title: Maternal HIV status associated with under-five mortality in rural Northern Malawi: a prospective cohort study.
abstract: BACKGROUND
  Under-five mortality is decreasing but with little change in neonatal mortality rates. We examined the effect of maternal HIV status on under-five mortality and cause of death since widespread availability of antiretroviral therapy in rural Malawi.
  
  
  METHODS
  Children born in 2006-2011 in the Karonga demographic surveillance area were included. Maternal HIV status was available from HIV serosurveys. Age-specific mortality rate ratios for children born to HIV-positive and HIV-negative mothers were obtained by fitting a Poisson model accounting for child clustering by mother and adjusting for potential confounders. Cause of death was ascertained by verbal autopsy.
  
  
  RESULTS
  There were 352 deaths among 6913 under-five singleton children followed for 20,754 person-years (py), giving a mortality rate of 17.0/1000 py overall, 218/1000 py (16.5/1000 live births) in neonates, 20/1000 py (17.4/1000 live births) in postneonatal infants, and 8/1000 py in 1-4 years old. Comparing those born to HIV-positive and HIV-negative mothers, the rate ratio adjusted for child age, sex, maternal age, parity, and drinking water source was 1.5 (95% confidence interval [CI]: 0.6 to 3.7) in neonates, 11.5 (95% CI: 7.2 to 18.5) in postneonatal infants, and 4.6 (95% CI: 2.7 to 7.9) in 1-4 years old. Birth injury/asphyxia, neonatal sepsis, and prematurity contributed >70% of neonatal deaths, whereas acute infections, malaria, diarrhea, and pneumonia accounted for most deaths in older children.
  
  
  CONCLUSIONS
  Maternal HIV status had little effect on neonatal mortality but was associated with much higher mortality in the postneonatal period and among older children. Greater attention to HIV care in pregnant women and mothers should help improve child survival, but broader interventions are needed to reduce neonatal mortality.
authors.affiliation: *Karonga Prevention Study, Karonga, Malawi; †London School of Hygiene and Tropical Medicine, Faculty of Infectious Disease Epidemiology, London, United Kingdom; and ‡University of Liverpool, Institute of Infection and Global Health, Department of Clinical Infection, Microbiology and Immunology, Liverpool, United Kingdom.
authors.forename: Menard L
authors.initials: ML
authors.lastname: Chihana
authors.forename: Alison
authors.initials: A
authors.lastname: Price
authors.forename: Sian
authors.initials: S
authors.lastname: Floyd
authors.forename: Sebastian
authors.initials: S
authors.lastname: Mboma
authors.forename: Hazzie
authors.initials: H
authors.lastname: Mvula
authors.forename: Keith
authors.initials: K
authors.lastname: Branson
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Saul
authors.forename: Basia
authors.initials: B
authors.lastname: Zaba
authors.forename: Neil
authors.initials: N
authors.lastname: French
authors.forename: Amelia C
authors.initials: AC
authors.lastname: Crampin
authors.forename: Judith R
authors.initials: JR
authors.lastname: Glynn
mesh_terms: D000328:Adult; D046688:Child Mortality; D002675:Child, Preschool; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000401:mortality*; D006801:Humans; D007223:Infant; D008295:Malawi / Q000453:epidemiology; D008297:Male; D011446:Prospective Studies; D012424:Rural Population; D055815:Young Adult