Antiretroviral therapy impact is huge, but gender disparities drive differences in death rates
DURBAN, South Africa – Globally adult life expectancy gained from 10-14 years over a decade following access to HIV treatment, the greatest life expectancy gains recorded in modern history, according to researchers from the London School of Hygiene and Tropical Medicine. Greater life expectancy gains were seen in South Africa alone, home to the world’s largest HIV epidemic.
This information was the good news portion of a symposium Monday examining household based demographic and surveillance data in 6 high HIV prevalence countries in eastern and southern Africa. The bad news came with data showing continuing life expectancy deficits of the HIV-infected populations in these regions — almost six years in South Africa and under two years in eastern African countries included in the study. Mortality remains high in the study sites for people with HIV compared to their uninfected counterparts, largely due to HIV and tuberculosis. The largest share of deaths occurred among people who had not started antiretroviral therapy, with 60 percent of all deaths occurring among people who had not yet started treatment. The most deaths among people who had started treatment were seen among people who started treatment between 2005 and 2009, and among people on treatment for 6 months or less, presumably because damage to their immune systems was by then already severe.
Funded by the Bill & Melinda Gates Foundation, the data was collected through surveillance and in-depth interviews of family members of people living with HIV in sites in Malawi, Kenya, Tanzania, Uganda, Zimbabwe and South Africa.
Interviews with family members of those who had died pointed to delays in testing, disclosure and access to care as key reasons for the premature deaths. Other barriers noted were poverty and its implications for money for transportation and adequate nutrition, the burden on the family caring for the person living with HIV, and the migration of the HIV patient to places that lacked local health clinics. Family members also said that adherence to HIV treatment was complicated by tuberculosis, malaria and meningitis. The researchers also pointed out that none of the clinics at the study sites reported consistent 100 percent availability of test kits, antiretroviral drugs and opportunistic infection medications.
A significant and growing gender gap between women and men in life expectancy, death rates and access to lifesaving HIV medicines supplied more of the bad news. With more women on antiretroviral therapy, women starting HIV treatment earlier, and women having lower rates of dropping out of care, women have lower death rates on antiretroviral treatment than men. Men also are twice as likely as women to die before being diagnosed with HIV, and this gender disparity in pre-treatment mortality has increased. Although men access HIV treatment after diagnosis at roughly the same rates as women, death rates among men after starting treatment are twice as high as for women. Consequently, the life expectancy gains for women from HIV treatment are much higher among women. Drivers of these differences are complex, and include greater access for women to testing and treatment in antenatal settings, and what the researchers called “ a deep-seated male reluctance to test and to start HIV treatment until they are very unwell.”
The burden of HIV mortality is higher among women because of the larger numbers of women in these regions who are infected with HIV. While male mortality rates are higher, the risk of HIV acquisition has declined for men, but not for women. Higher antiretroviral coverage in women protects their male partners, and growing numbers of medical circumcisions have provided additional protection from HIV for men.
They symposium was hosted by the Alpha network, a consortium of independent institutions.