Solving Operational Bottlenecks to achieve the NSP targets for Children Infected and Affected by HIV and AIDS Burden and Impact of HIV and AIDS in South African children. more questions than answers Debbie Bradshaw Burden of Disease Research Unit
Outline of presentation What do we know about mortality in children? What do we know about prevalence in children? What do models say about the burden and impact of HIV and AIDS in children? What does this mean for monitoring the NSP?
Demographic and Health Surveys Under 5 mortality, South Africa Deaths per 1 livebirths 1 8 6 4 2 1975 198 1985 199 1995 2 25? SADHS 1998 SADHS 1988-92 SADHS 23 Source: Department of Health
Agincourt DSS 1 Death rate for children <5 years, Agincourt Death rate per 1 8 6 4 2 1992-93 1994-95 1996-97 1998-99 2-1 22-3 Male Female Source: Kahn, 26
Registered deaths of children <5 8, Number of deaths under-5 years of age StatsSA and Population register 6, 4, 2, 1994 1995 1996 1997 1998 1999 2 21 22 23 24 25 26 Population register Stats SA Source: Stats SA and MRC
Completeness of population register 1 Completeness of < 5 population registration HA compared with Stats SA data Percentage 9 8 7 6 5 4 3 2 1 1-4 1998 1999 2 21 22 23 24 Source: Stats SA and MRC
Source: Stats SA Under 1 Deaths - STATS SA 1 9 8 7 6 5 4 3 2 WC EC NC FS KZN NW GT MP LIM 1 1997 1998 1999 2 21 22 23 24
Cause of death by age, 22 Causes of death under-5 years by age in 22, Stats SA 3 Other causes Number of deaths 25 2 15 1 Endocrine, nutritional and metabolic diseases (E-E9) External causes of morbidity and mortality (V1-Y98) Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R-R99) Diseases of the respiratory system (J-J99) 5 Certain infectious and parasitic diseases (A-B99) 1-7 days 8-28 days 29 days - 11 months 1 year 2-4 year Certain conditions originating in the perinatal period (P-P96) Age group Source: Stats SA
Number of deaths under-5 years of age ASSA23, StatsSA and Population register 12, 1, 8, 6, 4, 2, 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 StatsSA Population register ASSA23 Source: ASSA23, Stats SA and MRC
Estimated cause of death profile < 5 years, South Africa 2 Congenital abnormalities 4% Nutritional deficiencies 5% Noncommunicable 3% Injuries 5% HIV/AIDS 34% Perinatal conditions 28% Other infectious and parasitic excl HIV/AIDS 21% Source: Bradshaw et al., 24
Estimated child mortality by province, 2 3 Children under 5 years by province, 2 Deaths per 1 population 25 2 15 1 5 EC FS GT KZN LP MP NW NC WC Injuries Non-communicable diseases HIV/AIDS Other communicable diseases, perinatal and nutritional conditions Source: Bradshaw et al., 24
Source: ASSA23, HSRC 25, UNAIDS 26 What do we know about the prevalence of HIV in children? 1.% 9.% 8.% 7.% 6.% 5.% 4.% 3.% 2.% 1.%.% 2-4 5-9 1-14 2-14 ASSA23 HSRC5 UNAIDS
Projected impact of HIV - prevalence, incidence, AIDS deaths and orphans Number HIV+ and orphans 7 6 5 4 3 2 1 7 6 5 4 3 2 1 New infections and AIDS deaths 199 1992 1994 1996 1998 2 22 24 26 28 21 212 214 Total HIV+ AIDS orphans New infections AIDS deaths Source: ASSA23
Projected number of orphans (under age 18 years) 5. 4.5 4. 3.5 3. 2.5 2. 1.5 1..5. 199 1992 1994 1996 1998 2 22 24 26 28 21 212 214 Number of orphans (millions) Total orphans Paternal orphans Maternal orphans Double orphans Source: ASSA23
Projected proportion of all children whose mother has died under age 2, 6, 12 and 18 years 26% 24% 22% 2% 18% 16% 14% 12% 1% 8% 6% 4% 2% % 199 1992 1994 1996 1998 2 22 24 26 28 21 212 214 Maternal orphans as % of all children under-2 under-6 under-12 under-18 Source: ASSA23
Projected number of infected babies 6 5 4 3 2 1 2 21 22 23 24 25 26 27 28 29 21 211 212 213 214 215 Infected by breast-milk Infected perinatal Source: ASSA23
So what can we say? HIV is a major cause of the burden of disease in children and can be expected to continue Higher than expected child prevalence needs investigation including modes of transmission and the appropriateness of the models Data to monitor child mortality must be improved as part of the NSP Survey data needs to be improved Vital registration data needs to be improved for children
HMN Domains of Measurement Determinants of Health Socio-economic and demographic factors Environmental and behvioural risk factors Health System Inputs Outputs Outcomes Policy Information Coverage Financing Service Utilisation Human resources (availability Organisation and quality) Health status Mortality Morbidity/ Disability Well-being
Need to strengthen monitoring of the burden of HIV and AIDS on children Monitoring PMTPC in facilities Sentinel PCR testing of babies Facility based mortality audit through PIP and ChIP Population based surveys (programme coverage and mortality) Improve registration of deaths
Acknowledgments MRC Burden of Disease Research Unit MRC Biostatistics Unit UCT Center for Actuarial Research www.mrc.ac.za/bod/bod.htm