Linking the timing of a mother's and child's death: Comparative evidence from two rural South African population-based surveillance studies, 2000-2015

Care for the Caregiver: How Caregiver Mortality Affects Treatment Outcomes-An Observational Cohort Study

Despite improvements in HIV management, children and adolescents living with HIV remain vulnerable. Caregiver mortality in a large paediatric and adolescent HIV clinic in Johannesburg is described and the effect of the death of a caregiver on children and adolescents' HIV treatment outcomes was investigated. We analysed retrospective longitudinal data and included children or adolescents attending the clinic between 01 January and 31 December 2021 divided into those with documented primary caregiver mortality and those without (ever documented). Viral load, treatment regimens, CD4, and anthropometry were analysed for 2021. Caregiver vital status was recorded in 1171 (93%) of the 1260 patients attending in 2021. In 115 children or adolescents (10%) we found a documented death of caregiver(s). Amongst 1120 mothers, 100 (9%) had died; of 460 fathers, 18 (4%) had died and one (1%) of 100 other caregivers had died. A large number (n = 54 [45%]) of the 119 deaths occurred between 2016 and 2021 and 66 (69%) after the child/adolescent's enrolment in the clinic. In 2021, stunting and wasting were more common in the participants with caregiver death than those without (χ2 = 4.98, 6.64, p = 0.01 and 0.03 respectively). No significant difference was seen between the groups for viral load, treatment regimens and CD4 counts. Caregiver death was incompletely captured in the clinic database, suggesting that clinicians were unaware of the death of a caregiver. Children experiencing the death of a caregiver were more likely to be malnourished. We propose increasing attention on the wellbeing of caregivers in paediatric HIV services.

Mortality variability and differentials by age and causes of death in rural South Africa, 1994-2018

INTRODUCTION

Understanding mortality variability by age and cause is critical to identifying intervention and prevention actions to support disadvantaged populations. We assessed mortality changes in two rural South African populations over 25 years covering pre-AIDS and peak AIDS epidemic and subsequent antiretroviral therapy (ART) availability.

METHODS

Using population surveillance data from the Agincourt Health and Socio-Demographic Surveillance System (AHDSS; 1994-2018) and Africa Health Research Institute (AHRI; 2000-2018) for 5-year periods, we calculated life expectancy from birth to age 85, mortality age distributions and variation, and life-years lost (LYL) decomposed into four cause-of-death groups.

RESULTS

The AIDS epidemic shifted the age-at-death distribution to younger ages and increased LYL. For AHDSS, between 1994-1998 and 1999-2003 LYL increased for females from 13.6 years (95% CI 12.7 to 14.4) to 22.1 (95% CI 21.2 to 23.0) and for males from 19.9 (95% CI 18.8 to 20.8) to 27.1 (95% CI 26.2 to 28.0). AHRI LYL in 2000-2003 was extremely high (females=40.7 years (95% CI 39.8 to 41.5), males=44.8 years (95% CI 44.1 to 45.5)). Subsequent widespread ART availability reduced LYL (2014-2018) for women (AHDSS=15.7 (95% CI 15.0 to 16.3); AHRI=22.4 (95% CI 21.7 to 23.1)) and men (AHDSS=21.2 (95% CI 20.5 to 22.0); AHRI=27.4 (95% CI 26.7 to 28.2)), primarily due to reduced HIV/AIDS/TB deaths in mid-life and other communicable disease deaths in children. External causes increased as a proportion of LYL for men (2014-2018: AHRI=25%, AHDSS=17%). The share of AHDSS LYL 2014-2018 due to non-communicable diseases exceeded pre-HIV levels: females=43%; males=40%.

CONCLUSIONS

Our findings highlight shifting burdens in cause-specific LYL and persistent mortality differentials in two populations experiencing complex epidemiological transitions. Results show high contributions of child deaths to LYL at the height of the AIDS epidemic. Reductions in LYL were primarily driven by lowered HIV/AIDS/TB and other communicable disease mortality during the ART periods. LYL differentials persist despite widespread ART availability, highlighting the contributions of other communicable diseases in children, HIV/AIDS/TB and external causes in mid-life and non-communicable diseases in older ages.

Household structure, composition and child mortality in the unfolding antiretroviral therapy era in rural South Africa: comparative evidence from population surveillance, 2000-2015

OBJECTIVES

The structure and composition of the household has important influences on child mortality. However, little is known about these factors in HIV-endemic areas and how associations may change with the introduction and widespread availability of antiretroviral treatment (ART). We use comparative, longitudinal data from two demographic surveillance sites in rural South Africa (2000-2015) on mortality of children younger than 5 years (n=101 105).

DESIGN

We use multilevel discrete time event history analysis to estimate children's probability of dying by their matrilineal residential arrangements. We also test if associations have changed over time with ART availability.

SETTING

Rural South Africa.

PARTICIPANTS

Children younger than 5 years (n=101 105).

RESULTS

3603 children died between 2000 and 2015. Mortality risks differed by co-residence patterns along with different types of kin present in the household. Children in nuclear households with both parents had the lowest risk of dying compared with all other household types. Associations with kin and child mortality were moderated by parental status. Having older siblings lowered the probability of dying only for children in a household with both parents (relative risk ratio (RRR)=0.736, 95% CI (0.633 to 0.855)). Only in the later ART period was there evidence that older adult kin lowered the probability of dying for children in single parent households (RRR=0.753, 95% CI (0.664 to 0.853)).

CONCLUSIONS

Our findings provide comparative evidence of how differential household profiles may place children at higher mortality risk. Formative research is needed to understand the role of other household kin in promoting child well-being, particularly in one-parent households that are increasingly prevalent.