HIV treatment roll-out has had only a modest impact on mortality in Lusaka, Zambia

The scale-up of antiretroviral therapy (ART) programmes in Lusaka, Zambia, has been accompanied by only modest reductions in the city’s mortality rates, investigators report in the Bulletin of the World Health Organization. A series of cross-sectional household surveys conducted between 2004 and 2011 showed no significant reduction in the mortality rate.

The authors admit this finding was “unexpected” and highlights the importance of further increasing roll-out of therapy and supporting people to adhere to their treatment and remain in care. More encouragingly, the proportion of households with an orphaned child declined and there was also evidence that knowledge of HIV improved.

Thanks to ART, many people living with HIV now have a normal life expectancy. Excellent outcomes have been observed in people taking ART in sub-Saharan Africa. It is hoped that increased access to ART will translate into reductions in all-cause mortality in countries with generalised HIV epidemics. Short-term data from several southern African settings suggest this is the case.

A series of household surveys conducted in Lusaka, the capital of Zambia, between 2004 and 2011 provided investigators with the opportunity to assess the long-term impact of ART roll-out on all-cause morality. Twelve separate surveys were conducted in the city between these dates. Heads of households were asked to state the number of deaths in their household in the previous twelve months and to say if there were any orphaned children in their household. Data were also gathered on the use of ART by non-pregnant household members, rates of HIV testing and attitudes towards HIV infection.

Some 43,200 households participated in the surveys. Food security and employment increased over the period of the study, whereas refusal of medical treatment due to an inability to pay declined.

The households contributed a total of 204,263 person-years of follow-up. There were 2537 deaths.

The mortality rate fell from 1.94 per 100 person-years in early 2007 to 0.92 per 100 person-years in late 2011. But this reduction was not significant (p = 0.093).

However, the proportion of households with an orphan child fell from 17% to 7%.

There was also evidence of the scale of ART roll-out. In 2004, approximately 1% of households had a non-pregnant member taking ART; this had increased to over 7% in 2011.

HIV-related knowledge, attitudes and behaviours also improved, suggesting “the successful penetration of health communication messages about HIV among residents in Lusaka.” The authors also note “the stigma associated with HIV appears to be on the wane in Lusaka.”

But they conclude that the scale-up of ART has had only a modest impact on all-cause mortality in Lusaka.

The investigators therefore call for further expansion of ART coverage; greater effort to support treatment adherence and retention in care; and enhanced investment in health systems.

The authors conclude that Lusaka has benefited from HIV education and outreach programmes, but suggest “a realignment of the ART programme’s priorities may be needed to ensure maximal public health benefit.”