Life expectancy soars in Africa with introduction of antiretroviral drugs

BMJ 2013; 346 doi: (Published 21 February 2013) Cite this as: BMJ 2013;346:f1207
  1. Bob Roehr
  1. 1Washington

Antiretroviral (ARV) drugs for HIV have had a profound effect in Africa on patient treatment and society, two new studies show.

Adult life expectancy had fallen to 49.2 years in 2003 in KwaZulu-Natal, South Africa, based on a rural population cohort of more than 101 000 people who were hard hit by the disease and studied by experts from the Africa Center for Health and Population Studies.

Widespread use of ARV was introduced in September 2004, and life expectancy began to rebound almost immediately. According to the researchers’ study published in Science, life expectancy reached 60.5 years by 2011.1

Lead author Jacob Bor wrote, “The cost effectiveness ratio [of the ARV program] was $1593 [£1047; €1209] per life year saved, less than a quarter of South Africa’s 2011 per capita gross national income.

“Our estimates suggest that existing predictions of changes in adult life expectancy based on demographic models rather than directly observed data, as in our study, have substantially underestimated the effects of ARV scale-up on survival in HIV hyperendemic populations.”

The effect on society is even greater because untreated HIV morbidity and mortality disproportionately affects young adults in their prime earning years. By contrast, the authors argue, ARV reduces the number of new orphans, increases social stability, and for governments, “greatly increase the returns from investments in education and job training programs.”

In a second study published on 20 February, the United States Institute of Medicine (IOM) has evaluated the US HIV program known as PEPFAR (President’s Emergency Response for AIDS Relief).2

This evaluation was at the request of Congress to see whether the program, whose remit is about to expire this year, should be reauthorized.

The program has had a leading role in providing funding and technical support to help create the infrastructure possible to broadly expand the availability of ARV in Africa.

It has committed $54bn in support since its inception in 2003, either directly through bilateral aid programs or through the Global Fund to Fight AIDS, Tuberculosis, and Malaria.

The IOM study says, “PEPFAR has achieved—and in some cases surpassed—its initial ambitious aims. These efforts have saved and improved the lives of millions of people around the world. That success has in effect ‘reset’ the baseline and shifted global expectations for what can be achieved in partner countries.”

The PEPFAR program, says the study, must continue to shift from its initial emergency response to one that is more sustainable. The IOM makes recommendations in four main areas: “scaling up HIV programs, strengthening systems for the HIV response in partner countries, transitioning to a sustainable response in partner countries, and transforming knowledge management to improve effectiveness.”

Women are more likely than men to be infected with the virus. The report noted that “PEPFAR has placed a strong emphasis on addressing gender based violence, an important underlying driver of vulnerability in the HIV epidemic.”

Men who have sex with men are several times more likely to be infected than are other men,3 but the report summary mentioned them only briefly. Although the report made no specific recommendations for this population, it said that prevention should be “informed by epidemiological data and intervention effectiveness evidence. PEPFAR should support advances in prevention science to expand the availability of effective interventions where knowledge is lacking.”


Cite this as: BMJ 2013;346:f1207