Abstract Body

Background: Women have suffered the disproportionate burden of HIV infection in South Africa. However, with the scale-up of antiretroviral therapy (ART), women have been found to perform better throughout the “cascade of care”, including: higher rates of HIV testing, earlier ART initiation, better adherence and retention, and better clinical prognosis. To date, no study has assessed the implication of ART scale-up on sex-disparities in all-cause and HIV-specific mortality at the population level. Methodology: Demographic data on 54,477 women (6508 deaths from all causes and 3925 HIV-related deaths) and 46,809 men (6552 deaths from all causes and 3722 HIV-related deaths) were collected by health and demographic surveillance at the Africa Centre for Health and Population Studies for the period 2000-2011 for all members of all households in a 438 km2 surveillance area in rural KwaZulu-Natal. Cause of death was ascertained by verbal autopsy. Data were linked at the individual level to clinical records from the public-sector HIV treatment and care program. Annual rates of HIV-related and all-cause adult mortality were assessed separately for men and women. Annual female-to-male rate ratios were estimated in Poisson regression, with detailed controls for age. Trends in adult life expectancy and HIV-cause-deleted adult life expectancy were calculated. Finally, to illuminate opportunities for intervention, we assessed the proportion of HIV deaths in 2011 that accrued to men and women who had initiated ART, were in pre-ART care, or who never sought care for HIV in the public sector. Results: Following the beginning of ART scale-up in 2004, HIV mortality declined among both men and women. The female-to-male rate ratio for HIV mortality declined from 1.05 (95%CI 0.91-1.21) in 2004 to 0.75 (0.58-0.96) in 2011. Adult life expectancy improved for both men and women during the period of study (by 9.0 and 13.2 years respectively); however, the gap between female and male adult life expectancy nearly doubled (from about 4.5 years in 2004 to nearly 9 years in 2011). For men (women), 57% (41%) of HIV-related deaths occurred among persons who never sought care for HIV. Conclusions: ART scale-up has led to a much larger reduction in HIV mortality among women than among men, at the population level. A critical source of this disparity is the high number of deaths occurring among men who never seek clinical care for HIV. Further efforts to recruit men into HIV care and treatment are needed.