Mass HIV Treatment and Sex Disparities in Life Expectancy: Demographic Surveillance in Rural South Africa

Background

Women have better patient outcomes in HIV care and treatment than men in sub-Saharan Africa. We assessed—at the population level—whether and to what extent mass HIV treatment is associated with changes in sex disparities in adult life expectancy, a summary metric of survival capturing mortality across the full cascade of HIV care. We also determined sex-specific trends in HIV mortality and the distribution of HIV-related deaths in men and women prior to and at each stage of the clinical cascade.

Methods and Findings

Data were collected on all deaths occurring from 2001 to 2011 in a large population-based surveillance cohort (52,964 women and 45,688 men, ages 15 y and older) in rural KwaZulu-Natal, South Africa. Cause of death was ascertained by verbal autopsy (93% response rate). Demographic data were linked at the individual level to clinical records from the public sector HIV treatment and care program that serves the region. Annual rates of HIV-related mortality were assessed for men and women separately, and female-to-male rate ratios were estimated in exponential hazard models. Sex-specific trends in adult life expectancy and HIV-cause-deleted adult life expectancy were calculated. The proportions of HIV deaths that accrued to men and women at different stages in the HIV cascade of care were estimated annually.Following the beginning of HIV treatment scale-up in 2004, HIV mortality declined among both men and women. Female adult life expectancy increased from 51.3 y (95% CI 49.7, 52.8) in 2003 to 64.5 y (95% CI 62.7, 66.4) in 2011, a gain of 13.2 y. Male adult life expectancy increased from 46.9 y (95% CI 45.6, 48.2) in 2003 to 55.9 y (95% CI 54.3, 57.5) in 2011, a gain of 9.0 y. The gap between female and male adult life expectancy doubled, from 4.4 y in 2003 to 8.6 y in 2011, a difference of 4.3 y (95% CI 0.9, 7.6). For women, HIV mortality declined from 1.60 deaths per 100 person-years (95% CI 1.46, 1.75) in 2003 to 0.56 per 100 person-years (95% CI 0.48, 0.65) in 2011. For men, HIV-related mortality declined from 1.71 per 100 person-years (95% CI 1.55, 1.88) to 0.76 per 100 person-years (95% CI 0.67, 0.87) in the same period. The female-to-male rate ratio for HIV mortality declined from 0.93 (95% CI 0.82–1.07) in 2003 to 0.73 (95% CI 0.60–0.89) in 2011, a statistically significant decline (p = 0.046). In 2011, 57% and 41% of HIV-related deaths occurred among men and women, respectively, who had never sought care for HIV in spite of the widespread availability of free HIV treatment. The results presented here come from a poor rural setting in southern Africa with high HIV prevalence and high HIV treatment coverage; broader generalizability is unknown. Additionally, factors other than HIV treatment scale-up may have influenced population mortality trends.

Conclusions

Mass HIV treatment has been accompanied by faster declines in HIV mortality among women than men and a growing female–male disparity in adult life expectancy at the population level. In 2011, over half of male HIV deaths occurred in men who had never sought clinical HIV care. Interventions to increase HIV testing and linkage to care among men are urgently needed.     

The Promise of Prevention: The Effects of Four Preventable Risk Factors on National Life Expectancy and Life Expectancy Disparities by Race and County in the United States

Background

There has been substantial research on psychosocial and health care determinants of health disparities in the United States (US) but less on the role of modifiable risk factors. We estimated the effects of smoking, high blood pressure, elevated blood glucose, and adiposity on national life expectancy and on disparities in life expectancy and disease-specific mortality among eight subgroups of the US population (the “Eight Americas”) defined on the basis of race and the location and socioeconomic characteristics of county of residence, in 2005.

Methods and Findings

We combined data from the National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System to estimate unbiased risk factor levels for the Eight Americas. We used data from the National Center for Health Statistics to estimate age–sex–disease-specific number of deaths in 2005. We used systematic reviews and meta-analyses of epidemiologic studies to obtain risk factor effect sizes for disease-specific mortality. We used epidemiologic methods for multiple risk factors to estimate the effects of current exposure to these risk factors on death rates, and life table methods to estimate effects on life expectancy. Asians had the lowest mean body mass index, fasting plasma glucose, and smoking; whites had the lowest systolic blood pressure (SBP). SBP was highest in blacks, especially in the rural South—5–7 mmHg higher than whites. The other three risk factors were highest in Western Native Americans, Southern low-income rural blacks, and/or low-income whites in Appalachia and the Mississippi Valley. Nationally, these four risk factors reduced life expectancy at birth in 2005 by an estimated 4.9 y in men and 4.1 y in women. Life expectancy effects were smallest in Asians (M, 4.1 y; F, 3.6 y) and largest in Southern rural blacks (M, 6.7 y; F, 5.7 y). Standard deviation of life expectancies in the Eight Americas would decline by 0.50 y (18%) in men and 0.45 y (21%) in women if these risks had been reduced to optimal levels. Disparities in the probabilities of dying from cardiovascular diseases and diabetes at different ages would decline by 69%–80%; the corresponding reduction for probabilities of dying from cancers would be 29%–50%. Individually, smoking and high blood pressure had the largest effect on life expectancy disparities.

Conclusions

Disparities in smoking, blood pressure, blood glucose, and adiposity explain a significant proportion of disparities in mortality from cardiovascular diseases and cancers, and some of the life expectancy disparities in the US. Please see later in the article for the Editors'' Summary     

The Changing Gender Differences in Life Expectancy in Chinese Cities 2005-2010

Objectives

To analyze the gender difference in life expectancy in Chinese urban people and explore the age-specific and cause-specific contributions to the changing gender differences in life expectancy.

Methods

Data of life expectancy and mortality were obtained from “Annual statistics of public health in China.” The gender difference was analyzed by decomposition method, including age-specific decomposition and cause-specific decomposition.

Results

Women lived much longer than men in Chinese urban areas, with remarkable gains in life expectancy since 2005, respectively. The gender difference reached a peak in 2007. Mortality difference between men and women in the 60–79 age group made the largest contributions to the gender gap in life expectancy in all 6 years. Among causes of death, cancers, circulatory diseases and respiratory diseases made the largest contributions to the gender gap. 33–38% of the gender gap were caused by cancers, among which lung cancer contributed 0.6 years of the overall gap. The contribution of cancers to the gender gap reduced over time, mostly influenced by the narrowing effect of liver cancer on gender gap. Traffic accidents and suicide were the external causes influencing the gender gap, contributing 10–16% of the overall difference.

Conclusion

Public health efforts to reduce excess mortalities for cancers, circulatory disease, respiratory diseases, and suicide among men in particular might further narrow the gender gap in life expectancy in Chinese cities.     

Effects of Insufficient Physical Activity on Mortality and Life Expectancy in Jiangxi Province of China, 2007-2010

Background

Physical inactivity remains an under-researched field in terms of studying burden of disease at provincial level, and no studies have examined the effects of inactivity on life expectancy (LE) in China. The purpose of this study was to estimate mortality risk and LE effects associated with insufficient levels of physical activity in Jiangxi province.

Methods/Findings

Prevalence of risk factors and mortality counts were extracted from Chronic Diseases and Risk Factors Surveillance Survey (CDRFSS) and Disease Surveillance Points system (DSP), respectively. Insufficient physical activity (IPA) was defined as less than 150 minutes of moderate-intensity physical activity or 60 minutes of vigorous-intensity physical activity per week, accumulated across work, home, transport and discretionary domains. Population-attributable fractions (PAF) were used to calculate the mortality attributable to risk factors, and life table methods were used to estimate the LE gains and LE shifts. Monte Carlo simulation techniques were used for uncertainty analysis. Overall, 5 885 (95% uncertainly interval (UI), 5 047–6 506) and 8 578 (95% UI, 8 227–9 789) deaths in Jiangxi province were attributable to IPA in 2007 and 2010, respectively. The LE gains for elimination of attributable deaths were 0.68 (95% UI, 0.61–076) in 2007, and increased to 0.91 (95% UI, 0.81–1.10) in 2010. If the prevalence of IPA in 2010 had been decreased by 50% or 30%, 3 678 (95% UI, 3 220–4 229) or 2 090 (95% UI, 1 771–2 533) deaths would be avoided, and 0.40 (95% UI, 0.34–0.53) or 0.23 (95% UI, 0.16–0.31) years of LE gained, respectively.

Conclusions

Adults in Jiangxi province of China have a high and increasing prevalence of IPA. Due to the deaths and potential LE gains associated with IPA, there is an urgent need to promote physical activity, one of the most modifiable risk factors, within China''s health care reform agenda.     

Overweight,Medical Comorbidity and Health‐related Quality of Life in a Community Sample of Women and Men

Associations among gender, overweight and obesity, medical comorbidity, and health‐related quality of life (HRQoL) were examined in a general population sample of 4,181 women and men aged 18–65 years. Anthropometric measurements and medical comorbidity were assessed as part of a computer‐assisted physician interview. HRQoL was assessed with the Physical and Mental Component Summary scales of the Medical Outcomes Study Short Form (SF‐36 PCS, MCS). General linear models were used to examine the associations among gender, weight status, medical comorbidity, and HRQoL. Controlling for age, social status, the occurrence of specific medical conditions, and the total number of medical conditions, mild obesity was associated with impairment in physical health functioning, as measured by the PCS, among women, whereas impairment in men's physical health was apparent only for moderate obesity. There was no association between weight status and psycho‐social functioning, as measured by the MCS, in women, whereas overweight was associated with better perceived psycho‐social functioning in men. The findings are consistent with the hypothesis that w omen suffer a disproportionately large share of the disease burden of overweight and obesity that is not due solely to differences in medical comorbidity. The possibility that aspects of emotional well‐being may mediate the association between obesity and physical health functioning warrants further attention in this regard. The findings also indicate the need to stratify data by gender and to include more sensitive measures of psycho‐social functioning in future studies.     

Examining the Relationship between Life Expectancy,Reproduction, and Educational Attainment

Life history theory aims to explain the relationship between life events, recognizing that the fertility and growth schedules of organisms are dependent on environmental conditions and an organism’s ability to extract resources from its environment. Using models from life history theory, we predict life expectancy to be positively correlated with educational investments and negatively correlated with adolescent reproduction and total fertility rates. Analyses of UN data from 193 countries support these predictions and demonstrate that, although variation is evident across world regions, strong interactions exist among life expectancy, reproductive investments, and educational attainment, and these relationships occur independently of economic pressures and disease burdens. The interactions are strongest, however, in countries with a life expectancy of ≥60 years as these countries tend to have stable economies and a limited HIV/AIDS burden. These findings suggest that policies aimed at influencing education and reproductive decisions should consider environmental characteristics that drive people’s expectations about their longevity.     

Life Expectancy and the Timing of Life History Events in Developing Countries

Life history theory predicts that greater extrinsic mortality will lead to earlier and higher fertility. To test this prediction, I examine the relationship between life expectancy at birth and several proxies for life history traits (ages at first sex and first marriage, total fertility rate, and ideal number of children), measured for both men and women. Data on sexual behaviors come from the Demographic and Health Surveys (DHS). Two separate samples are analyzed: a cross-sectional sample of 62 countries and a panel sample that includes multiple cross-sectional panels from 48 countries. Multivariate regression analysis is used to control for potential confounding variables. The results provide only partial support for the predictions, with greater support among women than men. However, the prediction is not supported in sub-Saharan African countries, most likely owing to the nonequilibrium conditions observed in sub-Saharan Africa with respect to life expectancy. The applicability of the model to understanding HIV/AIDS risk behaviors is discussed.     

History, Power and Identity: Ethnogenesis in the Americas, 1492-1992

History, Power and Identity: Ethnogenesis in the Americas, 1492-1992. Jonathan D. Hill. ed. Iowa City: University of Iowa Press, 1996. 277 pp.     

Waist Circumference,BMI, Smoking,and Mortality in Middle‐Aged Men and Women

Objective: Measurement of waist circumference alone as a proxy of abdominal fat mass has been suggested as a simple clinical alternative to BMI for detecting adults with possible health risks due to obesity. Research Methods and Procedures: From 1993 to 1997, 27, 178 men and 29, 875 women, born in Denmark, 50 to 64 years of age, were recruited in the Danish prospective study Diet, Cancer and Health. By the end of the year 2000, 1465 deaths had occurred. We evaluated the relationship between waist circumference and BMI (simultaneously included in the model) and all‐cause mortality. We used Cox regression models to estimate the mortality‐rate ratios and to consider possible confounding from smoking. Results: Waist circumference among both men and women showed a strong dose‐response type of relationship with mortality when adjusted for BMI, whereas the low range of BMI was inversely associated with mortality when adjusted for waist circumference. A 10% larger waist circumference corresponded to a 1.48 (95% confidence interval: 1.36 to 1.61) times higher mortality over the whole range of waist circumference. The associations were independent of age and time since baseline examination. Restriction to never smokers showed a similar pattern, but a weakening of the associations. Discussion: Despite the high correlation between waist circumference and BMI, the combination may be very relevant in clinical practice because waist circumference for given BMI was a strong predictor of all‐cause mortality. The inverse association between BMI and mortality for given waist circumference was diminished in never smokers, particularly for high values of BMI.     

Homophily,Close Friendship,and Life Satisfaction among Gay,Lesbian, Heterosexual,and Bisexual Men and Women

Friends play important roles throughout our lives by providing expressive, instrumental, and companionate support. We examined sexual orientation, gender, and age differences in the number of friends people can rely on for expressive, instrumental, and companionate support. Additionally, we examined the extent to which people relied on same-gender versus cross-gender friends for these types of support. Participants (N = 25,185) completed a survey via a popular news website. Sexual orientation differences in number of same-gender and cross-gender friends were generally small or non-existent, and satisfaction with friends was equally important to overall life satisfaction for all groups. However, the extent to which people’s friendship patterns demonstrated gender-based homophily varied by sexual orientation, gender, and age. Young adult gay and bisexual men, and to some extent bisexual women and older bisexual men, did not conform to gendered expectations that people affiliate primarily with their own gender.     

Urinary Excretion of Silicon in Men,Non-pregnant Women,and Pregnant Women: a Cross-sectional Study

Biological Trace Element Research - Silicon is a trace element found mainly in plant-based food and proposed to be beneficial for bone health. Urinary excretion of Si has been shown to be a...     

Mortality Trends in Women and Men Presenting with Acute Coronary Syndrome: Insights from a 20-Year Registry

Background

Coronary artery disease (CAD) is the leading cause of mortality worldwide. The present study evaluated the impact of gender in patients hospitalized with acute coronary syndromes (ACS) over a 20-year period in Qatar.

Methods

Data were collected retrospectively from the registry of the department of cardiology for all patients admitted with ACS during the study period (1991–2010) and were analyzed according to gender.

Results

Among 16,736 patients who were admitted with ACS, 14262 (85%) were men and 2474 (15%) were women. Cardiovascular risk factors were more prevalent among women in comparison to men. On admission, women presented mainly with non-ST-elevation ACS and were more likely to be undertreated with β-blockers (BB), antiplatelet agents and reperfusion therapy in comparison to men. However, from 1999 through 2010, the use of aspirin, angiotensin-converting enzyme inhibitors and BB increased from 66% to 79%, 27% to 41% and 17% to 49%, respectively in women. In the same period, relative risk reduction for mortality was 64% in women and 51% in men. Across the 20-year period, the mortality rate decreased from 27% to 7% among the Middle Eastern Arab women. Multivariate logistic regression analysis showed that female gender was independent predictor of in-hospital mortality (odd ratio 1.51, 95% CI 1.27–1.79).

Conclusions

Women presenting with ACS are high-risk population and their in-hospital mortality remains higher for all age groups in comparison to men. Although, substantial improvement in the hospital outcome has been observed, guidelines adherence and improvement in the hospital care have not yet been optimized.     

Lifebuoy Men, Lux Women: Commodification, Consumption, and Cleanliness in Modern Zimbabwe

Lifebuoy Men, Lux Women: Commodification, Consumption, and Cleanliness in Modern Zimbabwe. Timothy Burke. Durham, NC: Duke University Press, 1996. 298 pp.