The Long-Term Impact of HIV and Orphanhood on the Mortality and Physical Well-Being of Children in Rural Malawi

No published studies from sub-Saharan Africa have recorded child mortality and morbidity by maternal HIV status beyond age 3 years. More information on the impact of orphanhood on child physical well-being is required, especially as the number of children orphaned by AIDS is projected to increase substantially in the period to 2010. Survival and well-being of children of HIV-positive mothers will depend on their own HIV status and also on their parents' health status.

As part of the Karonga Prevention Study in Malawi, the survival and physical well-being of children by maternal HIV status and parental mortality has been examined in a retrospective cohort study with a follow-up of over 10 years.

From population-based surveys in Karonga District, Malawi, in the 1980s, 197 individuals were identified as HIV-positive. As a comparison group, 396 HIV-negative individuals were chosen to match the HIV-positive individuals for age, sex, area of residence at the time of the survey and family structure. All 593 individuals together with their spouses and offspring were followed up in 1998-2000. An interview was conducted with the individual themselves, a guardian or an appropriate proxy. Adults were tested for HIV, after counseling and if consent was given, and post-test counseling was given to those who wanted to know their results. Data were collected on mortality and recent morbidity. Anthropometric measurements were also recorded. A verbal postmortem was filled for deaths, using different questionnaires for deaths in the neonatal period, in childhood or in adulthood. The verbal postmortems were independently reviewed by three physicians.

Four groups of children were defined according to the HIV status of the mother at the time of the child's birth and evidence of subsequent seroconversion in the parents. Group 1 had an HIV-positive mother. In group 2, the mother may have been HIV-positive. Group 3 were children where the mother was HIV-negative at the time of the child's birth but there was evidence of subsequent seroconversion in the mother or father. Group 4 were children of HIV-negative mothers. Of the 593 index individuals, 582 were traced, identifying 2,520 offspring, of whom 1,141 could be assigned to groups 1-4. These 1,141 children were born to 407 mothers (160 HIV-negative and 45 HIV-positive index mothers, and 202 spouses of index fathers). Eighteen children were born to parents who were both HIV-positive index individuals.

Among those with HIV-positive mothers, mortality was 27 percent in infants, 46 percent in those under 5 years and 49 percent in those under 10 years. The corresponding figures for those with HIV-negative mothers were 11 percent, 16 percent and 17 percent. Death of HIV-positive mothers, but not of HIV- negative mothers or of fathers, was associated with increased child mortality. Among survivors who were still resident in the district, neither maternal HIV status nor orphanhood was associated with stunting, being wasted, or reported ill-health.

Mortality in children under 5 years is much higher in children born to HIV-positive mothers than in those born to HIV-negative mothers. With 10 percent of pregnant women HIV-positive, the researchers estimated that approximately 18 percent of under-5 deaths in this population are attributable to HIV. Most of the excess is attributable to vertical transmission of HIV. The findings suggest that, in terms of physical well-being, the extended family in this society has not discriminated against surviving children whose parents have been ill or have died as a result of HIV/AIDS.

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