The impact of antiretroviral treatment on mortality trends of HIV-positive adults in rural Uganda: a longitudinal population-based study, 1999-2009

Objective To investigate trends in all-cause adult mortality after the roll-out of an antiretroviral therapy (ART) programme in rural Uganda. Methods Longitudinal population-based cohort study of approximately 20 000 residents in rural Uganda. Mortality in adults aged 1559 years was determined for the 5-year period (19992003) before introduction of ART in January 2004 and for the 5-year period afterwards. Poisson regression was used to estimate mortality rate ratios (RRs) for the period before ART, 1 year after ART introduction (from January 2004 to January 2005) and more than 1 year after ART introduction. Trends in mortality were analysed by HIV status, age and sex. Results Before ART became available, the mortality rate (deaths per 1000 person-years) was 4.0 (95% CI = 3.34.8) among HIV-negative individuals and 116.4 (95% CI = 101.9133.0) among HIV-positive individuals. During the period January 2004end November 2009, 279 individuals accessed ART. In the year after ART was introduced, the mortality rate (deaths per 1000 person-years) among HIV-negative individuals did not change significantly (adjusted RR = 0.95, 95% CI = 0.611.47), but among HIV-positive individuals dropped by 25% to 87.4 (adjusted RR = 0.75, 95% CI = 0.531.06). In the period 20052009, the mortality rate (deaths per 1000 person-years) among HIV-positive individuals fell further to 39.9 (adjusted RR = 0.33, 95% CI = 0.260.43). The effect was greatest among individuals aged 3044 years, and trends were similar in men and women. Conclusion The substantially reduced mortality rate among HIV-positive individuals after ART roll-out lends further support to the intensification of efforts to ensure universal access to ART.