The effect of gender on the long-term course and outcome of schizophrenia in rural Ethiopia: a population-based cohort.

BACKGROUND: Although some studies have suggested that women with schizophrenia are more likely to achieve positive outcomes, the evidence-base is fraught with inconsistencies. In this study we compare the long-term course and outcomes for men and women living with schizophrenia in rural Ethiopia. METHODS: The Butajira course and outcome study for severe mental disorders is a population-based cohort study. Community ascertainment of cases was undertaken between 1998 and 2001, with diagnostic confirmation by clinicians using the Schedules for Clinical Assessment in Neuropsychiatry. Findings from annual outcome assessments were combined with clinical records, patient and caregiver report, and psychiatric assessments at 10-13 years using the Longitudinal Interval Follow-up Evaluation- LIFE chart. For the sub-group of people with schizophrenia (n = 358), we compared course of illness and treatment, co-morbidity, recovery, social outcomes and mortality between men and women. Multivariable analyses were conducted for modelling associations identified in bivariate analyses according to blocks shaped by our a priori conceptual framework of the biological and social pathways through which gender might influence the course and outcome of schizophrenia. RESULTS: Looking into over 10-13 years of follow-up data, there was no difference in the functioning or recovery in women compared to men (AOR = 1.79, 95% CI = 0.91, 3.57). Women were less likely to report overall life satisfaction (AOR = 0.22, 95% CI = 0.09, 0.53) or good quality of spousal relationships (AOR = 0.09, 95% CI = 0.01-1.04). Men were more likely to have co-morbid substance use and there was a trend towards women being more likely to be prescribed an antidepressant (AOR = 2.38, 95% CI = 0.94, 5.88). There were no gender differences in the course of illness, number of psychotic episodes or adherence to medications. CONCLUSION: In this rural African setting, we found little evidence to support the global evidence indicating better course and outcome of schizophrenia in women. Our findings are suggestive of a gendered experience of schizophrenia which varies across contexts. Further investigation is needed due to the important implications for the development of new mental health services in low and middle-income country settings.

Excess mortality in severe mental illness: 10-year population-based cohort study in rural Ethiopia.

BACKGROUND: Evidence on mortality in severe mental illness (SMI) comes primarily from clinical samples in high-income countries. AIMS: To describe mortality in people with SMI among a population cohort from a low-income country. METHOD: We followed-up 919 adults (from 68 378 screened) with SMI over 10 years. Standardised mortality ratios (SMR) and years of life lost (YLL) as a result of premature mortality were calculated. RESULTS: In total 121 patients (13.2%) died. The overall SMR was twice that of the general population; higher for men and people with schizophrenia. Patients died about three decades prematurely, mainly from infectious causes (49.6%). Suicide, accidents and homicide were also common causes of death. CONCLUSIONS: Mortality is an important adverse outcome of SMI irrespective of setting. Addressing common natural and unnatural causes of mortality are urgent priorities. Premature death and mortality related to self-harm should be considered in the estimation of the global burden of disease for SMI.

Suicide and suicide attempts in people with severe mental disorders in Butajira, Ethiopia: 10 year follow-up of a population-based cohort.

BACKGROUND: People with severe mental disorders (SMD) are at higher risk of suicide. However, research into suicide attempts and completed suicide in people with SMD in low- and middle-income countries is mostly limited to patients attending psychiatric facilities where selection bias is likely to be high. METHODS: A population-based cohort of 919 people with SMD from rural Ethiopia (who received standardized clinician diagnoses of schizophrenia (n = 358) major depressive disorder (n = 216) and bipolar I disorder (n = 345)) were followed up annually for an average of 10 years. The Longitudinal Interval Follow-up Evaluation chart was administered by psychiatrists and used to evaluate systematically suicidal behavior and risk factors, which may be amenable to intervention. RESULTS: Over the follow-up period, the cumulative risk of suicide attempt was 26.3% for major depression, 23.8% for bipolar I disorder and 13.1% for schizophrenia, (p < 0.001). The overall incidence of completed suicide was 200.2/100,000 person-years (CI = 120.6, 312.5). Hanging was the most frequent method used (71.5%) for both attempters and completers. Most people who completed suicide were successful on the first attempt (84.2%), but the case-fatality rate for suicide attempt was 9.7%. In the adjusted logistic regression model, being currently married (Adjusted OR) =2.17, 95% CI = 1.21, 3.91), and having a diagnosis of bipolar I disorder (Adjusted OR = 2.59, 95% CI = 1.57, 4.26) or major depression (Adjusted OR = 2.71, 95% CI = 1.60, 4.58) were associated significantly with increased risk of suicide attempts. CONCLUSION: In this sample of people with SMD from a rural setting, the rate of suicide was high. Initiatives to integrate mental health service into primary care need to focus on limiting access to suicide methods in people with SMD in addition to expanding access to mental health care.

Studying the context of psychoses to improve outcomes in Ethiopia (SCOPE): Protocol paper.

BACKGROUND: Global evidence on psychosis is dominated by studies conducted in Western, high-income countries. The objectives of the Study of Context Of Psychoses to improve outcomes in Ethiopia (SCOPE) are (1) to generate rigorous evidence of psychosis experience, epidemiology and impacts in Ethiopia that will illuminate aetiological understanding and (2) inform development and testing of interventions for earlier identification and improved first contact care that are scalable, inclusive of difficult-to-reach populations and optimise recovery. METHODS: The setting is sub-cities of Addis Ababa and rural districts in south-central Ethiopia covering 1.1 million people and including rural, urban and homeless populations. SCOPE comprises (1) formative work to understand care pathways and community resources (resource mapping); examine family context and communication (ethnography); develop valid measures of family communication and personal recovery; and establish platforms for community engagement and involvement of people with lived experience; (2a) a population-based incidence study, (2b) a case-control study and (2c) a cohort study with 12 months follow-up involving 440 people with psychosis (390 rural/Addis Ababa; 50 who are homeless), 390 relatives and 390 controls. We will test hypotheses about incidence rates in rural vs. urban populations and men vs. women; potential aetiological role of khat (a commonly chewed plant with amphetamine-like properties) and traumatic exposures in psychosis; determine profiles of needs at first contact and predictors of outcome; (3) participatory workshops to develop programme theory and inform co-development of interventions, and (4) evaluation of the impact of early identification strategies on engagement with care (interrupted time series study). Findings will inform development of (5) a protocol for (5a) a feasibility cluster randomised controlled trial of interventions for people with recent-onset psychosis in rural settings and (5b) two uncontrolled pilot studies to test acceptability, feasibility of co-developed interventions in urban and homeless populations.

The future of public health doctoral education in Africa: transforming higher education institutions to enhance research and practice.

The African Union and the Africa Centers for Disease Control and Prevention issued a Call to Action in 2022 for Africa's New Public Health Order that underscored the need for increased capacity in the public health workforce. Additional domestic and global investments in public health workforce development are central to achieving the aspirations of Agenda 2063 of the African Union, which aims to build and accelerate the implementation of continental frameworks for equitable, people-centred growth and development. Recognising the crucial role of higher education and research, we assessed the capabilities of public health doctoral training in schools and programmes of public health in Africa across three conceptual components: instructional, institutional, and external. Six inter-related and actionable recommendations were derived to advance doctoral training, research, and practice capacity within and between universities. These can be achieved through equitable partnerships between universities, research centres, and national, regional, and global public health institutions.

Multidimensional and intergenerational impact of Severe Mental Disorders.

BACKGROUND: Severe Mental Disorders (SMDs) affect multiple generations although this is poorly studied. The aim of this study was to investigate the intergenerational and multidimensional impacts of SMD in rural Ethiopia. METHODS: This comparative study was nested within an existing population-based cohort study. We collected data from a total 5762 family members of 532 households (266 households with at least one family member with SMD and 266 sex and age matched mentally well controls from the neighborhood) in 2019. The main outcomes were multidimensional poverty, mortality, food insecurity, and family satisfaction. FINDINGS: Multidimensional poverty Index was higher in the households of persons with SMD (74·44%) than the comparison households (38·35%). School attendance was lower in children of people with SMD (63·28%) than children of the comparisons (78·08%). The median years of schooling was also lower among children of people with SMD than the controls. This lower attendance was also true among siblings of people with SMD (35·52%) than the comparisons (49·33%). Over the course of 20 years, family members who have a person with SMD in their household had 23% increased risk of death compared to family members who did not have a person with SMD in their household. Severe food insecurity was also higher in the SMD households (20·68%) than the comparison (13·53%) while family satisfaction was lower. INTERPRETATION: Families of people with SMD experience pervasive multidimensional and intergenerational impacts. Interventions should consider the broader family social and healthcare needs of the broader family.

Clinical course and outcome of schizophrenia in a predominantly treatment-naive cohort in rural Ethiopia.

The established view that schizophrenia may have a favorable outcome in developing countries has been recently challenged; however, systematic studies are scarce. In this report, we describe the clinical outcome of schizophrenia among a predominantly treatment-naive cohort in a rural community setting in Ethiopia. The cohort was identified in a 2-stage sampling design using key informants and measurement-based assessment. Follow-up assessments were conducted monthly for a mean duration of 3.4 years (range 1-6 years). After screening 68 378 adults, ages 15-49 years, 321 cases with schizophrenia (82.7% men and 89.6% treatment naive) were identified. During follow-up, about a third (30.8%) of cases were continuously ill while most of the remaining cohort experienced an episodic course. Only 5.7% of the cases enjoyed a near-continuous complete remission. In the final year of follow-up, over half of the cases (54%) were in psychotic episode, while 17.6% were in partial remission and 27.4% were in complete remission for at least the month preceding the follow-up assessment. Living in a household with 3 or more adults, later age of onset, and taking antipsychotic medication for at least 50% of the follow-up period predicted complete remission. Although outcome in this setting appears better than in developed countries, the very low proportion of participants in complete remission supports the recent observation that the outcome of schizophrenia in developing countries may be heterogeneous rather than uniformly favorable. Improving access to treatment may be the logical next step to improve outcome of schizophrenia in this setting.

The 10-year functional outcome of schizophrenia in Butajira, Ethiopia.

BACKGROUND: Long-term functional schizophrenia outcomes are not well characterized in low-income environments because of the rarity of prospective studies. OBJECTIVES: To assess and describe long-term schizophrenia's functional outcomes and potential outcome predictors. METHODS: Following a baseline assessment, 316 people with schizophrenia were studied for 10 years, on average. Of the total, 79 were incident cases: cases with onset of the illness occurring two years or less from entry into the study. SF-36 scores of physical and social functioning were used to assess functional outcomes. Linear mixed models were employed to evaluate the association of functioning with potential predictors. RESULTS: Social and physical functioning scores regarding the cohort were lower than the population's norm for most of the follow-up period. Incident cases had better function than prevalent cases. Fifteen percent of incident and 30% of prevalent cases had reduced social functioning for at least six years. Declining symptom severity during the follow-up period was significantly associated with improvement in social functioning. When baseline functioning was controlled for, the long-term trend in functionality was not associated with demographic or illness characteristics (age and speed of onset, duration of illness and neuroleptic use at entry, substance use, and medication adherence). CONCLUSION: Long-term physical and social functioning of the population with schizophrenia were significantly lower than the population norm. A significant proportion of the cohort had lower functioning for the long-term. Functioning was not associated with demographic or illness characteristics of the study population.

Validity of the concept of minor depression in a developing country setting.

Evidence for validity of the diagnostic construct of minor depressive disorder comes primarily from reports on subthreshold depressive states rather than minor depressive disorder per se. We report on the prevalence, impact, and sociodemographic correlates of minor depressive disorder in a developing country setting as further validation of this diagnostic construct. Diagnostic assessment of 1714 adults of an island population in Ethiopia was carried out using the Composite International Diagnostic Interview. The lifetime prevalence of minor depressive disorder was 20.5% (95% confidence interval 18.6, 22.5%). One-third of cases had sought help and expressed suicidal ideation. Being divorced/widowed, middle-aged, and having somatic pain were independently associated with having minor depressive disorder. Only being divorced/widowed was a shared risk factor for both minor depressive disorder and bereavement. Minor depressive disorder seems to be a useful and valid diagnostic construct with particular clinical significance in this and, possibly, similar developing country settings.

Utility of the concept of minor depressive disorder: evidence from a large rural community sample in a developing country setting.

BACKGROUND: Evidence on the utility of the minor depressive disorder diagnostic construct in rural communities and developing countries is scarce. AIM: To assess the utility and validity of definitive minor depressive disorder in Ethiopia by determining its impact and sociodemographic correlates. METHODS: Assessment of 68,378 adults, aged 15-49 years, living in a largely rural district in Ethiopia using the Composite International Diagnostic Interview. RESULTS: The lifetime prevalence of minor depressive disorder was 2.2% (95% CI=2.1%, 2.3%). Age, marital status, education and unemployment independently predicted minor depressive disorder. Over 80% of cases used health services, 55.1% experienced persistent thoughts of death and 14.6% attempted suicide. LIMITATION: Findings are based on lifetime estimates. CONCLUSIONS: Minor depressive disorder is an important public health problem in rural Ethiopia, as shown by the associated high health service use and risk behaviour. Sociodemographic correlates suggest aetiological continuity with major depression. Thus our findings extend the clinical and public health utility of this diagnostic construct to rural community and developing country settings.

Symptomatic and functional outcome of bipolar disorder in Butajira, Ethiopia.

BACKGROUND: Limited information is available on the outcome of bipolar disorder in developing countries. OBJECTIVE: To describe the symptomatic and functional outcome of bipolar disorder. METHODS: The psychoses and affective disorder modules of the CIDI were used to screen 68,378 individuals by a door-to-door survey of a defined district in Ethiopia. In addition, key informants were used to identify individuals with probable major mental illnesses. SCAN interviews were completed at the second stage to confirm the diagnosis. A total of 315 cases of bipolar disorder were identified, of which 264 (69 recent-onset and 195 prevalent cases) were prospectively followed for a mean of 2.5 (range 1-4) years by baseline and annual clinical assessments using symptom rating scales. Functional dimensions of the SF-36 scale were used to describe functional outcome. Random coefficient analyses were used to evaluate potential correlates of outcome. RESULTS: The magnitudes of mania and depression symptoms were elevated at baseline but improved with follow-up, although the improvement was less marked for depression. Sociodemographic or clinical variables were not associated with the improvements in symptomatic outcome. Between 35% and 47% of the recent-onset cases had functional role restrictions, while 42-52% of long-standing cases had such restrictions during the follow-up years. Similarly, social and physical functioning deficits were also present in 52-86% and 35-47% of recent-onset and long-standing cases, respectively. The magnitude of depression and mania symptoms was associated with poor functional outcome, while male sex, rural residence and being married were associated with better functional outcome. CONCLUSION: Although there were improvements in function with follow-up, between one-third and one-half of cases continued to have functional deficits.

Monitoring cause-specific adult mortality in developing countries: a comparison of data sources for Addis Ababa and its implications for policy and research.

Hospital statistics of causes of death for developing countries may be biased when the utilization of hospital services is low or selective. Using Addis Ababa, Ethiopia as an example, we argue that hospital data can be useful for demonstrating general cause-specific mortality patterns. In addition, a comparison of hospital statistics with data from a surveillance of burials allows for the identification of weaknesses in health services provision. We find a low level of hospital services utilization during terminal illness. Despite similarities in the cause of death structure in the different data sources, hospital statistics under-estimate the prevalence of infectious diseases. In addition, we identify an important gender bias in the utilization of health services in the direction of males being significantly more likely to die in medical facilities than females.

Khat and alcohol use and risky sex behaviour among in-school and out-of-school youth in Ethiopia.

BACKGROUND: Khat (an evergreen plant with amphetamine-like properties) and alcohol are widely consumed among the youth of Ethiopia. However, their relationship to risky sexual behaviour is not well described. This study was conducted to describe the magnitude of risky sexual behaviour (unprotected sex and early initiation of sexual activity) and its association with Khat and alcohol consumption in Ethiopian youths. METHODS: A probabilistic national sample of 20,434 in-school and out-of-school youths aged between 15 and 24 years of age was selected and interviewed regarding their sexual behavior and substance use. RESULTS: Over 20% of out-of-school youth had unprotected sex during the 12-month period prior to interview compared to 1.4% of in-school youth. Daily Khat intake was also associated with unprotected sex: adjusted OR (95% CI) = 2.26 (1.92, 2.67). There was a significant and linear association between alcohol intake and unprotected sex, with those using alcohol daily having a three fold increased odds compared to those not using it: adj. OR (95% CI) = 3.05 (2.38, 3.91). Use of substances other than Khat was not associated with unprotected sex, but was associated with initiation of sexual activity: adj. OR (95% CI) = 2.54 (1.84, 3.51). CONCLUSION: A substantial proportion of out-of-school youth engage in risky sex. The use of Khat and alcohol and other substances is significantly and independently associated with risky sexual behaviour among Ethiopian youths.

The distribution of mental disorders among an isolated island community in southern Ethiopia.

BACKGROUND: It is now recognized that surveys of unique communities are important to better understand the epidemiology of mental disorders. The Zeway islanders are completely different from the surrounding cultural groups, in the midst of whom they have been living in isolation for over three centuries. OBJECTIVES: To describe the prevalence and sociodemographic correlates of major mental disorders in this community. METHODS: Trained and supervised field workers were employed to conduct a door-to-door survey of the entire adult population of the islands using the Amharic CIDI (Composite International Diagnostic Interview). RESULTS: A total of 18.3% of the study subjects were classified as having ICD-10 diagnoses, excluding substance use disorders. The most prevalent CIDI/ICD-10 disorder in the study were neurotic and somatoform disorders (17%). Affective disorders were present in 2.2% while no cases of psychoses were found. The prevalence of tobacco use and alcohol dependence was 0.4% and 1.5%, respectively, with all cases being males. CONCLUSION: The pattern of occurrence of mental disorders in this isolated community is different from other populations in Ethiopia and elsewhere with no reported case of psychoses.

Long-term clinical course and outcome of schizophrenia in rural Ethiopia: 10-year follow-up of a population-based cohort.

BACKGROUND: Although the few available studies from LMICs report favorable outcome, the course of schizophrenia is more complex than has been indicated so far. METHODS: A sample of 361 people with a standardized clinical diagnosis of schizophrenia were recruited from a predominantly rural community in Ethiopia and followed up regularly for an average of 10years. Psychiatrists used the Longitudinal Interval Follow-up Evaluation chart to carry out assessment of illness course. Duration of time in clinical remission was the primary outcome. RESULT: About 61.0% of the patients remained under active follow-up, while 18.1% (n=65) were deceased. The mean percentage of follow-up time in complete remission was 28.4% (SD=33.0). Female patients were significantly more likely to have episodic illness course with no inter-episode residual or negative symptoms (χ(2)=6.28, P=0.012). Nearly 14.0% had continuous psychotic symptoms for over 75% of their follow-up time. Only 18.1% achieved complete remission for over 75% of their follow-up time. Later onset of illness was the only significant predictor of achieving full remission for over 50% of follow-up time in a fully adjusted model. Conventional antipsychotic medications were fairly well tolerated in 80% of the patients and 4.2% (n=15) experienced tardive dyskinesia. CONCLUSION: This population-based study is one of the very few long-term outcome studies of schizophrenia in LMICs. The study demonstrated clearly a differential and more favorable course and outcome for female patients but overall course and outcome of schizophrenia appeared less favorable in this setting than has been reported from other LMICs.

Mortality impact of AIDS in Addis Ababa, Ethiopia.

OBJECTIVE: To measure the impact of HIV on mortality in Addis Ababa, Ethiopia. DESIGN: A retrospective review of burials at three cemeteries, 1987-2001 and a prospective surveillance of burials at all (n = 70) cemeteries, February-May, 2001. METHODS: The age, sex, and date of burial were recorded; in the absence of denominators, we compared the ratio of deaths of persons 25-49 versus 5-14 years of age per calendar year, using logistic regression, adjusting for sex and site. The age- and sex- specific mortality were calculated and compared with pre-HIV mortality in 1984. RESULTS: Of 17,519 deaths, retrospectively reviewed, complete data were available for 6342 (47%) females and 7269 (53%) males. During 1987-2001, the '25-49' versus '5-14' group all-cause mortality ratio increased by 8.5% per calendar year (P < 0.05). A total of 5101 deaths were recorded in the prospective surveillance. Crude mortality rates were 9.5/1000 per year (men) and 7.1/1000 per year (women). In comparison with 1984, 5.0-times as many men and 5.3-times as many women died in the age group 35-39 years. Attributing the increase in mortality in ages 15-60 to HIV in the period 1984-2001, Ethiopian men and women have a probability of 18.8 and 17.8%, respectively, of dying of HIV before age 60. CONCLUSION: Burials increased significantly among the '25-49', versus the '5-14' group, during the period 1987-2001. This trend, and a five-times higher mortality in 2001 than in 1984 in those aged 35-39 years demonstrate a severe impact of HIV on mortality. Continuing surveillance of burials is recommended.

The sociodemographic correlates of schizophrenia in Butajira, rural Ethiopia.

OBJECTIVES: To describe the major sociodemographic correlates of schizophrenia, and their interactions, in a rural population of Ethiopia. METHODS: We have recently completed a study in Butajira to identify cases of major mental disorders for description of course and outcome. A total of 318 cases of schizophrenia were identified by a door-to-door survey of a predominantly rural population of close to 68,500 individuals. Cases were confirmed by use of the SCAN and clinical assessment. FINDINGS: The study showed that being male, under 35 years of age, unmarried, educated and living in an urban area were factors all associated with schizophrenia independently of each other. The risk of schizophrenia associated with being male was much higher in those aged 35 and over compared to those under 35 years of age. The risk of schizophrenia among males was higher in those not married (never married, separated, divorced or widowed) compared to those who were married. The association of marital status with schizophrenia was also more pronounced among those aged 35 year or over compared to those under 35. The association between schizophrenia and being unmarried was higher in urban than in rural areas. CONCLUSION: The sociodemographic correlates of schizophrenia in this rural population were similar to those described for the developed world. Furthermore, there were significant interactions between sex, age, marital status, area of residence and education as correlates of schizophrenia.

Comparison of computer assisted scan diagnoses and clinical diagnoses of major mental disorders in Butajira, rural Ethiopia.

One of the major difficulties in mental health research is finding suitable research instruments. In the last few decades questionnaires that are supposed to work in different languages and cultures have been developed by WHO to solve this problem. One of such instruments is SCAN, an instrument which uses computer algorithm to make a diagnosis. It is meant to be used for semi-structured interview by qualified psychiatrists or clinical psychologists. This and a few other research instruments have been translated and used in clinical and community settings for psychiatric research in Ethiopia over the last few years. In this study computer assisted SCAN Diagnoses and clinical diagnoses made by trainee psychiatrists in Butajira, a rural setting in Ethiopia, were compared Seven hundred twenty nine persons were diagnosed to have schizophrenia and bipolar disorder using both methods. The agreement between the clinical and SCAN derived diagnosis was shown to be 100% for schizophrenia (Kappa = 1.0). However, the agreement between the two methods of diagnosis was shown to be lower when it comes to subtypes of schizophrenia. The agreement for the diagnoses of bipolar disorder was 95.3%, kappa = 0.9, P < 0.0001 and for depression it was 93.0%, kappa = 0.8, p < 0.0001. Taking into account the limited number of psychiatrists and clinical psychologists in the third world countries like Ethiopia we have shown that using trainees in psychiatry for SCAN interview is a feasible and reliable method to identify major categories of mental disorders in community studies.

Health related quality of life (SF-36) survey in Butajira, rural Ethiopia: normative data and evaluation of reliability and validity.

UNLABELLED: The SF-36 health survey, a generic measure of health related quality of life (HRQOL), has been translated, evaluated in various languages and used in over 40 countries worldwide, although it has not been used in Ethiopia. OBJECTIVE: To measure the reliability and validity of the SF-36, to establish general population norms for various sex and age groups, to describe the effects of socio-demographic factors on SF-36 scores, and SF-36 scores in patients with major mental disorders. METHODS: Following the standard procedures of forward and back translation and adaptation, an Amharic SF-36 was developed This was subsequently used in a health survey of a general rural population of 1.990 in Butajira. The instrument was also used to interview a group of patients with schizophrenia, bipolar and depressive disorders. RESULTS: Mean scores of all of the eight domains of the SF-36 general population of Butajira decreased (indicating poorer HRQOL) with increasing age in both males and females. The odds of being in the lowest quartile of the PCS were 3.6 times higher in those aged 40-49 years when compared to those younger than 20 years Adjusted Odds Ratio (95% CI) = 3.62 (2.32, 5.66). In both males and females, the SF-36 scores for the eight domains and the two summary scales were significantly lower among all the three cases of major mental disorders compared to the general population. CONCLUSION: The SF-36 appears to be an appropriate measure for measuring health related quality of life in various population groups in Ethiopia.

Mortality impact of AIDS in Addis Ababa, Ethiopia.

OBJECTIVE: To measure the impact of HIV on mortality in Addis Ababa, Ethiopia. DESIGN: A retrospective review of burials at three cemeteries, 1987-2001 and a prospective surveillance of burials at all (n = 70) cemeteries, February-May, 2001. METHODS: The age, sex, and date of burial were recorded; in the absence of denominators, we compared the ratio of deaths of persons 25-49 versus 5-14 years of age per calendar year, using logistic regression, adjusting for sex and site. The age- and sex-specific mortality were calculated and compared with pre-HIV mortality in 1984. RESULTS: Of 17,519 deaths, retrospectively reviewed, complete data were available for 6342 (47%) females and 7269 (53%) males. During 1987-2001, the '25-49' versus '5-14' group all-cause mortality ratio increased by 8.5% per calendar year (P < 0.05). A total of 5101 deaths were recorded in the prospective surveillance. Crude mortality rates were 9.5/1000 per year (men) and 7.1/1000 per year (women). In comparison with 1984, 5.0-times as many men and 5.3-times as many women died in the age group 35-39 years. Attributing the increase in mortality in ages 15-60 to HIV in the period 1984-2001, Ethiopian men and women have a probability of 18.8 and 17.8%, respectively, of dying of HIV before age 60. CONCLUSION: Burials increased significantly among the '25-49', versus the '5-14' group, during the period 1987-2001. This trend, and a five-times higher mortality in 2001 than in 1984 in those aged 35-39 years demonstrate a severe impact of HIV on mortality. Continuing surveillance of burials is recommended.