Child mortality levels and trends by HIV status in Blantyre Malawi: 1989-2009.

INTRODUCTION: Continuous evaluation of child survival is needed in sub-Saharan Africa where HIV prevalence among women of reproductive age continues to be high. We examined mortality levels and trends over a period of approximately 20 years among HIV-unexposed and -exposed children in Blantyre Malawi. METHODS: Data from 5 prospective cohort studies conducted at a single research site from 1989 to 2009 were analyzed. In these studies children born to HIV-infected and -uninfected mothers were enrolled at birth and followed longitudinally for at least 2 years. Information on sociodemographic HIV infection status survival and associated risk factors was collected in all studies. Mortality rates were estimated using birth-cohort analyses stratified by maternal and infant HIV status. Multivariate Cox regression models were used to determine risk factors associated with mortality. RESULTS: The analysis included 8286 children. From 1989 to 1995 overall mortality rates (per 100 person-years) in these clinic-based cohorts remained comparable among HIV-uninfected children born to HIV-uninfected mothers (range 3.3-6.9) or to HIV-infected mothers (range 2.5-7.5). From 1989 to 2009 overall mortality remained high among all children born to HIV-infected mothers (range 6.3-19.3) and among children who themselves became infected (range 15.6-57.4 1994-2009). Only lower birth weight was consistently and significantly (P < 0.05) associated with higher child mortality. CONCLUSIONS: HIV infection among mothers and children contributed to high levels of child mortality in the African setting in the pretreatment era. In addition to services that prevent mother-to-child transmission of HIV other programs are needed to improve child survival by lowering HIV-unrelated mortality through innovative interventions that strengthen health infrastructure.