PEPFAR funding linked to lower death rate from all causes in Africa

PEPFAR funding for HIV programmes lowered the risk of death in countries receiving funds by around 16% between 2004-2008, without any clear indication that funding for HIV was having a negative effect on the ability to fight other diseases, Dr Eran Bendavid of Stanford University reported on Wednesday at the 19th Conference on Retroviruses and Opportunistic Infections in Seattle.

HIV development assistance from all countries reached $4 billion a year in 2009, but in recent years the scale of spending has been criticised on the grounds that it diverts resources from other health priorities and from strengthening health systems.

Funding for antiretroviral treatment has also come under fire as a form of “open-ended entitlement spending” in the United States, and some have questioned whether spending on HIV is a greater priority than campaigns to prevent malaria or to reduce maternal and infant deaths.

In an attempt to assess the impact of US international assistance for AIDS, researchers from Stanford University carried out a review of the relationship between US support provided through the President’s Emergency Plan for AIDS Relief (PEPFAR) and adult mortality in PEPFAR focus countries in sub-Saharan Africa, and whether there were differences in outcome between these countries and other African countries which did not receive PEPFAR support.

The authors conducted two analyses:

• A comparison of all-cause mortality between PEPFAR focus countries and non-focus countries in sub-Saharan Africa, to determine the impact of PEPFAR assistance on mortality.
• A comparison of changes in HIV-specific and all-cause mortality in PEPFAR focus countries to determine the extent to which PEPFAR funding might distort resource allocation away from health problems other than HIV.

In order to achieve a comparison between standardised mortality data sets the analysis used adult mortality data from Demographic and Health cross-sectional surveys, which survey households for information about deaths rather than using national death registries. The accuracy and completeness of death registries varies from country to country, whereas Demographic and Health Surveys (DHS) methods are replicated across the continent.

Data on 1.52 million adults from 27 countries were analysed.

The survey data were used to compare nine PEPFAR focus countries in sub-Saharan Africa and 18 other countries which did not receive comprehensive PEPFAR support.

Although PEPFAR focus countries had significantly larger populations, they had similar GDP per capita in 2008, and therefore similar levels of health system development. HIV prevalence was also similar between focus and non-focus countries. However focus countries received almost five times as much HIV-related assistance from the United States as non-focus countries, and twice as much assistance per person with HIV.

A comparison of adult mortality between 1998 and 2008 showed that after PEPFAR funding began in 2004 mortality rates began to diverge significantly; while mortality peaked at around 7.5 deaths per 1000 person-years in 2003 and remained stable between 2004 and 2008 in non-focus countries, it fell by almost 50% in PEPFAR focus countries, to 4 deaths per 1000 person-years in 2008.

Adjusted analysis showed adults had a 16% lower risk of death from all causes if they lived in a PEPFAR focus country (odds ratio 0.84, 95% confidence interval 0.72-0.99).

The researchers estimated that 740,800 all-cause adult deaths had been averted in PEPFAR focus countries between 2004 and 2008 (although the confidence interval was wide (443,300-1,808,500). In the same period, using data from UNAIDS, the researchers estimated that 631,388 HIV-related deaths were averted in the PEPFAR focus countries, possibly suggesting that health systems in PEPFAR focus countries have not suffered from a diversion of resources. However, Dr Bendavid warned that the evidence against any unintended negative health effects of PEPFAR funding remains inconclusive.