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Evidence for localised HIV related micro-epidemics associated with the decentralised provision of antiretroviral treatment in rural South Africa: a spatio-temporal analysis of changing mortality patterns (2007-2010)
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; INDEPTH Network, Kanda, Accra, Ghana.
Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; Department of African–American Studies, University of Maryland, Maryland, USA.
Department of Geography and Institute of Behavioral Science, University of Colorado at Boulder, Boulder, Colorado, USA.
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2014 (English)In: Journal of Global Health, ISSN 2047-2978, E-ISSN 2047-2986, Vol. 4, no 1, 010403Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: In this study we analysed the spatial and temporal changes in patterns of mortality over a period when antiretroviral therapy (ART) was rolled out in a rural region of north-eastern South Africa. Previous studies have identified localised concentrated HIV related sub-epidemics and recommended that micro-level analyses be carried out in order to direct focused interventions.

METHODS: Data from an ongoing health and socio-demographic surveillance study was used in the analysis. The follow-up was divided into two periods, 2007-2008 and 2009-2010, representing the times immediately before and after the effects on mortality of the decentralised ART provision from a newly established local health centre would be expected to be evident. The study population at the start of the analysis was approximately 73 000 individuals. Data were aggregated by village and also using a 2 × 2 km grid. We identified villages, grid squares and regions in the site where mortality rates within each time period or rate ratios between the periods differed significantly from the overall trends. We used clustering techniques to identify cause-specific mortality hotspots.

FINDINGS: Comparing the two periods, there was a 30% decrease in age and gender standardised adult HIV-related and TB (HIV/TB) mortality with no change in mortality due to other causes. There was considerable spatial heterogeneity in the mortality patterns. Areas separated by 2 to 4 km with very different epidemic trajectories were identified. There was evidence that the impact of ART in reducing HIV/TB mortality was greatest in communities with higher mortality rates in the earlier period.

CONCLUSIONS: This study shows the value of conducting high resolution spatial analyses in order to understand how local micro-epidemics contribute to changes seen over a wider area. Such analyses can support targeted interventions.

Place, publisher, year, edition, pages
Edinburgh University Global Health Society , 2014. Vol. 4, no 1, 010403
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-91960DOI: 10.7189/jogh.04.010403PubMedID: 24976962OAI: oai:DiVA.org:umu-91960DiVA: diva2:738708
Available from: 2014-08-19 Created: 2014-08-19 Last updated: 2017-12-05Bibliographically approved
In thesis
1. Who died, where, when and why?: an investigation of HIV-related mortality in rural South Africa
Open this publication in new window or tab >>Who died, where, when and why?: an investigation of HIV-related mortality in rural South Africa
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background

South Africa has experienced the most severe consequences of the HIV/AIDS pandemic. Every community has been affected in some way, many experiencing huge increases in mortality,particularly before antiretroviral therapies (ART) were readily available. However, the micro-level understanding of the HIV epidemic in South Africa is weak, because of a lack of detailed data for most of the population. This thesis is based on detailed individual follow-up in the Agincourt Health and Demographic Surveillance Site (HDSS) located in the Agincourt subdistrict of Mpumalanga Province and investigates micro-level determinants of HIV epidemiology and the impact of treatment provided.

Methods

The Agincourt HDSS has followed a geographically defined population since 1992,approximately the time when the HIV/AIDS epidemic first became apparent. This population based surveillance has included capturing details of all deaths, with cause of death determined by verbal autopsy, as well as the geographical location of individual households within the overall Agincourt area. Background information on the roll-out of ART over time was also recorded.

Results

A comparison immediately before and after the major roll-out of ART showed a substantial decrease in HIV-related mortality, greater in some local communities within the area than others. Individual determinants associated with a decreased risk of HIV/AIDS mortality included proximity to ART services, as well as being female, younger, and in higher socioeconomic and educational strata. There was a decrease in the use of traditional healthcare sources and an increase in the use of biomedical healthcare amongst those dying of HIV/AIDS between periods before and after the roll-out of ART.

Conclusions

Understanding micro-level determinants of HIV/AIDS infection and mortality was very important in terms of characterising the overall epidemic in this community. This approach will enable public health interventions to be more effectively targeted towards those who need them most in the continuing evolution of the HIV/AIDS epidemic.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2015. 81 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1736
Keyword
HIV, AIDS, Mortality, Determinants, Risk Factor, Spatial Epidemiology, Structural Determinant, Antiretroviral Therapy, Healthcare Access, South Africa, Sub-Saharan Africa, Traditional Medical Practitioner, Traditional Medicine, Tuberculosis, Health and Demographic Surveillance System, Global Health, Population Health, Epidemiology
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Epidemiology
Identifiers
urn:nbn:se:umu:diva-108610 (URN)978-91-7601-309-0 (ISBN)
Public defence
2015-10-09, Room 135 Building 9A, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2006–1512Wellcome trust, 058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z
Available from: 2015-09-18 Created: 2015-09-14 Last updated: 2015-10-14Bibliographically approved

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