前时期血清学数据的死亡率，但在 ART 可用后略高。
在基塞萨 HDSS 中，ART 的可用性与成年人总体死亡率的下降相对应，尽管降幅不如预期的那么大。使用 InterVA 估计 HIV 相关死亡率表明，在 ART 可用后，与 HIV 相关的死亡率变化较小。
