impact of hiv/aids and art on mortality in south african platinum miners: 1992-2008
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Impact of HIV/AIDS and ART on mortality in South African platinum miners: 1992-2008
Megan Lim, Robert Dowdeswell, Jill Murray, Judith Glynn, Nigel Field, & Pam Sonnenberg
Background
• Mortality in sub-Saharan Africa has risen dramatically since the 1990s
• Most deaths are due to HIV/AIDS• Implementation of ART should affect this• ART programmes show positive outcomes• What is the impact at population level?
Setting
• Platinum mine, North West Province • All employees receive free medical care• HIV programme includes prevention, VCT,
Wellness programme and ART (since 2003)• HIV prevalence around 27% in 2002
AIM• to examine the impact of HIV &
ART on mortality trends in South African Platinum Miners1992 to 2008
– All-cause mortality– Cause-specific mortality– Trends:
• baseline (1992-1994)• Pre ART (1995-March2003)• Post ART (April2003-2008)
Methods
• Retrospective data analysis from routine sources• Cause of death from autopsy, medical certificate &
death registry• Cohort
– All semi and unskilled male employees– Jan 1 1992 to Dec 31 2008– Medically boarded patients followed for additional year
Burden of Disease Groups
I. Communicable
II. Non-communicable
III. Violence and injuries
IV. HIV-related
Results• Study population 40,043 men• 280,918 person years of follow-up• 3277 deaths• Mortality rate 11.9 / 1000 person years
Violence and injuries
24%
HIV/AIDS related48%
Other medical causes
13%
Unknown9%
Other infections6%
Causes of mortality (Burden of Disease groups)
n=3277
Mortality by cause and year
0
3
6
9
12
15
18
21
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
Mo
rta
lity
/10
00
py
ALL CAUSE
Violence and injuries
Other medical
Other infectious
Mortality by cause and year
0
3
6
9
12
15
18
21
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
Mo
rta
lity
/10
00
py
ALL CAUSE
HIV/AIDS
Violence and injuries
Other medical
Other infectious
Mortality by cause and year
0
3
6
9
12
15
18
21
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
Mo
rta
lity
/10
00
py
ALL CAUSE
HIV/AIDS
Violence and injuries
Other medical
Other infectious
ART
Mortality by cause and year
0
3
6
9
12
15
18
21
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
Mo
rta
lity
/10
00
py
ALL CAUSE
HIV/AIDS
Violence and injuries
Other medical
Other infectious
ART
Deaths from HIV in the ART era, programme and treatment status
Never registered
54%
Treated30%
Registered, not treated
16%
n=886
Causes of Death (%)
Cause of death (%)HIV negative/
unknown n=1620
HIV positive
pre ART n=769 post ART n=938
Violence and injuries 47 3 3
Natural 53 97 97
Infectious 12 57 64
TB 5 28 41
Pneumocystis (PCP)
0 5 5
Other Pneumonia 5 13 9
Other Infections 2 11 9
Other Medical 23 9 8
Unspecified 18 31 25
Causes of Death (%)
Cause of death (%)HIV negative/
unknown n=1620
HIV positive
pre ART n=769 post ART n=938
Violence and injuries 47 3 3
Natural 53 97 97
Infectious 12 57 64
TB 5 28 41
Pneumocystis (PCP)
0 5 5
Other Pneumonia 5 13 9
Other Infections 2 11 9
Other Medical 23 9 8
Unspecified 18 31 25
Causes of Death (%)
Cause of death (%)HIV negative/
unknown n=1620
HIV positive
pre ART n=769 post ART n=938
Violence and injuries 47 3 3
Natural 53 97 97
Infectious 12 57 64
TB 5 28 41
Pneumocystis (PCP)
0 5 5
Other Pneumonia 5 13 9
Other Infections 2 11 9
Other Medical 23 9 8
Unspecified 18 31 25
Causes of Death (%)
Cause of death (%)HIV negative/
unknown n=1620
HIV positive
pre ART n=769 post ART n=938
Violence and injuries 47 3 3
Natural 53 97 97
Infectious 12 57 64
TB 5 28 41
Pneumocystis (PCP)
0 5 5
Other Pneumonia 5 13 9
Other Infections 2 11 9
Other Medical 23 9 8
Unspecified 18 31 25
TB mortality rate in population
0.1
1.9
5.1
0
1
2
3
4
5
6
BASELINE PRE-ART POST-ART
TB
mo
rta
lity/
10
00
py
TB mortality rate in population
0.1
1.9
5.1
0
1
2
3
4
5
6
BASELINE PRE-ART POST-ART
TB
mo
rta
lity/
10
00
py
IRR 16 (7-36)
TB mortality rate in population
0.1
1.9
5.1
0
1
2
3
4
5
6
BASELINE PRE-ART POST-ART
TB
mo
rta
lity/
10
00
py
IRR 3 (2-3)
TB mortality rate in population
0.1
1.9
5.1
0
1
2
3
4
5
6
BASELINE PRE-ART POST-ART
TB
mo
rta
lity/
10
00
py
IRR 41 (18-92)
Discussion
• Rapid increase in mortality from 1997 to 2003• Decline in mortality after ART in 2003 • Increase in mortality from 2006 to 2008• Large increase in TB• Over half who died from HIV never accessed
Wellness programme• Never tested• Refused / unable to access programme
Limitations
Strengths
• Occupational setting• HIV status on living individuals unknown
• Large cohort• Long time period• Population-based• Accurate cause of death ascertainment
Conclusions• ART programmes are effective but population-based data
are required to evaluate their wider community impact • Population based evaluations need longer follow-up time• Need to address barriers to accessing programme• Emphasis on ART roll-out should be coupled with
integrated TB/HIV programmes
Acknowledgements• Study funded by Colt Foundation, UK• Megan Lim funded by NH&MRC, Australian government• Thanks to;
– Sr Poppy Ntehelang, Dr Lesego Rametsi, and Sr Connie Modise (Platinum Health)
– Dr Lettie la Grange and Charles Mbekeni (Anglo Platinum)– Karen Keulder (PMR)– Josephine Molate, Kele Tlhaole, Dineo Sefanyetso, and Pavlo
Matlakala (Colt Foundation)– Dr Craig Innes and Dr Victoria Johnstone (Aurum Institute)– Gill Nelson (NIOH)– Dr Andrew Copas (UCL)
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