Post on 17-Dec-2015
Assessment of PEPFAR’s Impact on Selected Health System Parameters
in Sub-Saharan African Countries
Presented by: Anya ShenViviane D. Lima, Wendy Zhang, Carly Heung, Alexis Palmer, Julio Montaner,
Robert Hogg, Nathan Ford, Edward Mills
MOAE0101
Overview
• PEPFAR results by September 2008 Supported treatment for more than 2.1 million peopleOverall HIV prevention estimates unknown. Estimated
240,000 mother-to-child transmissions averted10.1 million people received care globally
• Other published studiesDecreased HIV-related deaths in PEPFAR focus countries in
Sub-Saharan Africa comparing to other countries in the same region1
• ‘The President’s Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes’ Bendavid, et all. 2009
Research Objectives
• PEPFAR is a vertical program• There is a need to investigate the effect that disease-
specific vertical programs have on health systems and population health
• The objective:– Assessment of PEPFAR’s impact on selected population
health parameters in Sub-Saharan African countries
MethodsFocus countries: Botswana, Cote d’lvoire, Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Zambia
Control countries: Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Democratic Republic of Congo, Djibouti, Eritrea, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Lesotho, Liberia, Madagascar, Malawi, Mali, Niger, Senegal, Sierra Leone, Somalia, Sudan, Swaziland, Togo, Zimbabwe
Focus
Control
Methods• Longitudinal data collected from WHO, UN, World
Bank, US Census Bureau• Time frame
1. Pre-PEPFAR era [1999-2002]2. PEPFAR era [2004-2007]
• Comparison of trends in focus and control countries before and after the initiation of PEPFAR programs
• Mixed-effects Models, General Linear Regression Models
Mean Change between Pre-PEPFAR era and PEPFAR era, CI
Comparison of Mean Change between Focus and Control, CI*
P-value
Focus -10.76 (-13.49, -8.03 )* -5.14(-0.63, -9.66)* P=.0028
Control -5.62(-7.40, -3.83)*
60
80
100
120
140
160
180
1999 2000 2001 2002 2003 2004 2005 2006 2007
Un
der
5 M
ort
ali
ty R
ate
(p
er
1,0
00
liv
e b
irth
s)
Year
Under 5 Mortality Rate
Focus
Control
40
50
60
70
80
90
100
110
1999 2000 2001 2002 2003 2004 2005 2006 2007
Infa
nt M
ort
ali
ty R
ate
(per
10
0,0
00
li
ve b
irth
s)
Year
I nfant Mortality Rate
Focus
Control
Average Change between Pre-PEPFAR era and PEPFAR era, CI
Comparison of Average Change between Focus and Control, CI
P-value
Focus -3.18 (-5.50, -0.86)* 1.61(-2.21, 5.42) P=.246
Control -4.79(-6.28, -3.29)*
400
500
600
700
800
900
1999 2000 2001 2002 2003 2004 2005 2006 2007
Mate
rnal
Mort
ality
Rate
(p
er
10
0,0
00
liv
e
bir
ths)
Year
Maternal Mortality Rate
Focus
Control
Average Change between Pre-PEPFAR era and PEPFAR era, CI
Comparison of Average Change between Focus and Control, CI
P-value
Focus -43.46 (-68.21, -18.71 )* -6.58(-47.26, 34.09) P=.653
Control -36.88 (-52.80, -20.95)*
47
48
49
50
51
52
53
1999 2000 2001 2002 2003 2004 2005 2006 2007
Lif
e E
xp
ect
an
cy
Year
Life Expectancy
Focus
Control
Average Change between Pre-PEPFAR era and PEPFAR era, CI
Comparison of Average Change between Focus and Control, CI
P-value
Focus 0.42 (-0.20, 1.04) -0.08 (-1.10, 0.94) P=.825
Control 0.50 (0.10, 0.90)*
Pre-PEPARMean Annual Change (1999-2002)
PEPFARMean Annual Change (2004-2007)
Difference in Mean Annual Change between Two Eras*
Focus -0.30(-0.65, -0.05)* 0.81(0.52, 1.10)* 1.11(0.57, 1.75)*
Control 0.18(0.04, 0.41)* 0.45(0.37, 0.54)* 0.27(-0.04, 0.50)
47
48
49
50
51
52
53
1999 2000 2001 2002 2003 2004 2005 2006 2007
Lif
e E
xp
ect
an
cy
Year
Life Expectancy
Focus
Control
PRE-PEPFARMean Annual Change (1999-2002)
PEPFARMean Annual Change (2004-2007)
Difference in Mean Annual Change between Two Eras
Focus 2.95(-3.70 to 9.59) -2.52(-5.01 to -0.02)* -5.47(-14.60 to 3.68)
Control -1.31(-6.41 to 3.80) 3.26(-5.75 to 12.26) 3.26(-5.75 to 12.26)
HIV/TB Related Death Rate
20
30
40
50
60
70
80
90
100
1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
HIV
/TB
De
ath
Rat
e
FocusControl
60
70
80
90
100
110
120
130
140
1999 2000 2001 2002 2003 2004 2005 2006 2007
TB
Death
Rate
Year
TB Death Rate
Focus
Control
Pre-PEPFARMean Annual Change
(1999-2002)
PEPFARMean Annual
Change (2004-2007)
Difference in Mean Annual Change between Two Eras
Focus 5.52(-2.09 to 13.12) -3.41(-6.22 to -0.60)* -8.93(-19.34 to -1.49)*
Control -1.33(-7.21 to 4.55) 2.64(-1.74 to 7.03) 3.97(-2.81 to 14.24)
200
250
300
350
400
450
500
550
1999 2000 2001 2002 2003 2004 2005 2006 2007
TB
In
cid
en
ce R
ate
Year
TB I ncidence Rate
Focus
Control
Pre-PEPFARMean Annual Change
(1999-2002)
PEPFARMean Annual
Change (2004-2007)
Difference in Mean Annual rate of Change
between Two Eras
Focus 32.45(23.94, 40.97)* -13.21(-17.86, -8.57)* -45.66(-58.83, -32.51)*
Control 15.89(11.25, 20.53)* 2.44(-0.30, 5.17) -13.45(-20.83, -6.08)*
Mean Annual Change (1999-2002)
Mean Annual Change (2004-2007)
Difference in Mean Annual Change between Two Eras
Focus 18.84(11.01, 26.67)* -8.36(-11.81, -4.90)* -27.20(-38.48, -15.91)*
Control 8.29(4.51, 12.08)* -0.20(-2.04, 1.63)* -8.49(-2.88, 14.12)*
0
50
100
150
200
250
300
350
1999 2000 2001 2002 2003 2004 2005 2006 2007
HIV
/TB
Inci
denc
e R
ate
Year
HI V/ TB I ncidence Rate
Focus
Control
Limitations
• Other confounders - Global Fund• Countries not picked at random & significant
baseline differences.• Population-based survey estimates in resource
limited countries have the potential for bias and problems with results based on aggregated measures.
• Lack of data in key indicators.• Lack of continuous data.
Conclusion• This analysis demonstrates the impact of PEPFAR
funding on mortality rates & population health indicators in Sub-Saharan Africa
• A significantly improving trend is shown in U5MR and Life Expectancy in PEPFAR-focus countries when compared with control countries
• Positive trends are evident in maternal mortality (though non-sig) rates in focus countries from Pre-PEPFAR era to PEPFAR era.
Acknowledgement
• The author would like to thank Dr. Viviane D Lima and Wendy Zhang for their statistical support, co-authors and the rest of the BC Centre for Excellence staff for their support and encouragement.
• Special thanks to Dr. Edward Mills for his encouragement and guidance for without which this project would not have been started.