The scale-up of antiretroviral therapy has transformed the health of HIV-endemic populations in South Africa, with unprecedented gains in life expectancy (Bor et al. 2013) and significant reductions in HIV incidence (Tanser et al. 2013). To achieve the full potential benefits of ART scale-up, further evidence is needed on the pathways (behavioral vs. biological) through which ART coverage reduces incidence, and the reasons why so many people with HIV continue to die when life-saving ART is available. We will establish this evidence base through analysis of demographic and health surveillance data from rural KwaZulu-Natal. This research will inform interventions to maximize the impact of South Africa's ART program.

Public Health Relevance

: In two recent papers published in Science, we have demonstrated that public sector scale-up of ART in rural South Africa led to (i) large increases in adult life expectancy and (ii) significant declines in HIV infection risk, both measured at the population level (Bor et al. 2013; Tanser et al. 2013). And yet: HIV incidence and mortality rates remain unacceptably high in this HIV-endemic setting. To inform future implementation of ART programs, including under treatment-as-prevention scenarios, further evidence is needed in two areas: first, the mechanisms through which ART scale-up reduces HIV incidence - the 'pathways to prevention' - and in particular, the role of behavioral vs. biological pathways in determining community level incidence rates; and second, the reasons why people are still dying from HIV in the era of free and widely available ART. Information in these areas will inform wrap-around behavioral prevention interventions to augment treatment as prevention strategies and will shape efforts to improve outcomes across the cascade of HIV care and treatment. Evidence in these two areas will be critical to reducing the large lingering burden of HIV disease in South Africa. To establish this critical evidence base, we will analyze longitudinal health and demographic surveillance data collected by the Africa Centre for a complete population cohort in rural KwaZulu-Natal. These data include population-based HIV biomarker collection, data on sexual behaviors and ART knowledge and attitudes, and verbal autopsies to determine causes of all deaths in the population. Further, clinical records from the national ART program have been linked into the surveillance by national ID, enabling us to observe individuals as they progress through the complete cascade of HIV care, from HIV infection to recovery on ART, or death. Through epidemiological analysis, we will: determine the pathways through which high ART coverage reduces HIV incidence at the population level; and establish the determinants of HIV mortality in age of widespread ART availability. The study team is led by South Africa PI Frank Tanser, University of KwaZulu- Natal, and US PI Till Barnighausen, Harvard School of Public Health, and will support several mentored post- doctoral opportunities at the Africa Centre.

National Institute of Health (NIH)
Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD)
Research Project (R01)
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AIDS Clinical Studies and Epidemiology Study Section (ACE)
Program Officer
White, Della
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Kwazulu-Natal Research Institute Tb-HIV
South Africa
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GBD 2016 Mortality Collaborators (2017) Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 390:1084-1150
Geldsetzer, Pascal; Bärnighausen, Till (2017) Late-stage research for diabetes and related NCDs receives little funding: evidence from the NIH RePORTER tool. Lancet Diabetes Endocrinol 5:91-92
Harling, Guy; Gumede, Dumile; Mutevedzi, Tinofa et al. (2017) The impact of self-interviews on response patterns for sensitive topics: a randomized trial of electronic delivery methods for a sexual behaviour questionnaire in rural South Africa. BMC Med Res Methodol 17:125
Chanda, Michael M; Ortblad, Katrina F; Mwale, Magdalene et al. (2017) Contraceptive use and unplanned pregnancy among female sex workers in Zambia. Contraception 96:196-202
Tomita, Andrew; Vandormael, Alain M; Bärnighausen, Till et al. (2017) Social Disequilibrium and the Risk of HIV Acquisition: A Multilevel Study in Rural KwaZulu-Natal Province, South Africa. J Acquir Immune Defic Syndr 75:164-174
Alcalde-Rabanal, Jacqueline Elizabeth; Nigenda, Gustavo; Bärnighausen, Till et al. (2017) The gap in human resources to deliver the guaranteed package of prevention and health promotion services at urban and rural primary care facilities in Mexico. Hum Resour Health 15:49
GBD 2016 SDG Collaborators (2017) Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals in 188 countries: an analysis from the Global Burden of Disease Study 2016. Lancet 390:1423-1459
GBD 2016 DALYs and HALE Collaborators (2017) Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 390:1260-1344
Maheu-Giroux, Mathieu; Tanser, Frank; Boily, Marie-Claude et al. (2017) Determinants of time from HIV infection to linkage-to-care in rural KwaZulu-Natal, South Africa. AIDS 31:1017-1024
Rosenberg, Molly S; Gómez-Olivé, Francesc X; Rohr, Julia K et al. (2017) Sexual Behaviors and HIV Status: A Population-Based Study Among Older Adults in Rural South Africa. J Acquir Immune Defic Syndr 74:e9-e17

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