title: HIV-exposed children account for more than half of 24-month mortality in Botswana.
abstract: The contribution of HIV-exposure to childhood mortality in a setting with widespread antiretroviral treatment (ART) availability has not been determined.
  
  
  
  From January 2012 to March 2013, mothers were enrolled within 48 h of delivery at 5 government postpartum wards in Botswana. Participants were followed by phone 1-3 monthly for 24 months. Risk factors for 24-month survival were assessed by Cox proportional hazards modeling.
  
  
  
  Three thousand mothers (1499 HIV-infected) and their 3033 children (1515 HIV-exposed) were enrolled. During pregnancy 58 % received three-drug ART, 23 % received zidovudine alone, 11 % received no antiretrovirals (8 % unknown); 2.1 % of children were HIV-infected by 24 months. Vital status at 24 months was known for 3018 (99.5 %) children; 106 (3.5 %) died including 12 (38 %) HIV-infected, 70 (4.7 %) HIV-exposed uninfected, and 24 (1.6 %) HIV-unexposed. Risk factors for mortality were child HIV-infection (aHR 22.6, 95 % CI 10.7, 47.5 %), child HIV-exposure (aHR 2.7, 95 % CI 1.7, 4.5) and maternal death (aHR 8.9, 95 % CI 2.1, 37.1). Replacement feeding predicted mortality when modeled separately from HIV-exposure (aHR 2.3, 95 % CI 1.5, 3.6), but colinearity with HIV-exposure status precluded investigation of its independent effect. Applied at the population level (26 % maternal HIV prevalence), an estimated 52 % of child mortality occurs among HIV-exposed or HIV-infected children.
  
  
  
  In a programmatic setting with high maternal HIV prevalence and widespread maternal and child ART availability, HIV-exposed and HIV-infected children still account for most deaths at 24 months. Lack of breastfeeding was a likely contributor to excess mortality among HIV-exposed children.
authors.affiliation: Beth Israel Deaconess Medical Center, 110 Francis Street, Suite GB, Boston, MA, 02215, USA. rzash@bidmc.harvard.edu.|Botswana Harvard AIDS Institute Parternship, Private Bag BO320, Gaborone, Botswana. rzash@bidmc.harvard.edu.|Harvard T.H. Chan School of Public Health, 651 Huntington Ave, Boston, MA, 02115, USA. rzash@bidmc.harvard.edu.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Zash
authors.affiliation: University of Botswana, Faculty of Health Sciences, Gaborone, Botswana.
authors.forename: Sajini
authors.initials: S
authors.lastname: Souda
authors.affiliation: Goodtables Data Consulting, Oklahoma, USA.
authors.forename: Jean
authors.initials: J
authors.lastname: Leidner
authors.affiliation: Harvard T.H. Chan School of Public Health, 651 Huntington Ave, Boston, MA, 02115, USA.
authors.forename: Heather
authors.initials: H
authors.lastname: Ribaudo
authors.affiliation: Botswana Harvard AIDS Institute Parternship, Private Bag BO320, Gaborone, Botswana.
authors.forename: Kelebogile
authors.initials: K
authors.lastname: Binda
authors.affiliation: Botswana Harvard AIDS Institute Parternship, Private Bag BO320, Gaborone, Botswana.
authors.forename: Sikhulile
authors.initials: S
authors.lastname: Moyo
authors.affiliation: Botswana Harvard AIDS Institute Parternship, Private Bag BO320, Gaborone, Botswana.|Harvard T.H. Chan School of Public Health, 651 Huntington Ave, Boston, MA, 02115, USA.|Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: Powis
authors.affiliation: Ministry of Health, Gaborone, Botswana.
authors.forename: Chipo
authors.initials: C
authors.lastname: Petlo
authors.affiliation: Botswana Harvard AIDS Institute Parternship, Private Bag BO320, Gaborone, Botswana.
authors.forename: Mompati
authors.initials: M
authors.lastname: Mmalane
authors.affiliation: Botswana Harvard AIDS Institute Parternship, Private Bag BO320, Gaborone, Botswana.
authors.forename: Joe
authors.initials: J
authors.lastname: Makhema
authors.affiliation: Botswana Harvard AIDS Institute Parternship, Private Bag BO320, Gaborone, Botswana.|Harvard T.H. Chan School of Public Health, 651 Huntington Ave, Boston, MA, 02115, USA.|Harvard Medical School, Boston, MA, USA.
authors.forename: Max
authors.initials: M
authors.lastname: Essex
authors.affiliation: Botswana Harvard AIDS Institute Parternship, Private Bag BO320, Gaborone, Botswana.|Harvard T.H. Chan School of Public Health, 651 Huntington Ave, Boston, MA, 02115, USA.|Brigham and Women's Hospital, Infectious Diseases Division, 75 Francis Street, Boston, MA, 02115, USA.
authors.forename: Shahin
authors.initials: S
authors.lastname: Lockman
authors.affiliation: Botswana Harvard AIDS Institute Parternship, Private Bag BO320, Gaborone, Botswana.|Harvard T.H. Chan School of Public Health, 651 Huntington Ave, Boston, MA, 02115, USA.
authors.forename: Roger
authors.initials: R
authors.lastname: Shapiro
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use; D001902:Botswana / Q000453:epidemiology; D001942:Breast Feeding; D046688:Child Mortality; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy / Q000401:mortality* / Q000635:transmission; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D018445:Infectious Disease Transmission, Vertical; D008297:Male; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors
chemical_list: D019380:Anti-HIV Agents
keywords: Breastfeeding; Child mortality; HIV-exposed uninfected; HIV-infected children; PMTCT; Sub-Saharan Africa