The effect of maternal HIV status on under-5 mortality in rural northern Malawi: a prospective cohort study

Abstract

BackgroundUnder-5 child mortality is decreasing, but with little change in neonatal mortality rates. One of the factors associated with improvements in mortality is increasing the availability of antiretroviral therapy (ART) for expectant mothers. We looked at the effect of maternal HIV status on under-5 mortality and cause of death since ART became widely available in rural Malawi. MethodsChildren born between September, 2006, and December, 2011, in the Karonga Demographic Surveillance System were included. Maternal HIV status was derived from linked HIV sero-surveys. Age-specific mortality rate ratios of children born to HIV+ and HIV– mothers were obtained by fitting a Poisson random effects model, taking into account child clustering by mother and adjusting for potential confounders. Cause of death was ascertained by verbal autopsy. FindingsThere were 317 deaths among 7054 under-5 singleton children followed for 14 118 person-years. The mortality rate was 22·5 per 1000 person-years (95% CI 20·1–25·1). The neonatal mortality rate was 241 per 1000 person-years, similar in those born to HIV+ and HIV– mothers, rate ratio (RR) 0·7 (95% CI 0·1–3·6), adjusted for child sex and socioeconomic confounders. The mortality rate was 21·6 per 1000 person-years in postneonatal infants, adjusted RR 7·3 (95% CI 4·3–12·4) in those with HIV+ compared with HIV– mothers. In children aged 1–4 years, the mortality rate was 10·9 per 1000 person-years, adjusted RR 3·7 (95% CI 1·9–7·1) in those with HIV+ compared with HIV– mothers. Birth injury/asphyxia, neonatal sepsis, and prematurity contributed over 70% of neonatal deaths, while acute infections, malaria, diarrhoea, and pneumonia accounted for most deaths in older children. Nearly half the deaths in children of HIV+ mothers were attributed to HIV/AIDS. InterpretationMaternal HIV status did not increase neonatal mortality but was still associated with much higher mortality in older children. Greater uptake and retention of ART by pregnant women is needed to help improve child survival, but broader interventions are needed to reduce neonatal mortality. FundingWellcome Trust.