Neonatal mortality trends
Of the three AIDS models reviewed, only the UCT paediatric HIV model estimates NMR. This output was compared against UN-IGME and IHME estimates and vital registration data. The UN-IGME NMR trend remains higher than the trend from the UCT model but both show minimal decline over the past two decades (Fig. 3). The IHME NMR estimates follow the IHME U5MR trend with a peak in 2005. The rate of decline for neonatal mortality is significantly slower than under-five mortality after the neonatal period (Table 3). The ARR for NMR between 1990 and 2011 is 2.3% per year predicted by the UCT model, compared to 1.5% per year predicted by UN-IGME (Table 3). Data from vital registration combined with data from the District Health Information System confirms slow progress and suggests that the NMR has been virtually stagnant over the past decade . Contrary to other estimates and empirical data, the neonatal ARR according to IHME between 1990 and 2010 is 7.2% per year.
To our knowledge this is the first analytical comparison of AIDS models estimates and national and global data for the under-five mortality trends and child deaths due to AIDS in South Africa over this critical time period. In 2005, South Africa was one of only four countries globally with an under-five mortality rate higher than the 1990 baseline for the Millennium Development Goals. Over the past 5 years, all models and data sources agree that the nation has achieved one of the fastest rates of child mortality reduction in the world. This rapid decline is likely due to reduction in AIDS deaths through the scale up of PMTCT and expanded roll-out of ART services.
Given the different assumptions across the three AIDS models we expected wider variation in the mortality output estimates. Yet in terms of the overall trajectory since the start of the HIV epidemic there is consistency across the three AIDS models (Figs. 1 and 2). The rate at which AIDS deaths declined as a proportion of all child deaths was fastest in Spectrum. The UCT model predicted the highest proportion of child deaths due to AIDS in the most recent years. This could be due to the fact that the UCT model assumes a greater proportion of deaths in children infected vertically occur after the first year of life, with the result that AIDS deaths take longer to respond to changes in perinatal transmission rates compared with the other models. Additionally, the younger age distribution of paediatric ART initiation in the Spectrum and ASSA2008 models would lead to a faster decline in deaths in children under 5 years of age compared with the UCT model. In light of new programme data since the ASSA2008 release , ASSA has cautioned users to be aware that the model is likely to overstate the extent of recent AIDS mortality. AIDS deaths in ASSA2008 begin to level off after 2010 reflecting the absence of any allowance for new strategies in ASSA2008 (e.g. triple-drug prophylaxis in pregnant women, nevirapine prophylaxis in breastfed children and early ART initiation in infants). Furthermore, the ASSA2008 model assumes a lower percentage of women received HIV testing than recent data suggest, and neither ASSA2008 nor the UCT model allows for low rates of transmission amongst mothers who were on ART prior to conception.
The UN-IGME and IHME Global Burden of Disease Study 2010 estimates follow the same U5MR trend as the AIDS models, with levels peaking mid-decade followed by a rapid decline. The Global Burden of Disease Study 2010 estimates for South Africa address the increase in completeness in registration over the past decade, a problem that plagued previous IHME estimates . This concurrence across sources is new and may serve to minimize confusion among health planners and programmers. An ongoing collaborative and country-driven process defined by these criteria will further improve existing models as well as the quality of empirical data.
Given the accelerated pace of programmatic change, there is an increased urgency for frequent, reliable empirical data at national, provincial, and ideally, district level for rational health planning. Misclassification of AIDS deaths is still a major cause for concern in the vital registration data. Improvements in South Africa's death registration data systems include strengthening of the current vital registration system as well as regular household surveys with full pregnancy histories and sibling survival histories. In order to improve the quality of vital registration data, training in accurate completion of death certificates is critical, particularly the identification of AIDS as the underlying cause of death when appropriate. There is also scope to consider a verbal autopsy system for child deaths, which are reported outside health facilities and certified by someone other than a medical practitioner .
Officially, South Africa remains one of the countries making ‘insufficient progress’ to achieve the Millennium Development Goal 4 U5MR target of 21 by 2015 . Between 1990 and 2005 South Africa's rate of progress was worse than conflict-ridden countries of Iraq, Somalia and the Democratic Republic of the Congo. However, mortality has declined significantly since the middle of the last decade and South Africa's average annual rate of decline between 2006 and 2011 (10.3% according to UN-IGME) is the fourth fastest globally, with Rwanda being the only country in the region to achieve faster progress . The recent rate of decline is similar to improvement in other middle-income countries lauded for progress in reducing child mortality such as Brazil (ARR of 8.1%) and China (ARR of 8.5%).
Although interventions to address HIV/AIDS have been undertaken in the broader context of the district health system, mortality audit data and sample sites across the country also indicate that these interventions have reduced AIDS deaths without a significant knock-on effect for other causes of child death. The trajectory for child survival has shifted as PMTCT services and ART have become more widely available (Fig. 4) . Access to treatment and improved survival rates have meant that the overall HIV prevalence amongst women attending antenatal care has not changed significantly nationally since 2005 . Uptake of PMTCT services is high, with more than 98% of women getting tested for HIV during pregnancy and 92% of HIV-positive mothers receiving peripartum ART or prophylaxis in 2010 . The decline in the rate of vertical transmission before 6 weeks has exceeded expectations and has led to calls for the elimination of perinatal HIV transmission, but there is more work to be done. Significant variability remains in PMTCT service coverage and quality across the country and the scale-up of child ART has been slower than PMTCT services . In addition, the potential of postnatal transmission through breastfeeding must continue to be addressed in light of the welcome policy shift towards exclusive breastfeeding since 2010.
As non-AIDS deaths contribute an increasing proportion of under-five deaths, addressing these with a similar fervour to that shown to HIV/AIDS is a vital next step for the national child survival agenda. Over the past decade, the evidence does not point to large changes in other leading causes of death such as diarrhoea or pneumonia, or neonatal deaths . The 2009 introduction of the rotavirus and pneumococcal conjugate vaccines have likely contributed to subsequent mortality decline but the full impact likely would not be seen during the period under analysis due to a slow start to rollout and low coverage. South Africa's rates of immediate (within the first hour after birth) and exclusive breastfeeding are amongst the lowest in the world  and suggest a need for increased attention to this important intervention. The confusion around appropriate breastfeeding messages at the height of the HIV/AIDS epidemic may have led to poorer outcomes for HIV-negative children. An intersectoral approach to address water and sanitation, food security and improved access to social grants though a continuum of care that links care during pregnancy, childbirth, the postnatal period and childhood is required to target the country's remaining preventable deaths.
Both the data and programmatic action remains a challenge for neonatal deaths in particular (Panel 1). Although the UCT model and national data show NMR levels low and stagnant, UN-IGME suggests a higher level of NMR with slow progress. IHME estimates suggest rapid recent change in line with the U5MR trend but this is not based on the non-AIDS U5MR [28,31–35]. Across all available data the ARR for NMR over the second half of the last decade is slower than the reduction in deaths amongst children aged 1–59 months. The proportion of under-five deaths that occur in the neonatal period is increasing, making causes of death in the first month of life even more important to consider.
After years of rising mortality rates, the mortality picture for South Africa's children has shifted drastically. Opaque and conflicting messages have been replaced by data that can be used for action and accountability. It is unlikely that South Africa will achieve the MDG 4 target by the 2015 deadline but at the current pace, the target would be met before the end of the decade. Continued efforts to eliminate paediatric HIV transmission are essential, but failure to address other aspects of care including integrated high quality maternal and neonatal care means that child survival progress could stall even before 2015.
The authors acknowledge the helpful inputs from the South African Neonatal and Child Epidemiology Reference Group (SANCHERG) including Debbie Bradshaw, Tanya Doherty, Pam Groenwald, Debra Jackson, Leigh Johnson, Kate Kerber, Lori Lake, Ria Laubscher, Joy Lawn, Wondwassen Lerebo, Neil McKerrow, William Msemburi, Mphele Mulaudzi, Nadine Nannan, Edward Nicol, Mark Patrick, Bob Pattinson, Heston Phillips, Victoria Pillay-van Wyk, Roz Prinsloo, David Sanders, Cindy Stephen, Maletela Tuoane-Nkhasi, Sithembiso Velaphi. We thank Dr Kobus Herbst and Prof Marie-Louise Newell of the Africa Centre for Health and Population Studies surveillance funded by the Wellcome Trust and Africa Centre as well as Kathleen Kahn, Sam Clark, and Benn Sartorius of the Agincourt Health and Demographic Surveillance Site for providing data and comments.
K.J.K and J.E.L. conceived the analysis. K.J.K. wrote the first draft of the article. D.S. and D.J. were involved in the inception, design and supervised the project. R.E.D., L.J., M.M., H.P., W.M., N.P.W., M.O., N.N. and D.B. contributed the latest data from the models and empirical sources and compared outputs. All authors contributed to revisions of the article, approved the final article and take responsibility for the content.
Funding received: We acknowledge funding from the Bill & Melinda Gates Foundation through Saving Newborn Lives—a programme of Save the Children (K.J.K., J.E.L.), the Child Health Epidemiology Reference Group (K.J.K., J.E.L., D.J.), the South African National Research Foundation (D.J.).
Conflicts of interest
There are no conflicts of interest.
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AIDS models; child mortality; epidemiology; Millennium Development Goals; neonatal mortality; prevention of mother-to-child transmission; South Africa
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