Child Mortality in Rural Malawi: HIV Closes the Survival Gap between the Socio-Economic Strata

Lackson Kachiwanda,Basia Zaba,Andreas Jahn,Paul E M Fine,Amelia C Crampin,Nuala Mcgrath,Sian Floyd,Judith R Glynn,Venance Mwinuka

doi:10.1371/journal.pone.0011320

Abstract

BackgroundAs HIV-related deaths increase in a population the usual association between low socioeconomic status and child mortality may change, particularly as death rates from other causes decline.Methods/Principal FindingsAs part of a demographic surveillance system in northern Malawi in 2002-6, covering a population of 32,000, information was collected on socio-economic status of the households. Deaths were classified as HIV/AIDS-related or not by verbal autopsy. Poisson regression models were used to assess the association of socio-economic indicators with all-cause mortality, AIDS-mortality and non-AIDS mortality among children. There were 195 deaths in infants, 109 in children aged 1–4 years, and 38 in children aged 5–15. All-cause child mortality in infants and 1–4 year olds was similar in households with higher and lower socio-economic status. In infants 13% of deaths were attributed to AIDS, and there were no clear trends with socio-economic status for AIDS or non-AIDS causes. For 1–4 year olds 27% of deaths were attributed to AIDS. AIDS mortality was higher among those with better built houses, and lowest in those with income from farming and fishing, whereas non-AIDS mortality was higher in those with worse built houses, lowest in those with income from employment, and decreased with increasing household assets.Conclusions/SignificanceIn this population, since HIV infection among adults was initially more common among the less poor, childhood mortality patterns have changed. The usual gap in survival between the poor and the less poor has been lost, but because the less poor have been disproportionately affected by HIV, rather than because of relative improvement in the survival of the poorest.

Highlights

Associations between socioeconomic status and mortality have long been recognised
Pre-1900, being able to reach or afford health care would have been of limited benefit, and in predominantly rural communities, exposure to crowds and infectious diseases may have been limited among the poor
The HIV epidemic has produced some parallels with this historical situation

Summary

Introduction

Associations between socioeconomic status and mortality have long been recognised. Among rich and poor populations even fine gradations in relative poverty have been associated with differences in survival.[1,2] It is less clear if this has always been the case.[3] Pre-1900, being able to reach or afford health care would have been of limited benefit, and in predominantly rural communities, exposure to crowds and infectious diseases may have been limited among the poor. In many populations HIV initially affected the better off, more educated and more mobile sectors of the community.[4,5,6] And before the widespread availability of effective antiretrovirals and prevention of mother-to-child transmission, access to health care had limited impact on HIV-related mortality. As HIV-related deaths increase in a population the usual association between low socioeconomic status and child mortality may change, as death rates from other causes decline

Methods

Results

Conclusion