Age patterns and sex ratios of adult mortality in countries with high HIV prevalence

Objective: To compare the 2016 United Nations Programme on HIV/AIDS (UNAIDS) modelled estimates of adult mortality in sub-Saharan Africa to empirical estimates. Design: Age-specific mortality rates were obtained from nationally representative sibling survival data, recent household deaths and vital registration, and directly compared with UNAIDS estimates. Orphanhood prevalence derived from UNAIDS mortality estimates was compared with survey and census reports on the survival of children's parents. Methods: Age-specific mortality rates for adults aged 15–59 years were calculated from Demographic and Health Surveys and deaths reported in censuses or vital registration, adjusted for underreporting, whenever possible. Proportions of orphans were extracted from censuses and surveys for children aged 5–9 years. Results: UNAIDS estimates were significantly higher than sibling mortality estimates, except among men in countries with very high HIV prevalence. There was a better agreement between rates based on household deaths or vital registration and model outputs. Sex ratios (M/F) of adult mortality were lower in UNAIDS estimates. The modelled orphan prevalence was significantly higher than in surveys and censuses, again with the exception of paternal orphans in countries with very high HIV prevalence. Ratios of paternal-to-maternal orphans were lower in the UNAIDS model than surveys and censuses. Among women, increases in mortality due to AIDS were more concentrated in the age range 25–50 years in model outputs, as compared with empirical estimates. Conclusion: Discrepancies in levels, sex ratios and age patterns of adult mortality between empirical and UNAIDS estimates call for additional data quality assessments and improvements in estimation methods.