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African countries that received more intensive assistance from PEPFAR show decline in death rate

The JAMA Network Journals

Between 2004 and 2008, all-cause adult mortality declined more in African countries in which the AIDS relief program PEPFAR operated more intensively, according to a study in the May 16 issue of JAMA, a theme issue on Global Health.

"The effect of global health initiatives on population health is uncertain. Between 2003 and 2008, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the largest initiative ever devoted to a single disease, operated intensively in 12 African focus countries," according to background information in the article. PEPFAR has targeted the rapidly expanding human immunodeficiency virus (HIV) epidemic with a coordinated effort to increase HIV treatment, prevention, and care. PEPFAR scaled up the delivery of expanded antiretroviral therapy (ART) and supported large-scale prevention efforts. The initiative's effect on all-cause adult mortality has not been known.

Eran Bendavid, M.D., M.S., of Stanford University, Stanford, Calif., and colleagues examined the relationship between PEPFAR's implementation and trends in adult mortality. Using person-level data from the Demographic and Health Surveys (DHS), the researchers conducted cross-country and within-country analyses of adult mortality (annual probability of death per 1,000 adults between 15 and 59 years old) and PEPFAR activities. Across countries, adult mortality was compared in 9 African focus countries (Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, Tanzania, Uganda, and Zambia) with adult mortality in 18 African nonfocus countries from 1998 to 2008.

The study included data on 1,538,612 African adults collected from 41 surveys conducted in 27 countries between 1998 and 2008. During this time period, 60,303 deaths were captured in the DHS used in this study. Analysis of the data indicated relatively greater mortality declines among adults living in focus countries between 2004 and 2008, with mortality in the focus countries declining from 8.30 per 1,000 adults in 2003 to 4.10 per 1,000 in 2008. The mortality trends in nonfocus countries did not show a similar decline during the study period (from 8.5 in 2003 to 6.9 in 2008). After adjustments for country-level and personal characteristics, the odds of all-cause death was lower in the focus countries.

The authors also examined district-level data for Tanzania and Rwanda. High and low PEPFAR activity districts had similar populations, but program intensity was significantly different between the groups. Adults in Tanzania living in the regions with above-median (midpoint) PEPFAR intensity had a lower odds of mortality compared with adults living in regions with below-median intensity; in Rwanda, the similar comparison also revealed a lower odds of mortality for adults living in the regions with above-median PEPFAR intensity.

The researchers also found that, using the results for each focus country and generalizing to the size of each country's adult population, an estimated total of 740,914 all-cause adult deaths were averted between 2004 and 2008 in association with PEPFAR. In comparison, PEPFAR was associated with an estimated 631,338 HIV-specific deaths averted during the same period.

"In conclusion, we provide new evidence suggesting that reductions in all- cause adult mortality were greater in PEPFAR's focus countries relative to the nonfocus countries over the time period from 2004 through 2008. Our analysis suggests an association of PEPFAR with these improvements in population health," the authors write.

(JAMA. 2012;307[19]:2060-2067. Available pre-embargo to the media at

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Please Note: For this study, there will be multimedia content available, including the JAMA Report video, embedded and downloadable video, audio files, text, documents, and related links. This content will be available at 3 p.m. CT Tuesday, May 15 at this link.

Editorial: PEPFAR and Maximizing the Effects of Global Health Assistance

In an accompanying editorial, Ezekiel J. Emanuel, M.D., Ph.D., of the University of Pennsylvania, Philadelphia, writes that the "article by Bendavid et al is welcome news in helping to document the even greater benefits of PEPFAR not only on HIV/AIDS but on overall mortality in countries."

"However, the further question that must be asked by ethically responsible people and policy makers becomes: Is PEPFAR worth it? Many other global health programs are improving the health of poor people worldwide but are not funded anywhere near the level of PEPFAR. The fundamental ethical, economic, and policy question is not whether PEPFAR is doing good, but rather whether other programs would do even more good in terms of saving life and improving health. Clearly, besides treatment for HIV/AIDS, there are other highly effective and lower-cost interventions for the world's poor."

(JAMA. 2012;307[19]:2097-2099. Available pre-embargo to the media at

Editor's Note: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Emanuel reported receiving payment for speaking engagements unrelated to this work.


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