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Steep declines in population-level AIDS mortality following the introduction of antiretroviral therapy in Addis Ababa, Ethiopia

Reniers, Georgesa,b,c; Araya, Tekebashd; Davey, Gaild; Nagelkerke, Nicoe; Berhane, Yemaned,f; Coutinho, Roelg,h; Sanders, Eduard Ji,j

doi: 10.1097/QAD.0b013e32832403d0
Epidemiology and Social

Objectives: Assessments of population-level effects of antiretroviral therapy (ART) programmes in Africa are rare. We use data from burial sites to estimate trends in adult AIDS mortality and the mitigating effects of ART in Addis Ababa. ART has been available since 2003, and for free since 2005.

Methods: To substitute for deficient vital registration, we use surveillance of burials at all cemeteries. We present trends in all-cause mortality, and estimate AIDS mortality (ages 20–64 years) from lay reports of causes of death. These lay reports are first used as a diagnostic test for the true cause of death. As reference standard, we use the cause of death established via verbal autopsy interviews conducted in 2004. The positive predictive value and sensitivity are subsequently used as anchors to estimate the number of AIDS deaths for the period 2001–2007. Estimates are compared with Spectrum projections.

Results: Between 2001 and 2005, the number of AIDS deaths declined by 21.9 and 9.3% for men and women, respectively. Between 2005 and 2007, the number of AIDS deaths declined by 38.2 for men and 42.9% for women. Compared with the expected number in the absence of ART, the reduction in AIDS deaths in 2007 is estimated to be between 56.8 and 63.3%, depending on the coverage of the burial surveillance.

Conclusion: Five years into the ART programme, adult AIDS mortality has been reduced by more than half. Following the free provision of ART in 2005, the decline accelerated and became more sex balanced. Substantial AIDS mortality, however, persists.

aPopulation Program, Institute of Behavioral Science, University of Colorado, Boulder, Colorado, USA

bSchool of Social Sciences and School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

cOffice of Population Research, Woodrow Wilson School of Public and International Affairs, Princeton University, New Jersey, USA

dSchool of Public Health, Addis Ababa University, Addis Ababa, Ethiopia

eDepartment of Community Medicine, United Arab Emirates University, Al Ain, UAE

fAddis Continental Institute of Public Health, Ethiopia

gCenter for Infectious Disease Control, National Institute for Public Health and the Environment, The Netherlands

hAcademic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

iCentre for Geographic Medicine Research-Coast, Kenya Medical Research Institute, Kenya

jCentre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.

Received 8 September, 2008

Revised 20 November, 2008

Accepted 22 November, 2008

Correspondence to Georges Reniers, Population Program, Institute of Behavioral Science, University of Colorado, 1424 Broadway, IBS #3, Boulder, CO 80309-0484, USA. Tel: +1 303 492 2111; e-mail:

© 2009 Lippincott Williams & Wilkins, Inc.