Michel Garenne

*Institut Pasteur, Epidémiologie des Maladies Emergentes, Paris, Institut de Recherche pour le Développement (IRD), France* 

#### **1. Introduction**

236 Social and Psychological Aspects of HIV/AIDS and Their Ramifications

Population Reference Bureau (n.d.). *Rooting out AIDS-related stigma and discrimination*.

Republic of Botswana (2002a). *Botswana AIDS Impact Survey 2001*. Central Statistics Office.

Republic of Botswana (2002b). *Botswana National Strategic Framework for HIV/AIDS 2003-2009*.

Tabengwa, M., Menyatso, T., Dabutha, S., Awuah, M., Stegline, C. (2001). *Human rights, gender* 

UNAIDS (2007). *Reducing HIV Stigma and Discrimination: a critical part of national AIDS programmes*. Geneva: Joint United Nations Programme on HIV/AIDS. USAID (2006). *Can We Measure HIV/AIDS-Related Stigma and Discrimination? Current Knowledge* 

National AIDS Coordinating Agency. Gaborone, Botswana

June., Gaborone: Ministry of Labour and Home Affairs: 35-42.

*about Quantifying Stigma in Developing Countries*. USAID.

Accessed on 11/03/2011.

Gaborone, Botswana

http://www.prb.org/Template.cfm?Sectio...RelatedStgma\_and\_Discrimination.htm,

*and HIV/AIDS: analysis of the existing legal system and its shortcomings*; In Republic of Botswana: report of the First National Conference on Gender and HIV/AIDS, 21-23

> Child survival improved dramatically throughout the world over the past century. Measured as the under-five death rate (the probability of dying before reaching the fifth birthday), child mortality declined from values as high as 300 to 600 per 1000 live births to values as low as 5 to 10 per 1000 in most advanced countries, sometimes even lower, and values around or below 100 per 1000 in most developing countries. [Stolnitz, 1955 & 1965; United Nations, 1982; Ahmad et al., 2000] In industrialized countries this mortality decline was associated firstly with the development of hygiene, clean water supply, sanitation, improved nutrition, and more recently with major advances in preventive and curative medicine. [Szreter, 2003] In developing countries of Africa and Asia, child mortality decline seems more associated with preventive and curative medicine, and less so with hygiene and nutrition, although these have also improved in most cases. [Preston, 1980; Feachem and Jamison, 1991; Ahmad et al., 2000; Jamison et al., 2006]

> Beyond regular improvements associated with economic development, social change and modern medicine, reversals in the health transition might occur as a result of external shocks, such as emerging diseases. When a new very lethal disease appears, it may cause an increase in child mortality, despite a decline in mortality from other causes of death. Since 1980, the most important of these emerging diseases is HIV/AIDS, and the continent the most hardly hit by HIV is sub-Saharan Africa. [Newell et al., 2004; UNAIDS, 2010; Jamison et al., 2006] In addition to emerging infectious diseases, other heath threats could also contribute to increasing mortality, for instance various pollutions or exposure to health hazards which may cause cancer, and behavioural changes such as smoking, substance abuse and obesity, although these are more likely to affect adults than under-five children.

> Sub-Saharan Africa is very heterogeneous in terms of level of income, level of education, hygiene and sanitation, as well as culturally. Some countries are already quite advanced and modern (e.g. countries in the Southern cone), whereas others lag behind, with low income, low education, low hygiene and poor public health (e.g. Sahelian countries). The effects of an external shock such as an emerging disease are therefore likely to differ among these countries, partly because the spread of the disease might differ, partly because the response to it might differ, and partly because baseline values also differ. Trends in under-five mortality are also determined by other dynamics, and are often related with political

The Impact of HIV/AIDS on the Health Transition Among Under-Five Children in Africa 239

Fig. 1. Sub-Saharan African countries with DHS surveys, by large area

data are given in Purchasing Power Parity (PPP), and in constant 1990 dollars.1

'Constant value' of the dollar corrects for inflation overtime.

Data on under-five mortality were drawn from the maternity histories recorded in Demographic and Health Surveys (DHS). These surveys provide data that allow one to compute age specific death rates by period, and therefore the under-five death rate by calendar year. All 38 countries for which data were available were kept for the final analysis, covering most of continental sub-Saharan Africa, and several islands (see Figure 1). Data on HIV seroprevalence among pregnant women were taken primarily from the UNAIDS database. [UNAIDS, 2008] When necessary, they were completed with data from DHS surveys in a few countries. Data on Gross Domestic Product (GDP) were drawn from the data base built by Angus Maddison and colleagues in its latest edition [2010]. These income

The method for reconstructing under-five mortality trends has been explained in details in other documents [Garenne & Gakusi, 2004]. In brief, age specific death rates are computed

1'Purchasing Power Parity' corrects for the value of a common basket of goods across countries.

**2. Data** 

**3. Methods** 

stability (or crises) and with economic growth (or recessions), and with the local development of public health, so that the whole picture might appear confusing at first glance.

HIV stroke Africa in the mid-1970's, and spread rapidly throughout the continent, and extensively in Eastern and Southern Africa, with some pockets in West and Central Africa. [Buve et al., 2002; UNAIDS, 2010] By the mid-1990's HIV prevalence was already high in about half of African countries and increasing rapidly, with values ranging from 5% to 15%, well beyond the 1% threshold considered necessary for a rapid spread in the general population. By the mid-2000's the epidemics had stabilized, and HIV prevalence was declining in most countries. Data on HIV prevalence deal primarily with adults aged 15-49 years, and often ignore the children. However, mother to child transmission of HIV is common, either before birth, during delivery or after delivery through breastfeeding, so that a significant proportion of newborns are infected with the virus, and likely to die shortly afterwards. Until recently, HIV infection to children born to HIV positive mothers was common and resulted in high mortality. Since then, efforts were made to limit the mother to child transmission by various means, and to treat infected children with newly available drugs.

The dynamics of HIV epidemics in Africa vary widely, with some countries heavily infected (as in Southern Africa) and some other hardly touched by the disease (as in Sahelian West Africa). As a result, the net effect of HIV/AIDS on child mortality is likely to be contrasted, depending on the country.

Several studies have tried to estimate the net effect of HIV/AIDS on child mortality in Africa. [Houweling et al. 2006; Korenromp et al., 2004, Mahy, 2003]. Adetunji [2000] provided an overview by comparing point estimates of under-five mortality in the late 1980's and early 1990's with the late 1990's, using published estimates from Demographic and Health Surveys (DHS). He showed an increase in mortality in countries with high HIV seroprevalence, but a decline in others. He found that in Africa HIV mortality accounted from 13% to 61% of under-five mortality depending on the country. Newell et al. [2004] conducted a similar exercise by using parameters of survival after HIV infection drawn from empirical evidence, and concluded that by year 2002 some 10% of deaths of children were caused by HIV/AIDS. Zaba et al. [2003] compared several countries, and found that HIV/AIDS could account from 10% of deaths of under-five children (in Malawi) to 60% (in Botswana). Walker et al. [2002] found 7.7% of under-five children due to HIV in 1999 in 39 African countries, with a range from 0.4% to 42% (in Botswana). Several authors have reproduced the figures recently issued by UNAIDS, and quote a value of 4.4% of under-five deaths due to HIV/AIDS in Africa [Black et al., 2010; Stanecki et al., 2010].

The aim of this paper is to provide a synthesis on the probable impact of HIV/AIDS on child mortality trends in Africa, in a broad historical context since 1950. We will stop in year 2005, the time when HIV/AIDS mortality was the highest among children. The situation changed after this date with respect to mother to child transmission and treatment with antiretroviral therapy. Furthermore, data were lacking after 2005 for many of countries selected for the study. We will focus on long term trends, and on the heterogeneity between countries, summarized in large areas or groups of countries. This study is an extension of earlier work which presented a full scale reconstruction of under-five mortality trends in countries of sub-Saharan Africa since 1950. [Garenne, 1996; Garenne & Gakusi, 2004 & 2006a]

Fig. 1. Sub-Saharan African countries with DHS surveys, by large area
