The burden of HIV mortality following the rollout of antiretroviral therapy: evidence from an observational community cohort study in KwaZulu-Natal, South Africa

BACKGROUND: Antiretroviral therapy (ART) substantially decreases morbidity and mortality among people living with HIV. In this study, we describe population-level trends in the adult life expectancy (LE), and trends in the residual burden of HIV mortality following the rollout of a public sector ART programme in one of the populations with the most severe HIV epidemics in the world. METHODS: Data come from a demographic and HIV surveillance system in northern KwaZulu-Natal (South Africa), and cover the calendar years 2001 through 2014. We use non-parametric survival analysis methods to estimate gains in the population-wide LE at age 15 since the introduction of ART, and the shortfall of the population-wide adult LE compared to that of the HIV negative population (i.e., the LE deficit). LE gains and deficits are further disaggregated by age and cause of death using demographic decomposition methods. FINDINGS: The dataset contains information on 93,903 adults who jointly contribute 535,428 person-years of observation to the analyses and 9,992 deaths. Since the rollout of ART in 2004, adult LE increased by 15·2 years for men (95%-CI: 12·4-17·8), and 17·2 years for women (95%-CI: 14·5-20·2). Reductions in pulmonary TB and HIV related mortality account for 79·7% of the LE gains among men, and 90·7% among women. For men, 9·5% is the result of a decline in external injuries. By 2014, the LE deficit had contracted to 1·2 years for men (95%-CI: -2·9-5·8) and to 5·3 years for women (95%-CI: 2·6-7·8). Pulmonary TB and HIV are responsible for 84·9% of the LE deficit among men in 2011-'14, and for 80·8% among women. INTERPRETATION: The burden of HIV on adult mortality in this population is rapidly shrinking, but remains sizable for women, despite their better engagement with HIV care services. The recent gains in adult life-years lived as well as the current LE deficit are almost exclusively due to differences in mortality attributed to HIV and pulmonary TB. FUNDING: Wellcome Trust, the Bill and Melinda Gates Foundation, and the National Institutes of Health.