Mother’s HIV status has a major impact on child, but not neonatal mortality

Maternal HIV status associated with under-five mortality in rural northern Malawi: A prospective cohort study

Chihana ML, Price A, Floyd S, Mboma S, Mvula H, Branson K, Saul J, Zaba B, French N, Crampin AC, Glynn JR. J Acquir Immune Defic Syndr. 2014 Oct 15. [Epub ahead of print]

Background: Under-five mortality is decreasing but with little change in neonatal mortality rates. We examined the effect of maternal HIV-status on under-five mortality and cause of death since widespread availability of antiretroviral therapy in rural Malawi.

Methods: Children born in 2006-2011 in the Karonga demographic surveillance area were included. Maternal HIV-status was available from HIV sero-surveys. Age-specific mortality rate ratios for children born to HIV-positive and HIV-negative mothers were obtained by fitting a Poisson model accounting for child clustering by mother and adjusting for potential confounders. Cause of death was ascertained by verbal autopsy.

Findings: There were 352 deaths among 6913 under-five singleton children followed for 20 754 person-years (py), giving a mortality rate of 17.0/1000py overall, 218/1000py (16.5/1000 live births) in neonates, 20/1000py (17.4/1000 live births) in post-neonatal infants and 8/1000py in 1-4 year-olds. Comparing those born to HIV-positive and HIV-negative mothers, the rate ratio, adjusted for child age, sex, maternal age, parity and drinking water source was 1.5 (95%CI 0.6-3.7) in neonates, 11.5 (95%CI 7.2-18.5) in post-neonatal infants and 4.6 (95%CI 2.7-7.9) in 1-4 year-olds. Birth injury/asphyxia, neonatal sepsis and prematurity contributed >70% of neonatal deaths, while acute infections, malaria, diarrhoea and pneumonia accounted for most deaths in older children.

Conclusions: Maternal HIV status had little effect on neonatal mortality but was associated with much higher mortality in the post-neonatal period and among older children. Greater attention to HIV care in pregnant women and mothers should help improve child survival but broader interventions are needed to reduce neonatal mortality.

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Editor’s notes: Child mortality remains a major public health problem in sub-Saharan Africa. A substantial proportion of under-five deaths are attributable to HIV in some countries, estimated as 13% in Malawi, where HIV prevalence is 10-14%.  Child mortality has declined in Malawi, and this large population-based study looked at causes of death from 2006-2012 when antiretroviral therapy (ART) was widely available.  Overall, child mortality was higher in children born to women living with HIV than women without HIV, but this effect was only seen after the neonatal period.  As expected, there were clear differences in causes of death by age. About half of the neonatal deaths were due to infections or prematurity, where HIV status may play a role. Therefore the small effect of the mother’s HIV status in this age group is interesting, although in line with other studies from sub-Saharan Africa.  Older children tended to die from acute infections such as pneumonia, diarrhoea and acute febrile diseases. Maternal HIV positive status was estimated to account for most of these deaths. Strengths of this study are the large number of children included and the length of follow up. The study was not designed to define the mechanisms underlying the excess mortality, and did not include data on child HIV status and other programmes such as vitamin supplementation, vaccination and duration of breast feeding. Optimisation of Option B+ will prevent further children from acquiring HIV and maintain the health of their mothers, but this study illustrates the need for a continued focus on other causes of neonatal mortality.

Africa
Malawi
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