Research question
What is the impact of HIV prevention and treatment programmes on the decline in early life mortality in rural South Africa?

AC research strategy
This study fits into objective 1 of Africa Centre’s current research strategy, namely, to further improve understanding of the impact of ART roll-out at individual, household, clinic and community level.

Rationale
Vertically-acquired HIV infection directly contributes to child mortality in high HIV prevalence areas, while maternal HIV infection and survival are important indirect factors. Recent evidence suggests the achievement of Millennium Development Goal (MDG) 4 in South Africa is currently off track due to the continued rise in child mortality rates since 1990. We present early life mortality rates in a largely rural population with high antenatal HIV prevalence, and investigate temporal and spatial associations with a prevention of mother-to-child transmission (PMTCT) programme, an HIV treatment programme, and maternal HIV.

Data sources and Methods
All births from January 2000 to January 2007 to women in the Africa Centre demographic surveillance were included. Under two child mortality rates (U2MR) computed as deaths per 1000 live-births per year; factors associated with mortality risk assessed with Weibull regression. Availability of PMTCT (single-dose nevirapine) and antiretroviral treatment (ART) in a programme included in multivariable analysis.

Findings
848 (6.2%) of 13,583 children under 2 years died. Deaths in under 2s declined by 49% between 2001 and 2006, from 86.3 to 44.1 deaths per thousand live-births. Mortality was independently associated with birth season (aHR 1.17, 95% CI 1.02-1.34), maternal education (1.21, 1.02-1.43), maternal HIV (4.31, 3.09-6.01) and ART availability (0.45, 0.32-0.64). Children born at home (unlikely to have received single-dose nevirapine (sdNVP)) had a 35% higher risk of dying than children born in a facility where sdNVP was available (1.35, 1.04-1.74). For 2005 births the availability of PMTCT and ART in public health programmes would have explained 8% and 31% of the decline in U2MR since 2000.

Policy implications
These findings highlight the importance of the PMTCT and especially maternal HIV treatment with direct benefits of improved survival of their young children. Urgent scaling-up of these programmes is needed if MDG4 is to be realised.