Using HIV-attributable mortality to assess the impact of antiretroviral therapy on adult mortality in rural Tanzania

Background: 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. Methods: 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. Results: 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. Discussion: 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.