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.
: 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.
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