These data suggest that survival after initiation of ART improved each year. This trend may result from patients starting treatment at earlier stages of disease and thus having better outcomes. This is consistent with a theme, described earlier in the section on care and support, that emerged from the interviews—that the increasing availability and success of ART has led to improved health outcomes for PLHIV. These data also exhibit clear sex differences in survival, with women faring better than men; this is similar to the result on retention presented earlier. An additional analysis from a subset of these data representing seven PEPFAR countries reveals similar sex differences in survival on ART (Figure 6-14a), including a breakdown of characteristics at baseline (Figure 6-14b).

These data indicate that men present later in the disease course and with more complications. One reason for this may be that, as described earlier, many women enrolled in ART are identified through screening for PMTCT (WHO, 2012d), an entry point that is not dependent on symptomatic presentation for HIV and is likely to catch more women in earlier stages.

The enrollment, retention, and mortality outcomes presented in this chapter for patients enrolled in these PEPFAR-supported treatment programs are consistent with the published literature, where men have also been shown to have a higher mortality rate than women when receiving antiretroviral therapy (Chen et al., 2008; Taylor-Smith et al., 2010). Possible reasons for the poorer outcomes on ART for men than for women include poor adherence to therapy (Chen et al., 2008; Taylor-Smith et al., 2010); starting therapy at a more advanced stage of the disease (Chen et al., 2008; Geng et al., 2011; Hawkins et al., 2011; Taylor-Smith et al., 2010); cultural norms with respect to stigma, fear, and pride (e.g., the culture of masculinity) (Chen et al., 2008); biological sex differences related to doses of the specified drugs in therapy (Taylor-Smith et al., 2010); and other outside factors such as smoking, alcohol consumption, and life expectancy (Taylor-Smith et al., 2010).

Issues related to the differences between men and women in HIV-related services are also discussed in Chapter 8.

Impact of PEPFAR on Population Health Outcomes

In addition to information about survival and mortality outcomes for patients enrolled in PEPFAR-supported care and treatment programs, an important question for an impact evaluation of PEPFAR is whether the PEPFAR program has had an impact on mortality at the population level. PEPFAR-supported HIV programs have the potential to reduce population mortality through their full range of activities and efforts, but the most



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