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Determinants of the risk of dying of HIV/AIDS in a rural South African community over the period of the decentralised roll-out of antiretroviral therapy: a longitudinal study
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network, Accra, Ghana.
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2014 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, 24826Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Antiretroviral treatment (ART) has significantly reduced HIV mortality in South Africa. The benefits have not been experienced by all groups. Here we investigate the factors associated with these inequities.

DESIGN: This study was located in a rural South African setting and used data collected from 2007 to 2010, the period when decentralised ART became available. Approximately one-third of the population were of Mozambican origin. There was a pattern of repeated circular migration between urban areas and this community. Survival analysis models were developed to identify demographic, socioeconomic, and spatial risk factors for HIV mortality.

RESULTS: Among the study population of 105,149 individuals, there were 2,890 deaths. The HIV/TB mortality rate decreased by 27% between 2007-2008 and 2009-2010. For other causes of death, the reduction was 10%. Bivariate analysis found that the HIV/TB mortality risk was lower for: those living within 5 km of the Bhubezi Community Health Centre; women; young adults; in-migrants with a longer period of residence; permanent residents; and members of households owning motorised transport, holding higher socioeconomic positions, and with higher levels of education. Multivariate modelling showed, in addition, that those with South Africa as their country of origin had an increased risk of HIV/TB mortality compared to those with Mozambican origins. For males, those of South African origin, and recent in-migrants, the risk of death associated with HIV/TB was significantly greater than that due to other causes.

CONCLUSIONS: In this community, a combination of factors was associated with an increased risk of dying of HIV/TB over the period of the roll-out of ART. There is evidence for the presence of barriers to successful treatment for particular sub-groups in the population, which must be addressed if the recent improvements in population-level mortality are to be maintained.

Place, publisher, year, edition, pages
2014. Vol. 7, 24826
Keyword [en]
HIV, mortality, determinants, global health, population health, healthcare access, South Africa
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-97436DOI: 10.3402/gha.v7.24826PubMedID: 25416322OAI: oai:DiVA.org:umu-97436DiVA: diva2:772816
Funder
Wellcome trust, 058893/Z/99/AWellcome trust, 069683/Z/02/ZWellcome trust, 069683/Z/08/Z
Available from: 2014-12-17 Created: 2014-12-17 Last updated: 2017-12-05Bibliographically approved
In thesis
1. Who died, where, when and why?: an investigation of HIV-related mortality in rural South Africa
Open this publication in new window or tab >>Who died, where, when and why?: an investigation of HIV-related mortality in rural South Africa
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background

South Africa has experienced the most severe consequences of the HIV/AIDS pandemic. Every community has been affected in some way, many experiencing huge increases in mortality,particularly before antiretroviral therapies (ART) were readily available. However, the micro-level understanding of the HIV epidemic in South Africa is weak, because of a lack of detailed data for most of the population. This thesis is based on detailed individual follow-up in the Agincourt Health and Demographic Surveillance Site (HDSS) located in the Agincourt subdistrict of Mpumalanga Province and investigates micro-level determinants of HIV epidemiology and the impact of treatment provided.

Methods

The Agincourt HDSS has followed a geographically defined population since 1992,approximately the time when the HIV/AIDS epidemic first became apparent. This population based surveillance has included capturing details of all deaths, with cause of death determined by verbal autopsy, as well as the geographical location of individual households within the overall Agincourt area. Background information on the roll-out of ART over time was also recorded.

Results

A comparison immediately before and after the major roll-out of ART showed a substantial decrease in HIV-related mortality, greater in some local communities within the area than others. Individual determinants associated with a decreased risk of HIV/AIDS mortality included proximity to ART services, as well as being female, younger, and in higher socioeconomic and educational strata. There was a decrease in the use of traditional healthcare sources and an increase in the use of biomedical healthcare amongst those dying of HIV/AIDS between periods before and after the roll-out of ART.

Conclusions

Understanding micro-level determinants of HIV/AIDS infection and mortality was very important in terms of characterising the overall epidemic in this community. This approach will enable public health interventions to be more effectively targeted towards those who need them most in the continuing evolution of the HIV/AIDS epidemic.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2015. 81 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1736
Keyword
HIV, AIDS, Mortality, Determinants, Risk Factor, Spatial Epidemiology, Structural Determinant, Antiretroviral Therapy, Healthcare Access, South Africa, Sub-Saharan Africa, Traditional Medical Practitioner, Traditional Medicine, Tuberculosis, Health and Demographic Surveillance System, Global Health, Population Health, Epidemiology
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Epidemiology
Identifiers
urn:nbn:se:umu:diva-108610 (URN)978-91-7601-309-0 (ISBN)
Public defence
2015-10-09, Room 135 Building 9A, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2006–1512Wellcome trust, 058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z
Available from: 2015-09-18 Created: 2015-09-14 Last updated: 2015-10-14Bibliographically approved

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Mee, PaulCollinson, Mark AKahn, KathleenTollman, Stephen MByass, Peter

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