Trends in the burden of HIV mortality after roll-out of antiretroviral therapy in KwaZulu-Natal, South Africa: an observational community cohort study

Background: Antiretroviral therapy (ART) substantially decreases morbidity and mortality in people living with HIV. In this study, we describe population-level trends in the adult life expectancy and trends in the residual burden of HIV mortality after the roll-out of a public sector ART programme in KwaZulu-Natal, South Africa, one of the populations with the most severe HIV epidemics in the world. Methods: Data come from the Africa Centre Demographic Information System (ACDIS), an observational community cohort study in the uMkhanyakude district in northern KwaZulu-Natal, South Africa. We used non-parametric survival analysis methods to estimate gains in the population-wide life expectancy at age 15 years since the introduction of ART, and the shortfall of the population-wide adult life expectancy compared with that of the HIV-negative population (ie, the life expectancy deficit). Life expectancy gains and deficits were further disaggregated by age and cause of death with demographic decomposition methods. Findings: Covering the calendar years 2001 through to 2014, we obtained information on 93 903 adults who jointly contribute 535 428 person-years of observation to the analyses and 9992 deaths. Since the roll-out of ART in 2004, adult life expectancy increased by 15 . 2 years for men (95% CI 12 - 4-17 . 8) and 17 . 2 years for women (14 - 5-20 . 2). Reductions in pulmonary tuberculosis and HIV-related mortality account for 79 . 7% of the total life expectancy gains in men (8 . 4 adult life-years), and 90 . 7% in women (12 . 8 adult life-years). For men, 9 . 5% is the result of a decline in external injuries. By 2014, the life expectancy deficit had decreased to 1 . 2 years for men (-2 . 9 to 5 . 8) and to 5 . 3 years for women (2 . 6-7 . 8). In 2011-14, pulmonary tuberculosis and HIV were responsible for 84 . 9% of the life expectancy deficit in men and 80 . 8% in women. Interpretation: The burden of HIV on adult mortality in this population is rapidly shrinking, but remains large for women, despite their better engagement with HIV-care services. Gains in adult life-years lived as well as the present life expectancy deficit are almost exclusively due to differences in mortality attributed to HIV and pulmonary tuberculosis.