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September 12, 2012

PEPFAR and Adult Mortality—Reply

Author Affiliations

Author Affiliations: Division of General Medical Disciplines (Dr Bendavid; ebd@stanford.edu) and Centers for Health Policy and Outcomes Research (Dr Miller), Stanford University, Stanford, California; and Office of the US Global AIDS Coordinator, US Department of State, Washington, DC (Dr Holmes).

JAMA. 2012;308(10):972-973. doi:10.1001/jama.2012.9249

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.