Meeting international goals in child survival and HIV/AIDS

Background: After a decade of focused efforts to reduce under-5 mortality results have been mixed, with the HIV/AIDS epidemic often used to explain reversing trends. We investigated this assumption by estimating HIV-attributable under-5 mortality in 39 countries in sub-Saharan Africa and comparing it to total mortality in children younger than 5 years between 1990 and 1999. Methods: Annual HIV-attributable under-5 mortality was estimated in a four-step process with previously obtained data from antenatal clinics in 39 countries based on HIV sero-prevalence among pregnant women. This process produced estimates of: the number of children born to HIV-infected women; the number of children infected via mother-to-child-transmission of HIV; the number of HIV-infected children who died before age 5 years; and the number of HIV-infected children who died before age 5 years adjusted for competing causes of mortality. Findings: An estimated 330 000 children younger than age 5 years died in sub-Saharan Africa in 1999 with HIV infection. When corrected for competing causes of mortality, HIV infection caused 7.7% of under-5 deaths in 1999, a significant rise from 2% in 1990. Five countries (Botswana, Namibia, Swaziland, Zambia, and Zimbabwe) have rates of HIV-attributable under-5 mortality of above 30 per 1000. An additional 16 countries have HIV-specific under-5 mortality rates between 10 and 25 per 1000. The remaining 18 countries have rates under 10 per 1000. Interpretation: HIV/AIDS is an increasingly important cause of under-5 mortality in Africa. However, in many African countries, slowing or reversal of trends in child mortality cannot be explained by HIV alone. To meet international goals for reductions in child mortality, efforts must continue to focus on HIV/AIDS, but must also strengthen health systems that can deliver available interventions for the other major killer diseases of children in the developing world.