THE IMPACT OF HIV-1 INFECTION ON MORTALITY IN CHILDREN UNDER 5 YEARS OF AGE IN SUB-SAHARAN AFRICA - A DEMOGRAPHIC AND EPIDEMIOLOGIC ANALYSIS

Objective: To estimate the effects of the HIV-1 epidemic on mortality in children under 5 years of age in urban and rural populations in eas tern and central, and southern Africa. Methods: A lifetable method tha t allows for the effects of competing causes (i.e., mortality due to H IV and other causes) was used to estimate mortality. Our calculations used published and unpublished data on HIV-1 infection in African adul ts and children (incidence and prevalence, vertical transmissions, tra nsmission by blood transfusion and natural history), and typical basel ine fertility and child mortality data. The results were applied to mo del rural and urban populations to explore the effects of parameters s uch as mortality in HIV-1-infected children, fertility in infected mot hers and overall population growth. Results: We estimate that child mo rtality will rise substantially because of the prevalence of HIV-1 in urban areas. There will be little difference in the absolute levels of increase in mortality between areas in eastern and central, and south ern Africa with similar levels of HIV infection; however, in relative terms the effect will be more noticeable in southern Africa because of the lower baseline mortality. Towns with severe epidemics (30% adult seroprevalence) might experience a rise in child mortality of one-thir d in eastern and central Africa and three-quarters in southern Africa. This will cancel or reverse existing advantages in urban over rural l evels of child mortality and th is effect wi II be more pronounced in southern Africa. The exact impact of HIV-1 will vary according to mort ality among HIV-1-infected children and to fertility among infected wo men. However, changes in age structure and population growth have rela tively little impact on mortality. Conclusions: There are likely to be substantial increases in child mortality in sub-Saharan Africa as a r esult of HIV-1 infection. The main determinant of childhood infection is the scale of the epidemic among adults. Increases in mortality will depend on local adult seroprevalence but are hard to predict precisel y because of possible variation in death rates among HIV-1-infected ch ildren. In rural areas with low seroprevalence other diseases will rem ain the main cause of mortality. However, in urban areas families and health services will have to face considerably increased demands from ill and dying children.