Mapping HIV mortality in six Latin American countries using incomplete vital registration systems

Abstract

Background HIV remains a public health priority in Latin America, but across the region HIV mortality is not in universal decline. While it is known that the burden of HIV is concentrated in urban areas and high-risk groups, detailed subnational estimates that cover multiple countries and years are lacking, due, in part, to incomplete vital registration systems and statistical challenges related to estimating mortality rates in areas with low numbers of HIV deaths. Methods Using vital registration (VR) data ranging from 2000 to 2017, we estimated the HIV mortality rate and the number of HIV deaths by age group, sex, and municipality in Brazil, Colombia, Costa Rica, Ecuador, Guatemala, and Mexico. We modelled HIV mortality using a Bayesian spatially explicit mixed-effects regression model that incorporates prior information on VR completeness. We calibrated our results to the Global Burden of Disease Study 2017. Results All countries displayed over a 40-fold difference in age-standardized HIV mortality between municipalities with the highest and lowest HIV mortality rate in the last year of study for men, and over a 20-fold difference for women. Despite decreases in HIV mortality in all countries—apart from Ecuador—across the period of study, we find broad variation in relative changes in HIV mortality at the municipality level and increasing relative inequality over time in all countries. National age patterns reflected shifts in mortality to older age groups over time and in the latest year of study, the median age group among those who died from HIV ranged by 5 to 15 years among countries at the municipality level. In all six countries included in this analysis, HIV deaths were concentrated in fewer than 10% of municipalities in the latest year of study. Conclusions Our subnational estimates of HIV mortality revealed significant spatial variation and diverging local trends in HIV mortality over time and by age group. This analysis provides a framework for incorporating data from incomplete VR systems and could be used to understand local needs and guide more geographically precise public health intervention to reduce HIV-related deaths.