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)