HIV This Week

Reniers G, Araya T, Davey G, Nagelkerke N, Berhane Y, Coutinho R, Sanders EJ. Steep declines in population-level AIDS mortality following the introduction of antiretroviral therapy in Addis Ababa, Ethiopia. AIDS. 2009;23:511-518.

Assessments of population-level effects of antiretroviral therapy programmes in Africa are rare. Reniers and colleagues use data from burial sites to estimate trends in adult AIDS mortality and the mitigating effects of antiretroviral therapy in Addis Ababa. Antiretroviral therapy has been available since 2003, and for free since 2005. To substitute for deficient vital registration, the authors use surveillance of burials at all cemeteries. They present trends in all-cause mortality, and estimate AIDS mortality (ages 20-64 years) from lay reports of causes of death. These lay reports are first used as a diagnostic test for the true cause of death. As reference standard, the authors use the cause of death established via verbal autopsy interviews conducted in 2004. The positive predictive value and sensitivity are subsequently used as anchors to estimate the number of AIDS deaths for the period 2001-2007. Estimates are compared with Spectrum projections. Between 2001 and 2005, the number of AIDS deaths declined by 21.9% and 9.3% for men and women, respectively. Between 2005 and 2007, the number of AIDS deaths declined by 38.2 for men and 42.9% for women. Compared with the expected number in the absence of antiretroviral therapy, the reduction in AIDS deaths in 2007 is estimated to be between 56.8% and 63.3%, depending on the coverage of the burial surveillance. Five years into the antiretroviral therapy programme, adult AIDS mortality has been reduced by more than half. Following the free provision of antiretroviral therapy in 2005, the decline accelerated and became more sex balanced. Substantial AIDS mortality, however, persists.

Editors’ note: When vital registration systems do not function well enough to provide accurate cause-specific adult mortality estimates, burial surveillance can provide data for realistic estimates of the impact of antiretroviral treatment programmes. During 2003-2005, the Ethiopian national programme required a co-payment of 28-80USD per month and AIDS mortality fell 15.8% in Addis Ababa, more in men than in women. The decline was far sharper between 2005 and 2007 (40.6%) when antiretroviral treatment was free, with greater declines observed for women. This study demonstrates the utility of using other information sources to monitor programme effects when vital registration is deficient and suggests a restraining effect of co-payments on antiretroviral treatment uptake, particularly for women who may have less access to resources for financing treatment.

Marcellin F, Abé C, Loubière S, Boyer S, Blanche J, Koulla-Shiro S, Ongolo-Zogo P, Moatti JP, Spire B, Carrieri MP; and the EVAL Study Group. Delayed first consultation after diagnosis of HIV infection in Cameroon. AIDS. 2009;23:1015-1019.

Marcellin and colleagues set out to study the impact of both decentralization of HIV care and individual factors on delayed first consultation (>/=6 months) after HIV diagnosis in Cameroon, in the context of the national antiretroviral treatment scale-up program. The national cross-sectional multicenter survey EVAL (ANRS 12-116) was conducted from September 2006 to March 2007 in 27 HIV centres in Cameroon. Logistic regression was used to characterize patients with delayed first consultation among 3151 HIV-infected adults. Fifteen percent of patients reported a delay of at least 6 months before their first consultation after HIV diagnosis. In the multivariate analysis adjusted for the frequency of visits to the HIV centre, independent correlates of reporting a delay of at least 6 months before consulting included the characteristics of the HIV centres (created before 2005 and located in small or medium-size hospitals) and the following individual patient characteristics: sex and matrimonial status (women living in a couple), the circumstances of the HIV diagnosis (test not performed in the hospital providing HIV care, test performed during a voluntary screening campaign) and patient’s negative perception of antiretroviral treatment toxicity. Delays before first consultation for HIV care in Cameroon have been reduced, thanks to the full implementation of the national program of decentralization. Results underline the importance of coordinating diagnosis with treatment activities and the need to develop counselling actions, focusing on the balance between antiretroviral treatment effectiveness and its potential side effects. Counselling should also be part of patients’ follow-up after diagnosis during voluntary screening campaigns.

Editors’ note: This is the first nation-wide study in sub-Saharan Africa to explore components of the causal process leading to late access to antiretroviral treatment: late HIV diagnosis versus delayed first consultation after HIV diagnosis. Decentralisation of HIV services in Cameroon has had the benefit of more prompt access to care, with 57% of patients experiencing a delay of less than 1 month between HIV diagnosis and their first medical consultation for HIV care. With many of the factors influencing delayed onset of antiretroviral treatment highlighted by this study, now programme planners and implementers can introduce modifications to reduce the delay. Their focus should be on the 15% who are not assessed for antiretroviral treatment until 6 months or more after HIV diagnosis and those who are lost to follow-up after an initial HIV diagnosis.