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.