Decreased HIV-associated mortality rates during scale-up of antiretroviral therapy, 2011-2016: a population-based cohort study.

OBJECTIVE: HIV-associated mortality rates in Africa decreased by 10%-20% annually in 2003-2011, after the introduction of antiretroviral therapy (ART). We sought to document HIV-associated mortality rates in the general population in Kenya after 2011 in an era of expanded access to ART.

DESIGN: We obtained data on mortality rates and migration from a health and demographic surveillance system (HDSS) in Gem, western Kenya, and data for HDSS residents aged 15-64 years from home-based HIV-counseling and testing (HBCT) rounds in 2011, 2012, 2013, and 2016.

METHODS: Mortality trends were determined among a closed cohort of residents who participated in at least the 2011 round of HBCT.

RESULTS: Of 32,467 eligible HDSS residents, 22,688 (70%) participated in the 2011 round and comprised the study cohort. All-cause mortality rates declined from 10.0 (95% confidence interval [CI] 8.4-11.7) per 1000 in 2011 to 7.4 (95% CI 5·7-9·0) in 2016, while the mortality rate was stable among HIV-uninfected residents, at 5.7 per 1000 person-years. Among HIV-infected residents, mortality rates declined from 30.5 per 1000 in 2011 to 15.9 per 1000 in 2016 (average decline, 6% per year). The HIV-infected group receiving ART had higher mortality rates than the HIV-uninfected group (adjusted rate ratio (aRR), 2.8; 95% CI 2.2-3.4), as did the HIV-infected group who did not receive ART (aRR, 5.3; 95% CI 4.5-6.2).

CONCLUSIONS: Mortality rates among HIV-infected individuals declined substantially during ART expansion between 2011 and 2016, though less than during early ART introduction. Mortality trends among HIV-infected populations are critical to understanding epidemic dynamics.