We provide robust evidence that PEPFAR has been associated with a decline in all-cause adult mortality in the African countries where it operated most intensively. Our study utilizes direct evidence from surveys and individual-level reports of mortality. Sub-national analyses in Tanzania and Rwanda yield broadly consistent findings. Although the evidence for positive, negative, or no spillovers with respect to adult mortality is inconclusive, we note that overall, PEPFAR had been associated with improvements in adult mortality. As discussions about the role of US involvement in global health activities evolve, the implications and limitations of these findings deserve further consideration.
Several possible factors may have contributed to PEPFAR's apparent success. First, PEPFAR's investment has been larger than any previous commitment for a single disease. Development assistance for health has grown from about 4% of US development assistance in 1999 to over 20% by 2008, and PEPFAR accounts for a large share of this growth.1
Second, PEPFAR's structure was unusual, with its implementation relying on experienced non-governmental organizations and academic centers that were rewarded for reaching aggressive coverage targets. Finally, PEPFAR's comprehensive approach to scaling up treatment programs enabled a cogent set of related activities such as antiretroviral procurement processes and supply chain management.
Our estimates of all-cause adult deaths averted and HIV-specific deaths averted are consistent with either positive, negative, or no spillovers mortality effects associated with PEPFAR. Although the point estimate of the reduction in all-cause adult deaths is larger than the estimated reduction in HIV-related deaths, the confidence limits overlap broadly. The HIV-specific mortality benefits associated with PEPFAR were obtained from modeled estimates, making their direct comparison to all-cause mortality benefits uncertain.
The study's measurements and findings uniquely strengthen the topic's evidence base. A previous study concluded that PEPFAR was not associated with changes in adult mortality.12
That study, however, relied on more aggregated data from the years 2000 and 2006, limiting its ability to detect relative changes within the study period and not studying benefits that evolved more slowly over time (emerging after 2006, for example). Another study relied on modeled data to estimate mortality benefits, with lingering concerns about data validity.9,27
Our use of individual-level data over a longer period of time improves upon these limitations and advances the understanding of factors associated with adult mortality. We find that education of the index woman is associated with lower adult mortality. While the literature on the health benefits of personal education is extensive, we show that this effect is additionally present in siblings.28,29
We also find that a measure of government effectiveness suggests mortality is lower in countries with better governance. While the association between governance and indicators of population health such as child mortality has been previously demonstrated, its association with adult mortality has not been well established.30
Our findings are also notable for the consistent association between HIV development assistance and improvements in population health when many studies of development assistance programs fail to find meaningful changes in targeted outcomes.31,32
Other examples where assistance was associated with its intended goals have also been in the health arena, including smallpox eradication and control of polio.33,34
PEPFAR's success with HIV, however, may be the clearest demonstration of aid's effectiveness in recent years.
Our study has several limitations. First, other factors that coincide with PEPFAR's timing and geographic activity may confound the analysis. Notably, a different epidemic phase between the focus and non-focus countries could lead to earlier mortality declines in focus countries unrelated to PEPFAR. Our range of sensitivity analyses investigate this possibility, but we cannot fully rule out the possibility of phase offset. A successful treatment campaign, however, can alter the epidemic phase, maintaining the possible role played by PEPFAR in adult mortality improvements. Second, past work has shown that adult mortality estimation from surveys is biased by imperfect recall and under-representation of high-mortality families.18,35
Bias could also be introduced if adult mortality is underestimated in countries with high HIV mortality because of selection against sibships with HIV-infected index women. However, previous analyses suggest that the bias is approximately constant over time, limiting its role in this analysis.18
Third, not all the focus countries were included in this study. Botswana, South Africa, and Côte d'Ivoire did not have suitable data for this analysis – and the conclusions cannot therefore be generalized to all focus countries. Botswana and South Africa, in particular, carry a heavy HIV burden, and their omission could change PEPFAR's overall effect, though the direction of change is unclear. Fourth, our sub-national analyses cannot fully overcome the concern over unobserved confounders. Finally, we assumed that all siblings live within the same urban/rural environment as the index woman, as well as the same country (for cross-country analysis) or district (for sub-national analyses). We do not have evidence for or against this assumption's validity.
Overall, we provide new evidence suggesting that reductions in all-cause adult mortality were greater in PEPFAR's focus countries relative to the non-focus countries over the time period between 2004 and 2008. Our analysis suggests an association of PEPFAR with these improvements in population health. These benefits could have important implications for other domains of human welfare.36–39