Evaluating Outcomes of the President's Emergency Plan for AIDS Relief in Africa
Authors: Julio S.G. Montaner
Journal: Annals of Internal Medicine (2010)

Letters19 January 2010Evaluating Outcomes of the President's Emergency Plan for AIDS Relief in AfricaJulio S.G. Montaner, MD, Viviane D. Lima, PhD, and Brian G. Williams, PhDJulio S.G. Montaner, MDFrom St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada; and South African Centre for Epidemiological Modelling and Analysis (SACEMA), Stellenbosch 7600, South Africa.Search for more papers by this author, Viviane D. Lima, PhDFrom St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada; and South African Centre for Epidemiological Modelling and Analysis (SACEMA), Stellenbosch 7600, South Africa.Search for more papers by this author, and Brian G. Williams, PhDFrom St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada; and South African Centre for Epidemiological Modelling and Analysis (SACEMA), Stellenbosch 7600, South Africa.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-152-2-201001190-00019 SectionsSupplemental MaterialAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:Bendavid and Bhattacharya (1) reported on PEPFAR and its positive effects on HIV-related prevalence and AIDS mortality in certain sub-Saharan African countries since its implementation in 2003. The authors compared trends in HIV prevalence (reported as the number of persons living with HIV infection) and AIDS mortality (reported as number of deaths) before and after the initiation of PEPFAR activities in 12 focus countries and 29 control counties that had a generalized HIV epidemic in 1997 to 2002 and 2004 to 2007. On the basis of 4 years of PEPFAR activity, AIDS mortality from 2004 to 2007 decreased the most in focus countries compared with control countries (10.5 percentage points lower; P = 0.001), and prevalence trends did not differ between groups (1.7 percentage points lower; P = 0.124).On the basis of these results, we hypothesized that PEPFAR activities would also be associated with decreased HIV incidence in focus countries. To test this hypothesis, we obtained raw prevalence data and AIDS and non-AIDS mortality data for adults and children from 1997 to 2006 from UNAIDS (2) and the U.S. Census Bureau (3) and population estimates from 1997 to 2006 from the U.S. Census Bureau (4). We used the following formula to estimate HIV incidence in each of the 41 countries from 1997 to 2006:Incidence (t0,t1) = Prevalence (t1) – Prevalence (t0) + AIDS Deaths (t0,t1) + Non-AIDS Deaths (t0,t1) (A)In brief, t0 is the beginning of the time interval, and t1 is the end of the time interval, for t0, t1 = 1997, …, 2007; with t0 < t1. Note that by using the formula (A), we were only able to estimate HIV incidence from 1997 to 2006.Appendix Figures 1 and 2 show HIV incidence from 1997 to 2006 by control countries and focus countries, respectively. A general trend is toward lower HIV incidence rates, with notable exceptions, including Lesotho, Sudan, Swaziland, and Togo among the control countries, and Kenya, Mozambique, Namibia, and Zambia among the focus countries. Overall, 28% (8 of 29) of the control countries and 50% (6 of 12) of the focus countries had decreased incidence from 2003 to 2006. Finally, the median percentage change in HIV incidence rate between 2003 and 2006 was 1.76 percentage points (interquartile range [IQR], −0.20 to 3.35 percentage points) for control countries and 0.96 percentage points (IQR, −2.41 to 23.56 percentage points) for focus countries.Several authors (5, 6) have recently postulated that expanded antiretroviral therapy coverage may play an important role in curbing the global spread of HIV. Our incidence estimates for focus and control countries are compatible with the postulated beneficial effect of treatment on the prevention of HIV transmission. However, caution should be exerted when using this ecological approach to evaluate these results, because the selection of focus and control countries was not random, PEPFAR comprises a number of activities not limited to the introduction of antiretroviral therapy, and PEPFAR is part of a complex national response. Therefore, given the breadth of PEPFAR-supported activities and the complex nature of the country-level response, further research and careful prospective monitoring of the relative contribution of interventions, such as expanded antiretroviral therapy, to the growth of the HIV epidemic is needed. Because of the current economic climate, scientific evidence regarding the relative effect of public health interventions is critical to inform public policy in attempts to control the spread of HIV.Julio S.G. Montaner, MDViviane D. Lima, PhDSt. Paul's Hospital, University of British ColumbiaVancouver, British Columbia, CanadaBrian G. Williams, PhDSouth African Centre for Epidemiological Modelling and AnalysisStellenbosch 7600, South AfricaReferences1. Bendavid E, Bhattacharya J. The President's Emergency Plan for AIDS Relief in Africa: an evaluation of outcomes. Ann Intern Med. 2009;150:688-95. [PMID: 19349625] LinkGoogle Scholar2. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2008 Report on the global AIDS epidemic. Accessed at www.unaids.org/en/KnowledgeCentre/HIVData/Epidemiology/latestEpiData.asp on 1 December 2009. Google Scholar3. U.S. Census Bureau. International Data Base. Table 008 Vital Rates and Events. Accessed at www.census.gov/ipc/www/idb/tables.html on 1 December 2009. Google Scholar4. U.S. Census Bureau. International Data Base. Table 001 Total Midyear Population. Accessed at www.census.gov/ipc/www/idb/tables.html on 1 December 2009. Google Scholar5. Montaner JS, Hogg R, Wood E, Kerr T, Tyndall M, Levy AR, et al. The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic. Lancet. 2006;368:531-6. [PMID: 16890841] CrossrefMedlineGoogle Scholar6. Granich RM, Gilks CF, Dye C, De Cock KM, Williams BG. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet. 2009;373:48-57. [PMID: 19038438] CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada; and South African Centre for Epidemiological Modelling and Analysis (SACEMA), Stellenbosch 7600, South Africa.Grant Support: By the Canadian Institutes of Health Research, Michael Smith Foundation for Health Research through Fellowship, and National Institutes of Health.Disclosures:Grants received: J.S.G. Montaner (Abbott, Argos Therapeutics, Bioject, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Hoffmann-La Roche, Janssen-Ortho, Merck Frosst, Panacos, Pfizer, Schering, Serono, Theratechnologies, Tibotec [Johnson & Johnson], Trimeris). PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoThe President's Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes Eran Bendavid and Jayanta Bhattacharya Evaluating Outcomes of the President's Emergency Plan for AIDS Relief in Africa Peter D. Johnson , Laura M. Heaton , Peter O. Way , Timothy B. Fowler , and Dianna M. Edgil Evaluating Outcomes of the President's Emergency Plan for AIDS Relief in Africa Eran Bendavid Evaluating Outcomes of the President's Emergency Plan for AIDS Relief in Africa Grace Sedio Metrics Cited ByTemporal Trends in Treatment Outcomes for HIV-1 and HIV-2-Infected Adults Enrolled in Côte d'Ivoire's National Antiretroviral Therapy Program 19 January 2010Volume 152, Issue 2Page: 131-132KeywordsAIDSAntiretroviral therapyHIVHIV infectionsHIV preventionHealth economicsPrevention, policy, and public healthPublic policy ePublished: 19 January 2010 Issue Published: 19 January 2010 CopyrightCopyright © 2010 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...