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Letters |

PEPFAR and Adult Mortality—Reply

Eran Bendavid, MD, MS; Charles B. Holmes, MD, MPH; Grant Miller, PhD, MPP
JAMA. 2012;308(10):972-973. doi:10.1001/jama.2012.9249.
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In Reply: Dr Shelton is concerned about the possibility of overestimating the association of PEPFAR with mortality in the 2 most populous countries, Ethiopia and Nigeria. This concern is only relevant to the estimation of the number of deaths averted and not to the main estimation of the overall mortality risk reduction. Shelton's point about the expectation of smaller effect on all-cause adult mortality from expansion of antiretroviral therapy in places where HIV prevalence is low is well taken. However, our country-specific estimates were based on the difference in the predicted mortality rates with and without PEPFAR for each country. As a result, the estimates of number of deaths averted in each of the 9 focus countries ranged from 2.4% to 17.4%. Our estimates involved substantial uncertainty (95% CI, 443 300-1 808 500 deaths averted), and our point estimate (740 800) should be viewed in that context.

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Figure. Age-Adjusted Mortality by the President's Malaria Initiative (PMI) Partner Country Group
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Differential mortality trends are not obvious between PMI partner and non–PMI partner countries while PMI was implemented. A narrow-bandwidth (0.6) lowess curve was used to fit the trend. Lowess (locally weighted scatterplot smoothing) is a nonparametric method of fitting a curve using local regressions for each point. Error bars indicate 95% confidence intervals.

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September 12, 2012
James D. Shelton, MD, MPH
JAMA. 2012;308(10):972-973. doi:10.1001/jama.2012.9243.
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