DHS COMPARATIVE

REPORTS 35

CHILD SURVIVAL BY HIV STATUS OF 

THE MOTHER: EVIDENCE FROM DHS 

AND AIS SURVEYS

SEPTEMBER 2014

This publication was produced for review by the United States Agency for International Development (USAID). The report was prepared by

Joy Fishel, Ruilin Ren, Bernard Barrere, and Trevor Croft of ICF International.

DHS Comparative Reports No. 35 

Child Survival by HIV Status of the Mother: 

Evidence from DHS and AIS Surveys 

Joy D. Fishel 

Ruilin Ren 

Bernard Barrère 

Trevor N. Croft 

ICF International 

Rockville, Maryland, USA 

September 2014 

Corresponding author: Joy D. Fishel, International Health and Development, ICF International, 530 

Gaither Road, Suite 500, Rockville, Maryland, USA; phone 301-407-6500; fax: 301-407-6501; Email: 

joy.fishel@icfi.com 
Acknowledgments: The authors thank Thomas Pullum for providing input into the design of the analysis 

and recommendations on how to discuss the results. We are also grateful to Erica Nybro for her ideas on 

how to present the data and for creating several of the figures in the report. 

Editor: Bryant Robey 

Document Production: Yuan Cheng 

This study was carried out with support provided by the United States Agency for International 

Development (USAID) through The DHS Program (#GPO–C–00–08–00008–00). The views expressed 

are those of the author and do not necessarily reflect the views of USAID or the United States 

Government. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. For additional information about the DHS Program contact: 

DHS Program, ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA; phone: 301-

407-6500, fax: 301-407-6501, email: reports@dhsprogram.com, Internet: www.dhsprogram.com. 

Recommended citation: 

Fishel, Joy D., Ruilin Ren, Bernard Barrère, and Trevor N. Croft. 2014. Child Survival by HIV Status of 

the Mother: Evidence from DHS and AIS Surveys. DHS Comparative Reports No. 35. Rockville, 

Maryland, USA: ICF International. 
iii 

Contents 

Tables ........................................................................................................................................................... v 

Figures .......................................................................................................................................................... v 

Preface ........................................................................................................................................................ vii 

Abstract ....................................................................................................................................................... ix 

Executive Summary ................................................................................................................................... xi 

1. Introduction ............................................................................................................................................ 1 

2. Background ............................................................................................................................................ 3 

2.1. MTCT Rates and Timing of Transmission .................................................................................... 3 

2.2. Mortality Rates for Children with HIV ......................................................................................... 4 

2.3. Interventions to Reduce MTCT and Promote the Survival of Children Living with HIV ............. 4 

2.4. Differential Mortality Rates among Children of Women with and without HIV .......................... 6 

2.5. DHS Data in Context: What Do We Expect to Find? ................................................................... 7 

3. Data and Methods .................................................................................................................................. 9 

3.1. Limitations .................................................................................................................................. 10 

4. Results ................................................................................................................................................... 13 

5. Conclusions ........................................................................................................................................... 31 

References .................................................................................................................................................. 33 

v 

Tables 

Table 1. Surveys included in the analysis, HIV prevalence, number of women tested for HIV, number 

of HIV-positive women in the survey, and total fertility rate ...................................................... 10 

Table 2. Child mortality rates and confidence intervals for the 0-4 years preceding the survey, by 

HIV status of the mother at the time of the survey ...................................................................... 14 

Table 3. Relative risks of mortality of children of HIV-positive women compared with children of 

HIV-negative women, 0-4 years preceding the survey ................................................................ 24 

Figures 

Figure 1. Childhood mortality ratios by current HIV status of the mother ................................................ 16 

Figure 2. Relative risk of mortality of children of HIV-positive women compared with children of 

HIV-negative women, 0-4 years before the survey, only statistically significant results 

shown .......................................................................................................................................... 25 

Figure 3. Relative risk of under-five mortality of children of HIV-positive women to mortality of 

children of HIV-negative women by survey year, 0-4 years before the survey, only 

statistically significant results shown ......................................................................................... 27 

Figure 4. Trends in under-five mortality rates for children of HIV-positive women, 0-4 years before 

the survey .................................................................................................................................... 29 

vii 

Preface 

The Demographic and Health Surveys (DHS) Program is one of the principal sources of international data 

on fertility, family planning, maternal and child health, nutrition, mortality, environmental health, 

HIV/AIDS, malaria, and provision of health services. 

One of the objectives of The DHS Program is to provide policymakers and program managers in low- and 

middle-income countries with easily accessible data on levels and trends for a wide range of health and 

demographic indicators. DHS Comparative Reports provide such information, usually for a large number 

of countries in each report. These reports are largely descriptive, without multivariate methods, but when 

possible they include confidence intervals and/or statistical tests. 

The topics in the DHS Comparative Reports series are selected by The DHS Program in consultation with 

the U.S. Agency for International Development. 

It is hoped that the DHS Comparative Reports will be useful to researchers, policymakers, and survey 

specialists, particularly those engaged in work in low- and middle-income countries. 

Sunita Kishor 

Director, The DHS Program 

ix 

Abstract 

Mother-to-child transmission of HIV is the predominant cause of HIV infection in children. In the 

absence of treatment, children infected with HIV experience higher mortality rates than their HIVnegative counterparts. However, rapidly expanding programs for the elimination of mother-to-child 

transmission hold promise for greatly reducing the number of new pediatric HIV infections and 

improving the survival of children of HIV-positive women. 

This report presents the results of a bivariate analysis of data from 20 surveys in 13 countries conducted 

under the DHS Program between 2003 and 2012 in order to compare the levels of child mortality among 

children of HIV-positive and HIV-negative women, and to explore changes over time. Across all surveys 

in the analysis, children of HIV-positive women generally experience higher mortality rates than children 

of HIV-negative women. In 17 of 20 surveys studied, children of HIV-positive women have significantly 

higher under-five mortality rates than children of HIV-negative women. The relative risks range from 1.5 

in the 2011 Cameroon DHS to 3.6 in the 2006 Swaziland DHS. The results show little evidence of 

improvement in the survival of children of HIV-positive women compared with children of HIV-negative 

women over time. 

xi 

Executive Summary 

Mother-to-child transmission of HIV is the predominant cause of HIV infection in children. In the 

absence of treatment, children infected with HIV experience much higher mortality rates than their HIVnegative counterparts. However, rapidly expanding programs for the elimination of mother-to-child 

transmission (EMTCT) hold promise for greatly reducing the number of new pediatric HIV infections and 

improving the survival of children of HIV-positive women. 

This report analyses data from 20 surveys in 13 countries conducted under the DHS Program in order to 

compare the levels of child mortality among children of HIV-positive and HIV-negative women, and to 

explore changes over time. The child mortality rates are calculated from information gathered in the birth 

history in the woman’s interview, while the woman’s current HIV status is taken from an HIV test 

conducted as part of the surveys. The analysis consists of bivariate associations between child mortality 

and maternal HIV status for each individual survey. Mortality rates are presented for children of HIVpositive women, children of HIV-negative women, and all children combined. The analysis also 

calculates unadjusted relative risks to measure the probability of dying among children of HIV-positive 

women compared with the probability of dying among children of HIV-negative women. 

Across all surveys in the analysis, children of HIV-positive women generally experience higher mortality 

rates than children of HIV-negative women. In 17 of 20 surveys studied, children of HIV-positive women 

have significantly higher under-five mortality rates than children of HIV-negative women. These relative 

risks range from 1.5 in the 2011 Cameroon DHS to 3.6 in the 2006 Swaziland DHS. The greater risk of 

death among children of HIV-positive mothers compared with those of HIV-negative mothers is observed 

for all age groups, except during the neonatal period during which the mortality rates for children of HIVpositive and HIV-negative women are similar. The postneonatal period (1-12 months) appears to be the 

period during which children of HIV-positive women experience the greatest increased risk of mortality, 

with children of HIV-positive women being 3.2 times as likely to die as children of HIV-negative women, 

according to the average relative risk across all 20 surveys. 

To examine change over time, the analysis compared the mortality rates of children of HIV-positive and 

HIV-negative women in seven countries with two successive surveys. The results show little evidence of 

improvement in the survival of children of HIV-positive women compared with children of HIV-negative 

women in these countries over time. However, it is important note that due to the timing of data collection 

and the length of the reference periods for the surveys, many of the children in the analysis may have 

been exposed to HIV at a time when coverage of EMTCT interventions and anti-retroviral therapy was 

much lower than current levels, and when the interventions available, such as single-dose nevirapine, 

were less effective than those currently recommended. If the current goal of virtually eliminating new 

HIV infections in children is achieved and sustained for several years, population-based surveys will 

reflect the impact with diminishing differences between the mortality rates of children of HIV-positive 

and HIV-negative women. 

1 

1. Introduction 

In 2012, an estimated 260,000 children became newly infected with HIV/AIDS (UNAIDS 2013). In the 

absence of treatment, children infected with HIV experience high mortality rates, with some studies 

estimating that 35-59 percent of children infected with HIV die before reaching age 2 (Kourtis et al. 

2006). Over 90 percent of children living with HIV are believed to have been infected through mother-tochild transmission (MTCT) (WHO 2010a). The risk of MTCT can be greatly reduced through programs 

for the elimination of mother-to-child transmission (EMTCT), which include antiretroviral (ARV) 

medications for the mother and newborn, among other components. The coverage of national EMTCT 

programs has expanded rapidly since they began in the mid-2000s, but many women and newborns 

remain uncovered. Furthermore, women still receive drug regimens that are not in line with—and are less 

effective than—the latest recommendations (UNAIDS 2011). In addition to high mortality among 

children infected with HIV, uninfected children of HIV-positive mothers may also experience higher 

mortality than children of HIV-negative mothers. For all of these reasons, children of HIV-positive 

women are expected to experience higher mortality, on average, than children of HIV-negative women. 

This analysis attempts to answer three questions: 

1. Do surveys conducted by the Demographic and Health Surveys (DHS) Program provide evidence 

that children of HIV-positive women experience higher mortality rates than children of HIVnegative women? 

2. Does the excess risk of mortality differ by age of the child? 

3. Do the surveys provide evidence of improvement over time in the mortality of children of HIVpositive women, either in absolute terms or relative to the mortality of children of HIV-negative 

mothers? 

The survival of children of HIV-positive women has been measured in cohort studies and clinical trials, 

but little analysis has been done using the data available from nationally representative population-based 

surveys. A number of surveys conducted as part of the DHS Program include both HIV testing and a birth 

history in the woman’s interview. It is possible to use these data to calculate past child mortality rates by 

the current HIV status of the mother. The HIV status of the children themselves is not available, nor is the 

HIV status of the mother at the time the child was born. 

This report analyses data from 20 surveys in 13 countries conducted under the DHS Program in order to 

compare the levels of child mortality among children of HIV-positive and HIV-negative women, and to 

explore changes over time. Data are presented by the traditional component rates of child mortality—

neonatal, postneonatal, infant, child, and under-five mortality—in order to assess differences by age in the 

mortality rates of children of HIV-positive and HIV-negative women. 

3 

2. Background 

The data presented in this report were collected in the context of rapid evolution and expansion of 

EMTCT programs. In order to interpret what the mortality rates from this analysis may indicate about the 

effectiveness of these interventions, it is important first to take into consideration several key pieces of 

information: 

(1) What is the likelihood that a child born to an HIV-positive mother will acquire HIV, in the 

absence of intervention? 

(2) What are the mortality rates for children infected with HIV? 

(3) What standards of care were in place during the reference periods for these surveys, how effective 

are these standards of care, and what percentage of women and children were exposed to them? 

This section provides background information relevant to these questions. The section then summarizes 

the data available from clinical trials and cohort studies on the mortality rates of children of HIV-positive 

and HIV-negative women. Finally, the section applies the key conclusions from the literature to the 

current analysis and discusses some additional considerations that must be made when interpreting the 

mortality data from the surveys included in this report. 

2.1. MTCT Rates and Timing of Transmission 

There is no consensus on the exact probability of transmission of HIV from mother to child, and evidence 

indicates that transmission rates vary across populations. HIV can be transmitted from mother to child 

during pregnancy, during delivery, or during breastfeeding. Estimates for the risk of MTCT in 

breastfeeding populations in the absence of medical intervention generally range from 25 to 45 percent, 

meaning that 25 to 45 percent of children born to HIV-positive mothers acquire HIV (de Cock et al. 

2000). 

To estimate the probability of transmission at various stages from early pregnancy through childbirth, 

Kourtis and colleagues compared the effectiveness of different EMTCT regimens tested in clinical trials 

(Kourtis et al. 2006). Assuming an overall risk of MTCT with no medical intervention and no 

breastfeeding of 25 percent, they estimate that 5 percent of children become infected with HIV during the 

first eight months of pregnancy, 12 percent become infected during the last month of pregnancy, and 8 

percent become infected around the time of delivery. 

Breastfeeding duration is a principal determinant of the overall risk of transmission. Several studies have 

suggested that in the absence of treatment, breastfeeding for up to two years increases the cumulative risk 

of HIV transmission by roughly 10-20 percentage points (Fawzi et al. 2002; Miotti et al. 1999; Nduati et 

al. 2000; BHITS 2004; Dunn 1992), and accounts for around 40 percent of all HIV infections acquired 

through MTCT (Kourtis et al. 2006; Nduati et al. 2000). 
4 

2.2. Mortality Rates for Children with HIV

Mortality rates among children infected with HIV depend on background all-cause mortality, but 

evidence consistently shows that children infected with HIV experience higher mortality rates compared 

with HIV-negative children. In the European Collaborative Study (ECS), a prospective observational 

study to describe the natural history of HIV in children who acquired the infection from their mothers, 10 

percent of children died by age 1, and 28 percent died by age 5 (ECS 1994). 

Studies of HIV-infected children in Africa have found higher mortality rates than in Europe. In African 

settings, it is anticipated that around half of children who acquire HIV from their mothers will die before 

their second birthday (WHO 2010a). According to a pooled analysis of data from seven randomized 

MTCT trials in African countries, the risk of death by age 2 was about nine times higher among infected 

children than among uninfected children. An estimated 35 percent of infected children will die during the 

first year of life, and an estimated 53 percent of infected children will die by age 2 (Newell et al. 2004a). 

An observational study of children born to HIV-positive mothers in Rwanda found that the cumulative 

risk of death among infected children was 26 percent by age 1, 45 percent by age 2, and 62 percent by age 

5. By contrast, the cumulative risk of death at age 5 among uninfected children was only 4 percent (Spira 

et al. 1999). 

Other studies in Africa have also found similar differences in the cumulative mortality rates of infected 

and uninfected children of HIV-positive mothers (Dabis et al. 2001; Brahmbhatt et al. 2006). In short, 

there is strong evidence that HIV-positive children are at higher risk of death than their HIV-negative 

counterparts. At the same time, many HIV-positive children survive to reach age 2, age 5, and beyond, 

even in the absence of antiretroviral therapy (ART). 

Data from the ECS and French Pediatric HIV Infection Study indicate that around 20 percent of HIVpositive children progress to serious illness or death during the first year of life, followed by only around 

5 percent of children per year in years two through five (Stéphane et al. 1997). This rapid progression of 

HIV in some children may be associated with earlier age at infection. Evidence suggests that mortality is 

higher among children infected earlier in life or during pregnancy than among those infected later (Spira 

et al. 1999; Dabis et al. 2001; Marinda et al. 2007; Newell et al. 2004a; Newell et al. 2004b; Zijenah et al. 

2004). Furthermore, children infected during breastfeeding may live for several months before becoming 

infected and experiencing any increased risk of HIV-related mortality (Newell at el. 2004a). Though the 

prospective data for children up to age 5 is limited, these findings suggest that much of the higher 

mortality experienced by HIV-positive children may be accumulated during the first year or two of life. 

2.3. Interventions to Reduce MTCT and Promote the Survival of Children Living with HIV 

Elimination of MTCT involves multiple program elements, ranging from primary prevention of HIV 

infection among women of reproductive age, to prevention of unwanted pregnancies among women living 

with HIV, and to ART for women and their children (UNAIDS 2011). 

There is a substantial body of evidence from numerous clinical trials on the effectiveness of various drug 

regimens for the prevention of MTCT. The first such trial, PACTG 076, involved giving women a short 

course of zidovudine, an antiretroviral medication, during pregnancy and delivery, followed by 

zidovudine for the newborn for six weeks. The rate of MTCT in the experimental group was 8 percent, a 

two-thirds reduction from the 26 percent observed in the comparison group, which received no 

intervention (Connor et al. 1994). 

Though effective, this regimen initially was not feasible in low-resource settings. Less intensive regimens 

were pursued, including in the HIVNET 012 trial in Uganda. This trial involved a single dose of 
5 

nevirapine for the mother at the onset of labor and a single dose of nevirapine for the newborn within the 

first 72 hours. The rate of MTCT was 16 percent by 18 months (Guay et al. 1999; Jackson et al. 2003). 

This regimen was adopted in many low-resource settings due to its affordability and ease of 

administration (Kourtis et al. 2006). The single-dose nevirapine regimen also has its disadvantages, 

including sub-optimal efficacy and an association with drug resistance in both mothers and children 

(Abrams 2004). By contrast, ART during pregnancy and childbirth, with no breastfeeding, has been found 

to prevent nearly all cases of MTCT (Cooper et al. 2002). 

In African settings, increased risk of mortality has been associated with replacing breastfeeding with 

formula feeding (Thior 2006; Kagaayi et al. 2008), and with early and abrupt cessation of breastfeeding 

(Kuhn et al. 2008). Current recommendations call for breastfeeding and use of ART throughout the entire 

period that the child is at risk of acquiring HIV through breast milk (WHO 2013). 

As a reflection of the rapid advancement in this field, the World Health Organization (WHO) has issued 

four revisions in its EMTCT recommendations over the past decade. A brief review of these guidelines 

helps to understand what national policies may have been in place during the reference periods for the 

surveys in this analysis. (Issues pertaining to the reference period are discussed in greater detail in the 

following section, “DHS data in context”.) None of the WHO guidelines have considered single-dose 

nevirapine an optimum regimen; however, the 2004 and 2006 guidelines allowed for single-dose 

nevirapine in some circumstances (WHO 2004; WHO 2006). By the 2010 revision, single-dose 

nevirapine was not considered an advisable regimen anywhere (WHO 2010b). 

Since 2006, the WHO guidelines have recommended providing ART for pregnant women who require 

treatment for their own health, and prophylactic ART during pregnancy, childbirth, and at least some 

period of time after birth for pregnant women who did not satisfy the criteria to begin ART for their own 

health (WHO 2006). This general approach remains in place through the current 2013 guidelines, 

although the eligibility criteria for lifelong ART have expanded, and the prophylactic regimen has been 

strengthened to improve effectiveness, including a recommendation in the 2010 revision to use ART 

through the entire duration of breastfeeding (WHO 2010b). 

There is little evidence on the effectiveness of the exact regimen recommended in the current WHO 

guidelines, but the findings from studies testing various combination ARV regimens have led to a general 

consensus that appropriate intervention can reduce MTCT rates to less than 5 percent in breastfeeding 

populations (Thomas et al. 2011; Tonwe-Gold et al. 2007; SWEN Study Team 2008; Kilewo et al. 2008; 

Kilewo et al. 2009; Coovadia et al. 2012; Kumwenda et al. 2008; Chasela et al. 2010; Jamieson et al. 

2012; Kesho Bora Study Group 2011; Shapiro et al. 2010). 

Treatment innovations and increased availability of resources have been associated with a rapid increase 

in coverage of EMTCT services, and a decrease in the number of HIV infections and HIV-related deaths 

in infants (UNAIDS 2013). As of 2011, however, many countries were still using EMTCT drug regimens 

with sub-optimal efficacy, such as single-dose nevirapine (UNAIDS 2011). In 2012, coverage of EMTCT 

programs using multiple ARV drug regimens was estimated at 62 percent (UNAIDS 2013). 

Interpretation of mortality rates among children of HIV-positive women also requires an understanding of 

the coverage and effectiveness of interventions for children who acquire HIV from their mothers. 

Estimates for 2012 indicate that only 34 percent of eligible children were receiving ART (UNAIDS 

2013). Low coverage of programs for early infant diagnosis of HIV is one of many gaps in the EMTCT 

cascade contributing to lower coverage of ART and high mortality among children infected with HIV 

(Wettstein et al. 2012). 
6 

2.4. Differential Mortality Rates among Children of Women with and without HIV 

Having reviewed the evidence on the rates of MTCT, risks of mortality among children who acquired 

HIV from their mothers, and the effectiveness and coverage of EMTCT interventions, this report now 

discusses the findings from the published literature on differential mortality rates among children born to 

HIV-positive and HIV-negative mothers. 

Several prospective studies have been conducted in both clinic-based and population-based cohorts to 

compare the mortality rates of children born to HIV-positive and HIV-negative mothers. Zaba and 

colleagues analyzed the data from population-based cohort studies in Malawi, Uganda, and Tanzania in 

order to calculate excess child mortality due to maternal HIV infection (Zaba et al. 2005). The original 

studies were conducted in the 1980s and 1990s, when few women had access to EMTCT interventions. 

Across the three studies, the mortality rates of children of HIV-positive women were almost three times 

those of children of HIV-negative women. The probability of death by age 1 was 20 percent for children 

born to HIV-positive mothers, compared with 7 percent for children born to HIV-negative mothers. The 

probability of death by age 5 was 35 percent for children of HIV-positive mothers versus 11 percent for 

children of HIV-negative mothers. The analysis also found that the increased risk of mortality for children 

of HIV-positive mothers compared with children of HIV-negative mothers to be greatest during the first 

year of life and to decrease steadily with age. 

Studies among clinic populations have also found a statistically significant increased risk of mortality 

among children of HIV-positive mothers compared with children of HIV-negative mothers, in spite of 

widespread use of single-dose nevirapine and use of ART among some women. Compared with children 

of HIV-negative mothers, mortality among children of HIV-positive mothers was 2.3 times higher in the 

first year of life in a study in Mozambique, three times higher by age 9 months in a study in Zimbabwe, 

and more than four times higher by age 20 months in a study in Malawi (Naniche et al. 2009; Kurewa et 

al. 2010; Landes et al. 2012). Breaking down the first year of life into the first month (the neonatal period) 

and the remaining 11 months (the postneonatal period), the study in Mozambique found that all of the 

increased risk occurred during the postneonatal period, with no statistically significant differences found 

between the two groups in neonatal mortality (Naniche et al. 2009). 

Some studies have also compared the mortality rates of uninfected children born to HIV-positive mothers 

with those of children of HIV-negative mothers to examine whether or not mother’s HIV status may 

affect their children’s likelihood of survival even when the child is HIV-negative. Findings on this subject 

are mixed, with some analyses finding a significantly increased risk for HIV-negative children of HIVpositive mothers compared with children of HIV-negative mothers (Brahmbhatt et al. 2006; Marinda et al. 

2007), and others not (Landes et al. 2012; Spira et al. 1999). Kuhn and colleagues found that the degree of 

illness in HIV-positive mothers in Zambia was associated with the risk of death and hospitalization of 

their uninfected children (Kuhn et al. 2005). 

The death of the mother has a strong association with child mortality among children of both HIVpositive and HIV-negative mothers (Zaba et al. 2005; Newell et al. 2004a; Dabis et al. 2001; Landes et al. 

2012; Brahmbhatt et al. 2006; Kurewa et al. 2010). The analysis of three population-based studies by 

Zaba and colleagues (2005) perhaps lays out this relationship most clearly. Children of both HIV-positive 

and HIV-negative mothers experienced a risk of mortality during the time period one year before and two 

years after the mother’s death almost four times as high as children whose mothers did not die during the 

study period. Overall, 3 percent of children born into the three study populations experienced the death of 

their mothers: 1 percent of children born to HIV-negative mothers compared with 22 percent of children 

born to HIV-positive mothers. More recent work suggests that maternal mortality (deaths during 

pregnancy, childbirth, or in the 42 days following a birth) is eight times higher among HIV-positive 

women than HIV-negative women (Zaba et al. 2013). Clearly, increased risk of mother’s death is one way 
7 

maternal HIV status may increase the risk of mortality among both HIV-negative and HIV-positive 

children of HIV-positive mothers. 

2.5. DHS Data in Context: What Do We Expect to Find? 

The populations included in this analysis will fall somewhere between the best- and worst-case scenarios 

outlined in the preceding sections. In the worst-case scenario, MTCT rates are estimated at 25-45 percent, 

and roughly half of infected children will die before their second birthday. Mortality rates of children 

under age 5 who are born to HIV-positive women could be three times as high as the mortality rates of 

children born to HIV-negative women. In the best-case scenario, with the interventions recommended 

under current WHO guidelines, MTCT is anticipated to decrease to close to 5 percent, and optimal ART 

coverage for all children and eligible women could largely eliminate the increased risk of mortality for 

children of HIV-positive mothers. 

Given the rapid changes in EMTCT interventions, interpreting the data in this analysis requires an 

understanding of two important issues of timing: (1) what time period the mortality rates refer to, and (2) 

when children in this analysis are likely to have been at risk of acquiring HIV, relative to the time of data 

collection. The year of data collection for the surveys in this analysis ranges from 2003 to 2012. However, 

the mortality rates measured in each survey represent the risk of death during a period of five years 

preceding data collection. Furthermore, the year of birth of some children included in the mortality 

estimates will have occurred before this five-year reference period. For example, a child who has survived 

to age 4 and whose fourth birthday was at the beginning of the five-year reference period would have 

been born nine years before the survey. Children are at risk for MTCT during pregnancy, childbirth, and 

breastfeeding, so the time during which some of the children are likely to have been exposed to infection 

could extend back nearly a decade before the survey. Children who were born in the decade before the 

survey, but who died before the start of the five-year reference period are excluded. So the births 

stretching back eight to nine years will comprise relatively few of the births of children included in the 

analysis. Further, children with these “very early births” will only be included in those mortality rates that 

include children who died at older ages (i.e., the child mortality rates and under-five mortality rates, as 

defined in the Methods section of this report). 

Due to these timing issues, the percentage of women and children in these surveys who received any 

ARV drugs, much less the more effective EMTCT regimens that are currently recommended, is likely to 

be low. Single-dose nevirapine is likely to have been the national protocol for EMTCT during part of the 

reference periods for many of these surveys. As summarized above, WHO did not make a strong 

recommendation for countries to plan to phase out this regimen until 2006, and the WHO guidelines did 

not recommend ARV use throughout the duration of breastfeeding until 2010. Further, national EMTCT 

programs cannot adjust to these changes immediately. Countries need time to incorporate new 

recommendations into their national protocols and to change clinical practice. Fourteen of the twenty 

surveys in this analysis were completed in 2010 or earlier. In addition to less effective regimens being 

used in earlier years, the coverage of these regimens was also lower. For example, in 2005, the percentage 

of pregnant women receiving any ARVs to prevent MTCT, including for their own health, was estimated 

at only 15 percent in sub-Saharan Africa and 22 percent in the Caribbean. By 2008, coverage is estimated 

to have expanded to 45 percent in sub-Saharan Africa and 52 percent in the Caribbean (WHO 2010c). 

The literature provides some information about what to expect in terms of differences in excess risk of 

mortality due to maternal HIV by age of the child, but few clinical trials or prospective observational 

studies followed children long enough to have information on mortality up to age 5. The evidence 

suggests that differences in mortality between children of HIV-positive and HIV-negative women may be 

higher in the first year or two of life, with the exception of the neonatal period, where mortality rates have 

been found to be similar. 
8 

There are some reasons to expect that data from DHS surveys may show smaller differences between the 

mortality rates of children of HIV-positive and HIV-negative women than those in the published 

literature. DHS surveys differ from other sources of data on maternal HIV and child mortality in that they 

are cross-sectional. The cross-sectional nature of the data can produce several biases in this analysis 

(discussed in detail in the Limitations section), most of which would have the effect of underestimating 

the risk of mortality of children of HIV-positive women relative to the mortality of children of HIVnegative women. In addition, the small numbers of HIV-positive women in surveys for lower prevalence 

countries result in small numbers of children of HIV-positive women and low statistical power to detect 

statistically significant differences between the mortality rates of these children and those of children of 

HIV-negative women. 

 
9 

3. Data and Methods

The study uses data from DHS surveys and AIDS Indicator Surveys (AIS) that included a full birth 

history to measure childhood mortality, HIV serology testing, with the datasets for both available for 

analysis, and at least 120 children under age 5 exposed to the risk of mortality in each of the smaller age 

groups in the 0-4 years preceding the survey, excluding the month of interview.1

 The group of surveys 

meeting these criteria includes 20 surveys in 13 countries (see Table 1). As shown in Table 1, the national 

HIV prevalence estimates among women in these surveys range from less than 3 percent in Haiti to more 

than 30 percent in Swaziland. Direct mortality rates corresponding to the period of time 0-4 years 

preceding the survey were calculated for all children whose mothers participated in the survey HIV test, 

and then separately for children of HIV-positive and HIV-negative women.2

 Calculation of the mortality 

rates followed the standard procedures of the DHS Program, described elsewhere (Rutstein and Rojas 

2006). The mortality rates are weighted by the HIV sample weight. The component mortality rates are 

defined as follows: 

Neonatal mortality: The probability of dying in the first month of life 

Postneonatal mortality: The probability of dying after the first month of life but before the first 

birthday, calculated by convention as the difference between the infant 

mortality rate and the neonatal mortality rate 

Infant mortality (1q0): The probability of dying before the first birthday 

Child mortality (4q1): The probability of dying between the first and fifth birthdays 

Under-five mortality (5q0): The probability of dying before the fifth birthday 

Mortality rates, standard errors (SE), and confidence intervals were produced using SAS.3

 Unadjusted 

relative risks, defined as the ratio of the probability of dying among children of HIV-positive women to 

the probability of dying among children of HIV-negative women, were calculated for the five component 

rates for each survey in Excel using a two-tailed t-test. P-values were calculated in Excel using a normal 

approximation. A relative risk (RR) of greater than 1.0 indicates a higher risk of mortality for children of 

HIV-positive women compared with children of HIV-negative women, while an RR of less than 1.0 

indicates a lower risk of mortality for children of HIV-positive women. 

The mother’s HIV status is her HIV status at the time of the survey. HIV status of the mother at the time 

of the birth is not known, and may differ from her status at the time of the survey. HIV status of children 

is not known, nor is their exposure to any EMTCT interventions. No information is given on the cause of 

death. 

 

1

 The smaller age groups are defined as 0, 1-2, 3-5, 6-11, 12-23, 24-35, 36-47, and 48-59 months. Month 0 is used 

for neonatal mortality, all age groups 0-11 months are used for infant mortality and postneonatal mortality (because 

postneonatal mortality is calculated as the difference between infant and neonatal mortality), age groups 12-59 

months are used for child mortality, and all age groups are used for under-five mortality. 

2

 In many of these surveys, HIV testing was conducted in a sub-sample of households. The “total” mortality rates in 

this analysis may differ slightly from those published in the survey reports due to the exclusion of children whose 

mothers were not tested for HIV. 

3

 The confidence intervals used in this report correspond to ±2SE, and are thus slightly wider than a typical 95 

percent confidence interval, slightly increasing the chance of rejecting a true association.
10 

Table 1. Surveys included in the analysis, HIV prevalence, number of women tested for HIV, 

number of HIV-positive women in the survey, and total fertility rate 

Country Survey name 

HIV prevalence 

among women 

age 15-49 

(weighted) 

Number of 

women 

tested 

(unweighted) 

Number of 

women HIV+ 

(unweighted) 

Total 

fertility 

rate (TFR) 

Sub-Saharan Africa

Cameroon Cameroon DHS 2004 6.6 5,155 349 5.0 

Cameroon Cameroon DHS 2011 5.6 7,254 434 5.1 

Cote d’Ivoire Cote d’Ivoire AIS 2005 6.4 4,540 255 4.6 

Cote d'Ivoire Cote d'Ivoire DHS 2011-12 4.6 4,656 209 5.0 

Ethiopia Ethiopia DHS 2011 1.9 15,517 358 4.8 

Gabon Gabon DHS 2012 5.8 5,490 315 4.1 

Kenya Kenya DHS 2003 8.7 3,273 275 4.9 

Kenya Kenya DHS 2008-09 8.0 3,811 318 4.6 

Lesotho Lesotho DHS 2004 26.4 3,034 788 3.5 

Lesotho Lesotho DHS 2009 26.7 3,849 997 3.3 

Malawi Malawi DHS 2004 13.3 2,864 421 6.0 

Malawi Malawi DHS 2010 12.9 7,398 890 5.7 

Rwanda Rwanda DHS 2005 3.6 5,663 222 6.1 

Rwanda Rwanda DHS 2010 3.7 6,952 266 4.6 

Swaziland Swaziland DHS 2006-07 31.1 4,584 1,438 3.8 

Tanzania Tanzania AIS/MIS 2007-08 6.6 8,711 408 5.6 

Zambia Zambia DHS 2007 16.1 5,715 947 6.2 

Zimbabwe Zimbabwe DHS 2005-06 21.1 7,494 1,553 3.8 

Zimbabwe Zimbabwe DHS 2010-11 17.7 7,852 1,463 4.1 

Latin America/ 

Caribbean 

Haiti Haiti DHS 2012 2.7 9,329 249 3.5 

Note: TFR refers to the average number of live births a woman would have if she were subject to the current agespecific fertility rates throughout her reproductive years (age 15-49). Calculated for the three years preceding the 

survey. 

3.1. Limitations 

There are many limitations to any analysis on maternal HIV status and child mortality that uses crosssectional data, as these surveys do. Two of these limitations relate to the potential for underestimating the 

mortality rates for children of HIV-positive women relative to those of children of HIV-negative women, 

while two others address the limited nature of the data available. 

1. Children of deceased mothers are excluded. As noted above, the literature provides evidence that 

children of deceased mothers are at increased risk of mortality, and that children of HIV-positive 

women are more likely to experience a mother’s death than children of HIV-negative women. 

The proportion of children who are excluded due to the death of their mother (and are at higher 

risk of mortality themselves) will be greater in the group of children of HIV-positive women than 
11 

in the group of children of HIV-negative women. Therefore, this selection bias would result in 

greater underestimation in the mortality rates of children of HIV-positive women than in the 

mortality rates of children of HIV-negative women, potentially making the mortality rates for 

these two groups appear to be more similar than they really are. 

2. Children are classified by the HIV status of their mothers at the time of the survey, rather than the 

mother’s status at the time of pregnancy, delivery, or breastfeeding. Some women who are 

currently HIV-positive could have seroconverted since the time they were at risk for passing HIV 

to their children. Thus, some unexposed children will be included in the ‘exposed’ group. This 

misclassification could result in an underestimation of the mortality rates of children of HIVpositive women and thus the degree to which children of HIV-positive women are at increased 

risk of death compared with children of HIV-negative women. 

3. There is no information on the HIV status of children, either surviving or dead. The proportion of 

children of HIV-positive mothers who acquire HIV infection is unknown. It is not possible to 

compare MTCT rates across countries or over time, to assess mortality rates of HIV-positive 

children verses HIV-negative children, or to look for indirect effects of maternal HIV status on 

HIV-negative children of HIV-positive women. 

4. These surveys were not designed for the purpose of comparing the mortality rates of children of 

HIV-positive and HIV-negative women. The low numbers of HIV-positive women and of 

children of HIV-positive women lead to low precision in estimated mortality rates of these 

children. This low precision is particularly limiting when comparing one mortality rate of 

children of HIV-positive women with another, for example, across different component mortality 

rates within a single survey, or comparing rates across surveys to look at trends over time. 

13 

4. Results 

Table 2 presents the mortality rates and confidence intervals for all children, the children of HIV-positive 

women, and the children of HIV-negative women, for each survey. Figure 1 compares the mortality rates 

of children of HIV-positive women with those of HIV-negative women. The group of surveys includes a 

wide range of mortality profiles. The infant mortality rate (IMR) ranges from 36 per thousand live births 

in the 2012 Gabon DHS to 90 in the 2004-05 Lesotho DHS. Under-five mortality ranges from 62 per 

thousand live births in the 2012 Gabon DHS to 147 in the 2004 Cameroon DHS. 
14 

Table 2. Child mortality rates and confidence intervals for the 0-4 years preceding the survey, by 

HIV status of the mother at the time of the survey 

Survey 

HIV status of 

the mother 

Neonatal 

mortality 

Postneonatal 

mortality 

Infant 

mortality 

Child 

mortality 

Under-five 

mortality 

Sub-Saharan 

Africa 

Cameroon 

DHS 2004 

HIV negative 30 (23, 36) 44 (35, 53) 74 (63, 84) 72 (61, 82) 140 (126, 154) 

HIV positive 23 (3, 43) 117 (74, 161) 140 (94, 186) 130 (72, 189) 252 (188, 316) 

Total 29 (23, 35) 48 (39, 57) 78 (67, 88) 75 (65, 85) 147 (133, 161) 

 

Cameroon 

DHS 2011 

HIV negative 33 (27, 39) 27 (21, 32) 60 (51, 68) 67 (57, 78) 123 (109, 136) 

HIV positive 41 (17, 64) 93 (53, 133) 134 (87, 180) 63 (31, 95) 188 (132, 244) 

Total 33 (27, 39) 30 (24, 36) 63 (55, 72) 67 (57, 77) 126 (113, 139) 

 

Cote d’Ivoire 

AIS 2005 

HIV negative 40 (29, 50) 44 (31, 57) 83 (68, 99) 45 (32, 57) 124 (106, 143) 

HIV positive 44 (0, 91) 97 (10, 184) 141 (38, 244) 43 (5, 80) 178 (68, 288) 

Total 40 (29, 50) 47 (35, 59) 86 (72, 101) 45 (32, 57) 127 (110, 145) 

 

Cote d'Ivoire 

DHS 2011-

12 

HIV negative 42 (33, 51) 29 (20, 37) 71 (59, 82) 37 (30, 44) 105 (91, 119) 

HIV positive 55 (5, 106) 116 (31, 200) 171 (80, 262) 45 (4, 86) 208 (118, 298) 

Total 42 (33, 51) 32 (22, 41) 74 (61, 87) 37 (30, 44) 108 (94, 123) 

 

Ethiopia 

DHS 2011 

HIV negative 38 (32, 43) 22 (18, 26) 60 (53, 67) 30 (25, 35) 88 (79, 97) 

HIV positive 49 (0, 105) 16 (0, 38) 65 (5, 125) 49 (8, 90) 111 (42, 180) 

Total 38 (32, 43) 22 (18, 26) 60 (53, 67) 30 (25, 36) 89 (80, 97) 

 

Gabon 

DHS 2012 

HIV negative 23 (16, 30) 14 (9, 19) 36 (28, 45) 28 (19, 37) 63 (51, 76) 

HIV positive 22 (0, 58) 7 (0, 14) 29 (0, 65) 17 (1, 33) 45 (6, 85) 

Total 23 (15, 30) 13 (8, 18) 36 (27, 45) 27 (18, 36) 62 (50, 75) 

 

Kenya 

DHS 2003 

HIV negative 32 (22, 42) 42 (29, 54) 74 (59, 89) 31 (22, 39) 102 (85, 120) 

HIV positive 29 (4, 53) 84 (30, 137) 112 (47, 177) 149 (57, 241) 244 (151, 338) 

Total 32 (23, 41) 46 (33, 58) 78 (62, 93) 42 (30, 54) 117 (97, 136) 

 

Kenya 

DHS 2008-

09 

HIV negative 27 (16, 39) 12 (7, 17) 39 (26, 52) 18 (11, 26) 57 (42, 71) 

HIV positive 36 (8, 64) 60 (30, 90) 96 (56, 136) 104 (37, 171) 190 (119, 262) 

Total 28 (17, 38) 16 (10, 21) 43 (31, 56) 25 (16, 34) 67 (52, 83) 

 

Lesotho 

DHS 2004 

HIV negative 42 (27, 58) 27 (17, 38) 70 (52, 87) 22 (11, 32) 90 (70, 109) 

HIV positive 46 (23, 69) 94 (61, 126) 140 (101, 180) 54 (26, 81) 186 (142, 230) 

Total 44 (31, 56) 46 (34, 58) 90 (74, 106) 32 (21, 43) 119 (101, 137) 

 

Lesotho 

DHS 2009 

HIV negative 36 (25, 47) 20 (12, 29) 56 (42, 70) 17 (8, 26) 72 (56, 88) 

HIV positive 47 (18, 76) 102 (72, 132) 149 (106, 192) 57 (32, 81) 197 (153, 241) 

Total 39 (27, 50) 43 (33, 54) 82 (66, 98) 29 (19, 38) 108 (91, 126) 

(Continued...)
15 

Table 2. – Continued

Survey 

HIV status of 

the mother 

Neonatal 

mortality 

Postneonatal 

mortality 

Infant 

mortality 

Child 

mortality 

Under-five 

mortality 

 

Malawi 

DHS 2004 

HIV negative 31 (23, 40) 43 (31, 54) 74 (60, 89) 55 (41, 69) 125 (105, 146) 

HIV positive 47 (22, 71) 87 (54, 121) 134 (93, 175) 114 (76, 151) 232 (182, 283) 

Total 33 (25, 41) 48 (37, 58) 81 (67, 94) 62 (49, 75) 138 (119, 157) 

 

Malawi 

DHS 2010 

HIV negative 25 (20, 30) 26 (20, 32) 50 (43, 58) 41 (34, 48) 89 (80, 99) 

HIV positive 41 (22, 61) 78 (52, 103) 119 (88, 150) 108 (76, 139) 214 (176, 252) 

Total 26 (21, 31) 31 (25, 38) 58 (50, 66) 48 (41, 56) 103 (93, 113) 

 

Rwanda 

DHS 2005 

HIV negative 33 (27, 39) 46 (38, 53) 79 (68, 89) 63 (53, 72) 136 (123, 150) 

HIV positive 66 (20, 112) 102 (50, 154) 168 (100, 237) 120 (63, 176) 268 (190, 345) 

Total 34 (28, 40) 48 (40, 56) 82 (71, 92) 65 (56, 74) 141 (128, 155) 

 

Rwanda 

DHS 2010 

HIV negative 32 (26, 38) 25 (20, 29) 57 (49, 64) 25 (20, 30) 80 (72, 89) 

HIV positive 44 (10, 79) 74 (33, 115) 119 (67, 170) 47 (14, 79) 160 (107, 213) 

Total 33 (27, 39) 27 (22, 31) 59 (52, 67) 26 (21, 31) 83 (75, 92) 

 

Swaziland 

DHS 2006-

07 

HIV negative 16 (10, 22) 26 (18, 34) 42 (32, 52) 19 (12, 26) 60 (48, 73) 

HIV positive 31 (18, 44) 126 (103, 149) 157 (131, 183) 68 (48, 89) 215 (185, 246) 

Total 22 (16, 28) 65 (55, 76) 87 (75, 100) 38 (29, 47) 122 (107, 137) 

 

Tanzania 

AIS/MIS 

2007-08 

HIV negative 28 (22, 33) 28 (23, 33) 56 (48, 63) 33 (27, 39) 87 (78, 95) 

HIV positive 42 (16, 67) 62 (34, 91) 104 (62, 146) 83 (47, 120) 179 (126, 231) 

Total 28 (23, 34) 30 (25, 35) 58 (51, 66) 36 (30, 42) 92 (83, 101) 

 

Zambia 

DHS 2007 

HIV negative 30 (25, 36) 31 (25, 38) 62 (54, 69) 43 (35, 52) 102 (91, 114) 

HIV positive 64 (40, 89) 77 (51, 102) 141 (109, 173) 107 (79, 134) 233 (197, 268) 

Total 35 (29, 41) 37 (31, 44) 72 (64, 80) 52 (45, 60) 121 (110, 131) 

 

Zimbabwe 

DHS 2005-

06 

HIV negative 24 (18, 30) 19 (13, 25) 43 (33, 52) 14 (10, 19) 56 (46, 67) 

HIV positive 25 (13, 38) 99 (77, 120) 124 (100, 148) 51 (37, 66) 169 (142, 196) 

Total 24 (19, 30) 37 (30, 44) 62 (52, 71) 23 (18, 29) 84 (73, 95) 

 

Zimbabwe 

DHS 2010-

11 

HIV negative 27 (19, 34) 15 (11, 19) 42 (33, 50) 17 (12, 21) 58 (48, 67) 

HIV positive 40 (24, 57) 60 (43, 77) 100 (78, 123) 67 (43, 91) 160 (130, 190) 

Total 29 (22, 36) 23 (18, 27) 52 (44, 59) 26 (20, 32) 76 (67, 86) 

 

Latin 

America/ 

Caribbean 

 

Haiti DHS 

2012 

HIV negative 33 (26, 40) 25 (20, 31) 58 (50, 67) 29 (23, 36) 86 (75, 97) 

HIV positive 40 (4, 77) 129 (39, 219) 169 (81, 258) 60 (0, 122) 219 (93, 346) 

 Total 33 (27, 40) 29 (22, 35) 62 (53, 71) 31 (23, 38) 91 (78, 104) 
Figure 1. Childhood mortality ratios by current HIV status of the mother 

(Continued...)

16 
Figure 1. – Continued

(Continued...)

17 
Figure 1. – Continued

(Continued...)

18 
Figure 1. – Continued

(Continued...)

19 
Figure 1. – Continued

(Continued...)

20 
Figure 1. – Continued

(Continued...)

21 
Figure 1. – Continued

22 
23 

The results demonstrate a higher risk of mortality for children of HIV-positive women. The point 

estimates for mortality rates for most surveys tend to be higher for children of HIV-positive women than 

children of HIV-negative women. The confidence intervals for the mortality rates for children of HIVpositive women are much wider than those of HIV-negative women due primarily to the lower numbers 

of children of HIV-positive women in the survey samples. Despite the low precision of the mortality 

estimates of children of HIV-positive women, the difference in the mortality rates is large enough in 

several surveys that the confidence intervals do not overlap. 

The wide confidence intervals for children of HIV-positive women also hinder comparisons of their 

mortality rates at different ages within a survey, but the results show some general patterns. For most 

surveys, the mortality rates for children of HIV-positive and HIV-negative women are similar during the 

neonatal period. Evidence of the higher mortality experienced by the children of HIV-positive women 

begins to appear during the postneonatal period. In most surveys, the neonatal and postneonatal mortality 

rates tend to be similar for children of HIV-negative women. By contrast, the mortality rates for children 

of HIV-positive women tend to increase from the neonatal to the postneonatal period (though the increase 

is within sampling error except in a few higher-HIV prevalence countries). 

The IMR includes mortality experienced during the neonatal and postneonatal periods, and is heavily 

influenced by the neonatal mortality rate because mortality is so high during this period. The IMR may 

not be the most appropriate rate to use in understanding the impact of mother’s HIV status on child 

mortality because the high levels of background mortality experienced during the neonatal period could 

dilute the effect of HIV-related mortality occurring later in the first year of life. Nonetheless, the IMRs in 

the surveys included in this analysis tend to be higher for children of HIV-positive women than those of 

HIV-negative women. 

The child mortality rate does not include the neonatal period, nor the postneonatal period, but it does 

include a relatively long period of exposure, from age 1 to age 5. If mother’s HIV status has a stronger 

impact on child mortality during the second year of life, for example, than during the third through fifth 

years, grouping a period of higher risk for HIV-related mortality with a period of lower risk could appear 

to dilute the effect of mother’s HIV status during the younger ages included in the child mortality rate. 

For the majority of surveys in this analysis, the child mortality rate is lower than the IMR for children of 

both HIV-positive and HIV-negative women, and child mortality tends to be higher among children of 

HIV-positive women than among children of HIV-negative women. 

Like the IMR, the under-five mortality rate also includes deaths during the neonatal period, although 

neonatal deaths make up a smaller percentage of the deaths to children under age 5 compared with 

children under age 1. Deaths during the postneonatal and child periods make up the remainder of deaths 

in the under-five mortality rate. The under-five mortality rate provides a summary of the overall 

cumulative probability of death from birth to the fifth birthday. The under-five mortality rates are higher 

for children of HIV-positive women than those of HIV-negative women for nearly all surveys in this 

analysis, and the confidence intervals for many surveys do not overlap. The data for the 2012 Gabon DHS 

do not follow the general pattern. Children of HIV-positive women tend to have lower mortality rates 

than children of HIV-negative women, though the differences are well within sampling error. The overall 

mortality rates for this survey are low and may include some underestimation. 

Table 3 shows the unadjusted relative risks (RR) of the mortality of children of HIV-positive women 

compared with children of HIV-negative women. Figure 2 graphs the relative risks that are statistically 

significant at a level of p<0.05. As seen in Table 3, the vast majority of the relative risks are greater than 

1.0, and many are statistically significant, indicating that children of HIV-positive women are at increased 

risk of mortality compared with children of HIV-negative women. 
24 

Table 3. Relative risks of mortality of children of HIV-positive women compared with children of 

HIV-negative women, 0-4 years preceding the survey 

Survey name 

Neonatal 

mortality 

Postneonatal 

mortality 

Infant 

mortality 

Child 

mortality 

Under-five 

mortality 

Sub-Saharan Africa 

Cameroon DHS 2004 0.77 2.67 *** 1.90 ** 1.82 * 1.80 *** 

Cameroon DHS 2011 1.23 3.49 ** 2.24 ** 0.94 1.53 * 

Cote d’Ivoire AIS 2005 1.11 2.20 1.69 0.96 1.43 

Cote d'Ivoire DHS 2011-12 1.32 4.03 * 2.42 * 1.21 1.98 * 

Ethiopia DHS 2011 1.30 0.71 1.08 1.63 1.26 

Gabon DHS 2012 0.98 0.48 0.79 0.61 0.72 

Kenya DHS 2003 0.88 2.01 1.52 4.88 * 2.39 ** 

Kenya DHS 2008-09 1.33 5.10 ** 2.47 ** 5.67 * 3.36 *** 

Lesotho DHS 2004 1.09 3.45 *** 2.02 ** 2.48 * 2.08 *** 

Lesotho DHS 2009 1.32 5.02 *** 2.66 *** 3.33 ** 2.74 *** 

Malawi DHS 2004 1.49 2.04 * 1.81 ** 2.06 ** 1.85 *** 

Malawi DHS 2010 1.68 3.00 *** 2.36 *** 2.62 *** 2.39 *** 

Rwanda DHS 2005 2.00 2.24 * 2.14 ** 1.91 * 1.97 *** 

Rwanda DHS 2010 1.38 3.01 * 2.09 * 1.86 1.98 ** 

Swaziland DHS 2006-07 1.93 * 4.82 *** 3.72 *** 3.65 *** 3.57 *** 

Tanzania AIS/MIS 2007-08 1.51 2.22 * 1.87 * 2.54 ** 2.06 *** 

Zambia DHS 2007 2.13 ** 2.45 *** 2.29 *** 2.46 *** 2.27 *** 

Zimbabwe DHS 2005-06 1.06 5.26 *** 2.91 *** 3.58 *** 3.00 *** 

Zimbabwe DHS 2010-11 1.52 3.99 *** 2.41 *** 3.98 *** 2.78 *** 

Latin America/Caribbean 

Haiti DHS 2012 1.22 5.10 * 2.90 * 2.05 2.55 * 

Unweighted average relative risk 1.36 3.17 2.16 2.51 2.19 

* p<0.05; **p<0.01; ***p<0.001 
Figure 2. Relative risk of mortality of children of HIV-positive women compared with children of HIV-negative women, 0-4 years before 

the survey, only statistically significant results shown 

25 
26 

The RRs for neonatal mortality are statistically significant for only a couple of surveys, indicating that the 

neonatal mortality rates of the children of HIV-positive and HIV-negative women are not significantly 

different in most surveys. Among the surveys in this analysis, there is little evidence of increased risk of 

mortality to children of HIV-positive women during the first month of life. 

For postneonatal, infant, child, and under-five mortality, the RRs are statistically significant in more than 

half of the surveys. The statistically significant RRs for postneonatal mortality range from 2.0 in the 2004 

Malawi DHS to 5.3 in the 2005-06 Zimbabwe DHS, indicating that children of HIV-positive mothers are 

two to five times as likely as children of HIV-negative mothers to die between the ages of 1 and 12 

months. Most of the statistically significant RRs for infant mortality fall between 2.0 and 3.0, with the 

exception of the 2006 Swaziland DHS, in which children of HIV-positive women are nearly four times as 

likely to die before their first birthday compared with children of HIV-negative women. The inclusion of 

neonatal mortality in the IMR leads to lower relative risks for the IMR than for the postneonatal mortality 

rate. 

For the child mortality rate, most of the statistically significant RRs range from around 2.0 to 4.0, with 

higher RRs seen for the two Kenya surveys. The statistically significant RRs for under-five mortality 

range from 1.5 in the 2011 Cameroon DHS to 3.6 in the 2006 Swaziland DHS. The smaller relative 

standard errors of the under-five mortality rate estimates may contribute to smaller RRs having statistical 

significance (i.e., being significantly greater than 1.0). The RR of 1.5 for the 2011 Cameroon DHS is the 

smallest statistically significant RR across all of the component mortality rates. The RRs for under-five 

mortality are lower than the RRs for postneonatal and child mortality in many surveys, due to the 

contribution of the neonatal period during which the mortality rates for children of HIV-positive and 

HIV-negative women are similar. 

To assess whether or not there are specific ages among children at which maternal HIV infection may be 

associated with greater increased risk of child mortality, it is necessary to compare the RRs for the 

neonatal, postneonatal, and child mortality rates. These mortality rates break the first five years of life 

into three exhaustive and mutually exclusive exposure periods. The mortality rates for the neonatal period 

show little, if any, increased risk of death for children of HIV-positive women. There is evidence of 

increased risk for children of HIV-positive women during both the postneonatal and child periods; 

however, with the variation in the magnitude of the RRs across surveys, it is difficult to compare the risks 

of mortality during the postneonatal and child exposure periods in this analysis. The postneonatal period 

includes RRs of 4.0 or higher for the greatest number of surveys, and the simple unweighted average RR 

across all 20 surveys is 3.2 for postneonatal mortality, compared with 2.5 for child mortality. The highest 

RRs observed (5.7 and 4.9) are for child mortality, but both figures are from surveys in the same country 

and are quite a bit higher than the next highest RR of 4.0 for the 2010-2011 Zimbabwe DHS. The findings 

do not show very strong evidence of decreasing risk of death to children of HIV-positive women 

compared with children of HIV-negative women during the older ages, as might be suggested by the 

literature, but the grouping of four years of exposure in the child mortality rate may mask a trend of 

decreasing relative risk through this period. This hypothesis would be difficult to test with these data, 

however, given the low number of child deaths between the ages of one and five in individual surveys. 

Figure 2 also shows that there is some consistency in the magnitude of the RRs across the different 

component rates by country. On the one hand, from postneonatal through under-five mortality, Kenya, 

Swaziland, and Zimbabwe tend to be among the countries with higher RRs for mortality for children of 

HIV-positive women versus children of HIV-negative women. On the other hand, Cameroon, Malawi, 

Rwanda, and Tanzania tend to be among the countries with lower RRs. 

In theory, when overall levels of child mortality are higher, the proportion of mortality associated with 

maternal HIV status should be lower, leading to lower relative risks. Figure 3 plots the RRs for the under-
27 

five mortality of children of HIV-positive women compared with children of HIV-negative women 

against the overall under-five mortality rate for surveys with a RR for under-five mortality which is 

statistically significant at p<0.05. The findings show that, as expected, the under-five RRs tend to 

decrease as background mortality increases. The RR for the 2006 Swaziland DHS is higher than expected 

compared with other countries with similar under-five mortality rates. 

Figure 3. Relative risk of under-five mortality of children of HIV-positive women to mortality of 

children of HIV-negative women by survey year, 0-4 years before the survey, only statistically 

significant results shown

Caution must be used in interpreting trends over time in the mortality of children of HIV-positive women 

using data from DHS and AIS surveys. First, these surveys do not include information on whether or not 

a death is HIV-related, so changes in mortality rates to children of HIV-positive women must be 

interpreted with respect to changes in background levels of mortality. A decrease in mortality to children 

of HIV-positive women is undoubtedly a positive outcome; however, this cannot necessarily be 

interpreted as an improvement in the mortality of children of HIV-positive women relative to that of 

children of HIV-negative children. Similarly, a reduction in the relative risk of mortality for children of 

HIV-positive women compared with children of HIV-negative women could potentially hide a lack of 

change, or even an absolute increase in mortality for children of HIV-positive women, if overall mortality 

for children increased over time. 

Second, the low precision of the mortality rates for children of HIV-positive women in this analysis 

results in poor statistical power to assess changes between two surveys. It is possible to make meaningful 

comparisons between the mortality of children of HIV-positive and HIV-negative children within the 
28 

same survey largely due to the fact that the confidence intervals around the mortality rates of children of 

HIV-negative women are small. Once we begin to compare one mortality rate for children of HIVpositive women with another in this analysis, the large confidence intervals around both rates usually 

prevent the formulation of any statistically significant findings. 

Third, when using the under-five mortality rates for comparison, there could be some overlap in the two 

survey populations in terms of the time during which children in each survey would have been exposed to 

the risk of acquiring HIV. Although the pairs of surveys in each country occurred at least five years apart, 

and there is no overlap in the reference period for exposure to death, some of the births for the later 

survey could have occurred prior to that survey’s five-year reference period and extended back into the 

reference period for the earlier survey. Finally, it is important to recognize that the reference periods for 

these surveys are not that recent, especially given the timing of advances in EMTCT programs. A rough 

average of the mid-points of the reference periods is 2002 for the earlier surveys and 2008 for the later 

surveys. 

Figure 4 shows the under-five mortality rates for the children of HIV-positive women for the seven 

countries with data available for two surveys. Vertical lines in the Figure show the confidence intervals. 

There are no consistent findings regarding change in mortality rates of children of HIV-positive women 

over time. For a few surveys, the under-five mortality rates are roughly the same in the first and second 

surveys. The rates appear to increase over time in Cote d’Ivoire, but the changes are not statistically 

significant. Rates appear to have decreased in Cameroon, Kenya, and Rwanda, but among these countries 

only the change in Rwanda is statistically significant (p<0.05). It is important to note, however, that the 

absolute decrease in mortality of children of HIV-positive women in Rwanda does not represent an 

improvement in the outcomes of children of HIV-positive mothers relative to those of HIV-negative 

mothers. In both surveys, children of HIV-positive women were roughly twice as likely as children of 

HIV-negative women to die before age 5 (see Table 3). It appears that much of the decrease in mortality 

of children of HIV-positive women can be attributed to the large decrease in under-five mortality for all 

children in Rwanda over this period (see Table 2). 
29 

Figure 4. Trends in under-five mortality rates for children of HIV-positive women, 0-4 years before 

the survey 

0

50

100

150

200

250

300

350

2004 2011 2005 2011-

2012

2003 2008

-2009

2004 2009 2004 2010 2005 2010 2005-

2006

2010

-2011

Deaths per 1,000 live births

Cameroon Cote d'Ivoire Kenya Lesotho Malawi Rwanda * Zimbabwe

* p<0.05

31 

5. Conclusions 

To our knowledge, this analysis is the first to assess the relationship between maternal HIV status and 

child mortality using nationally representative data, and the findings largely support the results of the 

existing body of literature based on cohort studies and clinical trials. The general pattern across these 

surveys is that children of HIV-positive women experience higher mortality than children of HIVnegative women. In 17 of 20 countries studied, children of HIV-positive women have significantly higher 

under-five mortality rates than children of HIV-negative women. The increased risk is strong enough to 

be statistically significant even in surveys with low numbers of children of HIV-positive women. Given 

the potential for underestimating the mortality of children of HIV-positive women relative to that of 

children of HIV-negative women (as described in the Limitations section), and the low sample size of 

children of HIV-positive women, it is notable that the association between child mortality and mother’s 

HIV status is in the expected direction and is statistically significant across so many surveys. 

Strictly speaking, this bivariate analysis does not establish whether or not the higher risk of mortality 

among children of HIV-positive women compared with children of HIV-negative women can be 

attributed to maternal HIV status, either directly or indirectly. Nevertheless, supporting literature does 

provide evidence of a causal relationship between maternal HIV-status and child mortality. We do not 

address here the proximate causes of death. 

The analysis of mortality rates for different ages shows that the association between maternal HIV status 

and child mortality is weakest during the neonatal period. This finding is consistent with studies in the 

published literature, which tend to find similar mortality rates for children of HIV-positive and HIVnegative women during the neonatal period. The lack of evidence of higher risk of neonatal mortality 

among children of HIV-positive women may be due to several factors. First, background mortality rates 

are high during the first month of life. Neonatal deaths account for around one-third of all under-five 

deaths in the group of surveys included in this analysis. This is consistent with the international estimate 

of neonatal deaths comprising about one-third (34 percent) of under-five deaths across sub-Saharan 

Africa (UNICEF et al. 2013). Thus, the relative contribution of HIV-related mortality is likely to be lower 

during the neonatal period than at older ages. Second, in the absence of intervention, around 40 percent of 

children who acquire HIV through MTCT become infected with HIV during breastfeeding, and many of 

these children will become infected after the first month of life. Finally, even for children infected during 

pregnancy or childbirth, natural-history studies suggest that the excess risk of mortality accumulates 

gradually over several months. 

Statistically significant RRs indicating increased risk of mortality to children of HIV-positive women are 

found in 17 of 20 surveys for postneonatal mortality, and in 13 of 20 surveys for child mortality. The 

wide range in the statistically significant RRs during the postneonatal (2.0 to 5.3) and child (1.8 to 5.7) 

periods makes it difficult to determine which time period may include the greater excess risk of death for 

children of HIV-positive women; however, the unweighted average RR across the 20 surveys is higher for 

postneonatal than child mortality (3.2 compared with 2.5). Evidence indicates that the mortality risk for 

children of HIV-positive women relative to those of HIV-negative women may be greater in the second 

year of life than at older ages. The long exposure period in the child mortality rate may mask differences 

in relative risks of mortality within the age range. This topic merits further investigation, perhaps using 

pooled data since the number of deaths during this age range in individual surveys is low. 

There are many limitations in attempting to use these data to evaluate the effectiveness of EMTCT 

programs. As explained above, MTCT rates cannot be measured—the HIV status of the child and of the 

mother at the time of the birth are not known. Nor do the surveys collect information on exposure of 

individual women and children to prevention and treatment interventions. The data available in these 
32 

surveys can assess only whether or not there is a broad, population-level association between national 

advances in EMTCT and child outcomes. However, understanding the population-level coverage of 

interventions in effect for a survey is also difficult, given the rapid expansion of EMTCT programs that 

could have occurred within the five-year reference period preceding the survey. 

The comparison of successive surveys within each of seven countries in this analysis shows no clear 

evidence of significant improvement over time in the outcomes of children of HIV-positive women 

compared with children of HIV-negative women at the population level. Several factors could contribute 

to this finding. The statistical power could be insufficient to detect a change, or the overlap in the period 

of exposure to infection for the two surveys could dilute the comparison. Finally, despite remarkable 

progress in EMTCT programs during and since the time period examined in this analysis, gaps still 

remain. The coverage and effectiveness of EMTCT programs in place during the reference periods for the 

later surveys could have been insufficient to have resulted in an improvement in mortality at the 

population level. For the seven countries with two surveys in this analysis, the mid-points of the five-year 

reference periods are 2002 for the earlier surveys and 2008 for the later surveys. Given that the WHO 

guidelines did not completely move beyond single-dose nevirapine or extend the recommendation for use 

of ART through the duration of breastfeeding until 2010, it is unlikely that many of the children even in 

the later group of surveys were exposed to the more effective EMTCT regimens currently recommended. 

The size of the RRs for infant and under-five mortality for children of HIV-positive women versus 

children of HIV-negative women in this analysis (a two- to three-fold increase) is similar to that observed 

in clinical trials and cohort studies in populations with minimal exposure to EMTCT programs, or 

exposure to sub-optimal regimens. 

Current international goals call for reducing the number of new HIV infections in children by 90 percent 

between 2009 and 2015 and reducing the number of AIDS-related maternal deaths by half (UNAIDS 

2011). If these goals are achieved, we anticipate that the impact on mortality would be great enough to be 

observed in future DHS and AIS surveys. The relative risks for the mortality of children of HIV-positive 

women compared with children of HIV-negative women would decrease over time closer to 1.0 and 

would lose statistical significance. Due to the five-year exposure period preceding each survey, and the 

inclusion of births occurring before the start of the exposure period, these achievements would need to be 

sustained for several years before they could be fully reflected in cross-sectional surveys. 
33 

References

Abrams, E.J. “Prevention of Mother to Child Transmission of HIV Successes, Controversies and Critical 

Questions.” 2004. AIDS Review 6: 131–43. 

Brahmbhatt, H., G. Kigozi, F. Wabwire-Mangen, D. Serwadda, T. Lutalo, F. Nalugoda, N. Sewankambo, 

M. Kiduggavu, M. Wawer, and R. Gray. 2006. “Mortality in HIV-Infected and Uninfected Children of 

HIV-Infected and Uninfected Mothers in Rural Uganda.” Journal of Acquired Immune Deficiency 

Syndromes 41: 504-8. 

The Breastfeeding and HIV International Transmission Study Group (BHITS). 2004. “Late Postnatal 

Transmission of HIV-1 in Breast-Fed Children: An Individual Patient Data Meta-Analysis.” The Journal 

of Infectious Diseases 198: 2154-66. 

Chasela, C.S., M.G. Hudgens, D.J. Jamieson, D. Kayira, M.C. Hosseinipour, A.P. Kourtis, F. Martinson, 

G. Tegha, R.J. Knight, Y.I. Ahmed, D.D. Kamwendo, I.F. Hoffman, S.R. Ellington, Z. Kacheche, A. 

Soko, J.B. Wiener, S.A. Fiscus, P. Kazembe, I.A. Mofolo, M. Chigwenembe, D.S. Sichali, and C.M. van 

der Horst. 2010. “Maternal or Infant Antiretroviral Drugs to Reduce HIV-1 Transmission.” The New 

England Journal of Medicine 362: 2271-81. 

Connor, E.M., R.S. Sperling, R. Gelber, P. Kiselev, G. Scott, M.J. O’Sullivan, R. VanDyke, M. Bey, W. 

Shearer, R.L. Jacobson, E. Jimenez, E. O’Neill, B. Bazin, J.F. Delfraissy, M. Culnane, R. Coombs, M. 

Elkins, J. Moye, P. Stratton, and J. Balsley. 1994. “Reduction of Maternal-Infant Transmission of Human 

Immunodeficiency Virus Type 1 with Zidovudine Treatment.” The New England Journal of Medicine

331: 1173-80. 

Cooper, E.R., M. Charurat, L. Mofenson, I.C. Hanson, J. Pitt, C. Diaz, K. Hayani, E. Handelsman, V. 

Smeriglio, R. Hoff, and W. Blattner. 2002. “Combination Antiretroviral Strategies for the Treatment of 

Preganant HVI-1-Infected Women and Prevention of Perinatal HIV-1 Transmission.” Journal of Acquired 

Immune Deficiency Syndromes 29: 484-94. 

Coovadia, H.M., E.R. Brown, M.G. Fowler, T. Chipato, D. Moodley, K. Manji, P. Musoke, L. StranixChibanda, V. Chetty, W. Fawzi, C. Nakabiito, L. Msweli, R. Kisenge, L. Guay, A. Mwatha, D.J. Lynn, 

S.H. Eshleman, P. Richardson, K. George, P. Andrew, L.M. Mofenson, S. Zwerski, and Y. Maldonado. 

2012. “Efficacy and Safety of an Extended Nevirapine Regimen in Infant Children of Breastfeeding 

Mothers with HIV-1 Infection for Prevention of Postnatal HIV-1 Transmission (HPTN 046): A 

Randomized, Doubleblind, Placebo-Controlled Trial.” The Lancet 379: 221–8. 

Dabis, F., V. Leroy, K. Castetbon, R. Spira, M.L. Newell, and R. Salamon. 2001. “Preventing Mother-toChild Transmission of HIV-1 in Africa in the Year 2000.” AIDS 14: 1017-26. 

de Cock, K.M., M.G. Fowler, E. Mercier, I. de Vincenzi, J. Saba, E. Hoff, D.J. Alnwick, M. Rogers, and 

N. Shaffer. 2000. “Prevention of Mother-to-Child Transmission in Resource-Poor Countries: Translating 

Research into Policy and Practice.” Journal of the American Medical Association 283: 1175-82. 

Dunn, D.T., M.L. Newell, A.E. Ades, and C.S. Peckham. 1992. “Risk of Human Immunodeficiency Virus 

Type 1 Transmission through Breastfeeding.” The Lancet 340: 585-8. 

The European Collaborative Study (ECS). 1994. “Natural History of Vertically Acquired Human 

Immunodeficiency Virus-1 Infection.” Pediatrics 94: 815-9. 
34 

Fawzi, W., G. Msamanga, D. Spiegelman, B. Renjifo, H. Bang, S. Kapiga, J. Coley, E. Hertzmark, M. 

Essex, and D. Hunter. 2002. “Transmission of HIV-1 through Breastfeeding among Women in Dar es 

Salaam, Tanzania.” Journal of Acquired Immune Deficiency Syndromes 31: 331–8. 

Guay, L.A., P. Musyoke, T. Fleming, D. Bagenda, M. Allen, C. Nakabiito, J. Sherman, P. Bakaki, C. 

Ducar, M. Deseyve, L. Emel, M. Mirochnick, M.G. Fowler, L. Mofenson, P. Miotti, K. Dransfield, D. 

Bray, F. Mmiro, and J.B. Jackson. 1999. “Intrapartum and Neonatal Single-Dose Nevirapine Compared 

with Zidovudine for Prevention of Mother-to-Child Transmission of HIV-1 in Kampala, Uganda: 

HIVNET 012 Randomized Trial.” The Lancet 354: 795-802. 

Jackson, J.B., P. Musyoke, T. Fleming, L.A. Guay, D. Bagenda, M. Allen, C. Nakabiito, J. Sherman, P. 

Bakaki, M. Owor, C. Ducar, M. Deseyve, A. Mwatha, L. Emel, C. Duefield, M. Mirochnick, M.G. 

Fowler, L. Mofenson, P. Miotti, M. Gigliotti, D. Bray, and F. Mmiro. 2003. “Intrapartum and Neonatal 

Single-Dose Nevirapine Compared with Zidovudine for Prevention of Mother-to-Child Transmission of 

HIV-1 in Kampala Uganda: 18-Month Follow-Up of the HIVNET 012 Randomized Trial.” The Lancet

362: 859-68. 

Jamieson, D.J., C.S. Chasela, M.G. Hudgens, C.C. King, A.P. Kourtis, D. Kayira, M.C. Hosseinipour, 

D.D. Kamwendo, S.R. Ellington, J.B. Wiener, S.A. Fiscus, G. Tegha, I.A. Mofolo, D.S. Sichali, L.S. 

Adair, R.J. Knight, F. Martinson, Z. Kacheche, A. Soko, I. Hoffman, and C. van der Host. 2012. 

“Maternal and Infant Antiretroviral Regimens to Prevent Postnatal HIV-1 Transmission: 48-Week 

Follow-up of the BAN Randomized Controlled Trial.” The Lancet 379: 2449-58. 

Kagaayi, J., R.H. Gray, H. Brahmbhatt, G. Kigozi, F. Nalugoda, F. Wabwire-Mangen, D. Serwadda, N. 

Sewankambo, V. Ddungu, D. Ssebagala, J. Sekasanvu, G. Kigozi, F. Makumbi, N. Kiwanuka, T. Lutalo, 

S.J. Reynolds, and M.J. Wawer. 2008. “Survival of Infants Born to HIV-Positive Mothers, by Feeding 

Modality in Rakai, Uganda.” PLoS ONE 3: e3877. 

The Kesho Bora Study Group. 2011. “Triple Antiretroviral Compared with Zidovudine and Single-Dose 

Nevirapine Prophylasix during Pregnancy and Breastfeeding for Prevention of Mother-to-Child 

Transmission of HIV-1 (Kesho Bora Study): A Randomized Controlled Trial.” The Lancet Infectious 

Diseases 11: 171-80. 

Kilewo, C., K. Karlsson, A. Massawe, E. Lyamuya, A. Swai, F. Mhalu, and G. Biberfeld. 2008. 

“Prevention of Mother-to-Child Transmission of HIV-1 through Breast-Feeding by Treating Infants 

Prophylactically with Lamivudine in Dar es Salaam, Tanzania: The Mitra Study.” Journal of Acquired 

Immune Deficiency Syndromes 48: 315-23. 

Kilewo, C., K. Karlsson, M. Ngarina, A. Massawe, E. Lyamuya, A. Swai, R. Lipyoga, F. Mhalu, and G. 

Biberfeld. 2009. “Prevention of Mother-to-Child Transmission of HIV-1 through Breastfeeding by 

Treating Infants with Triple Antiretroviral Therapy in Dar es Salaam, Tanzania: The Mitra Plus Study.” 

Journal of Acquired Immune Deficiency Syndromes 52: 406-16. 

Kourtis, A.P., F.K. Lee, E.J. Abrams, D.J. Jamieson, and M. Bulterys. 2006. “Mother-to-Child 

Transmission of HIV-1: Timing and Implications for Prevention.” The Lancet Infectious Diseases 6: 726-

32. 

Kuhn, L., P. Kasonde, M. Sinkala, C. Kankasa, K. Semrau, N. Scott, W.Y. Tsai, S.H. Vermund, G.M. 

Aldrovandi, and D.M. Thea. 2005. “Does Severity of HIV Disease in HIV-Infected Mothers Affect 

Mortality and Morbidity among Their Uninfected Infants?” Clinical Infectious Diseases 41: 1654-61. 
35 

Kuhn, L., G.M. Aldrovandi, M. Sinkala, C. Kankasa, K. Semrau, M. Mwiya, P. Kasonde, N. Scott, C. 

Vwalika, J. Walter, M. Bulterys, W.Y. Tsai, and D.M. Thea. 2008. “Effects of Early Abrupt Weaning on 

HIV-Free Survival of Children in Zambia.” The New England Journal of Medicine 359: 130-141. 

Kumwenda, N.I., D.R. Hoover, L.M. Mofenson, M.C. Thigpen, G. Kafulafula, Q. Li, L. Mipando, K. 

Nkanaunena, T. Mebrahtu, M. Bulterys, M.G. Fowler, and T.E. Taha. 2008. “Extended Antiretroviral 

Prophylaxis to Reduce Breast-Milk HIV-1 Transmission.” The New England Journal of Medicine 359: 

119-29. 

Kurewa, E.N., F.Z. Gumbo, M.W. Munjoma, M.P. Mapingure, M.Z. Chirenje, S. Rusakaniko, and B. 

Stray-Pedersen. 2010. “Effect of Maternal HIV Status on Infant Mortality: Evidence from a 9-Month 

Follow-up of Mothers and Their Infants in Zimbabwe.” Journal of Perinatology 30: 88-92. 

Landes, M., M. van Lettow, A.K. Chan, I. Mayuni, E.J. Mayuni, E.J. Schouten, and R.A. Bedell. 2012. 

“Mortality and Health Outcomes of HIV-Exposed and Unexposed Children in a PMTCT Cohort in 

Malawi.” PLoS ONE 7: e47337. 

Marinda, E., J.H. Humphrey, P.J. Iliff, K. Mutasa, K.J. Nathoo, E.G. Piwoz, L.H. Moulton, P. Salama, 

and B.J. Ward. 2007. “Child Mortality According to Maternal and Infant HIV Status in Zimbabwe.” 

Pediatric Infectious Disease Journal 26: 519-26. 

Miotti, P.G., T.E.T. Taha, N.I. Kumwenda, R. Broadhead, L.A.R. Mtimavalye, L. van der Hoeven, J.D. 

Chiphangwi, G. Liomba, and R.J. Biggar. 1999. “HIV Transmission during Breastfeeding: A Study in 

Malawi.” Journal of the American Medical Association 282: 744–9. 

Naniche, D., A. Bardají, M. Lahuerta, A. Berenguera, I. Mandomando, S. Sanz, J.J. Aponte, B. Sigauque, 

P.L. Alonso, and C. Menéndez. 2009. “Impact of Maternal Human Immunodeficiency Virus Infection on 

Birth Outcomes and Infant Survival in Rural Mozambique.” American Journal of Tropical Medicine and 

Hygiene 80: 870-6. 

Newell, M.L., H. Coovadia, M. Cortina-Borja, N. Rollins, P. Gaillard, and F. Dabis. 2004a. “Mortality of 

Infected and Uninfected Infants Born to HIV-Infected Mothers in Africa: A Pooled Analysis.” The Lancet

364: 1236-43. 

Newell, M.L., H. Brahmbhatt, and P.D. Ghys. 2004b. “Child Mortality and HIV Infection in Africa: A 

Review.” AIDS 18(suppl 2): S27-34. 

Nduati, R., G.J. John, D. Mbori-Ngacha, B. Richardson, J. Overbaugh, A. Mwatha, J. Ndinya-Achola, J. 

Bwayo, F.E. Onyango, J. Hughes, and J. Kreiss. 2000. “Effect of Breastfeeding and Formula Feeding on 

Transmission of HIV-1: A Randomized Clinical Trial.” Journal of the American Medical Association

283: 1167–74. 

Rutstein, S.O., and G. Rojas. 2006. Guide to DHS Statistics. Calverton, Maryland, USA: ORC Macro. 

Shapiro, R.L., M.D. Hughes, A. Ogwu, D. Kitch, S. Lockman, C. Moffat, J. Makhema, S. Moyo, I. Thior, 

K. McIntosh, E. van Widenfelt, J. Leidner, K. Powis, A. Asmelash, E. Tumbare, S. Zwerski, U. Sharma, 

E. Handelsman, K. Mburu, B. Pharm, O. Jayeoba, E. Moko, S. Souda, E. Lubega, M. Akhtar, C. Wester, 

R. Tuomola, W. Snowden, M. Martinez-Tristani, L. Mazhani, and M. Essex. 2010. “Antiretroviral 

Regimens in Pregnancy and Breast-Feeding in Botswana.” The New England Journal of Medicine 362: 

2282-94. 
36 

Spira, R., P. Lepage, P. Msellati, P. van de Perre, V. Leroy, V. Simonon, E. Karita, and F. Dabis. 1999. 

“Natural History of Human Immunodefiency Virus Type 1 Infection in Children: A Five-Year 

Prospective Study in Rwanda.” Pediatrics 104: e56. 

Stéphane, B., M.L. Newell, M.J. Mayaux, D.T. Dunn, J.P. Teglas, C. Rouzioux, and C.S. Peckham. 1997. 

“Morbidity and Mortality in European Children Vertically Infected by HIV-1: The French Pediatric HIV 

Infection Study Group and European Collaborative Study.” Epidemiology 14: 442-50. 

Six Week Extended-Dose Nevirapine (SWEN) Study Team. 2008. “Extended-Dose Nevirapine to 6 

Weeks of Age for Infants to Prevent HIV Transmission via Breastfeeding in Ethiopia, India, and Uganda: 

An Analysis of Three Randomized Controlled Trials.” The Lancet 372: 300-13. 

Thior, I., S. Lockman, L.M. Smeaton, R.L. Shapiro, C. Wester, S.J. Heymann, P.B. Gilbert, L. Stevens, T. 

Peter, S. Kim, E. van Widenfelt, C. Moffat, P. Ndase, P. Arimi, P. Kebaabetswe, P. Mazonde, J. 

Makhema, K. McIntosh, V. Novitsky, T.H. Lee, R. Marlink, S. Lagakos, and M. Essex. 2006. 

“Breastfeeding plus Infant Zidovudine Prophylaxis for 6 Months vs Formula Feeding plus Infant 

Zidovudine for 1 Month to Reduce Mother-to-Child Transmission in Botswana.” Journal of the American 

Medical Association 296: 794-805. 

Thomas, T.K., R. Masaba, C.B. Borkowf, R. Ndivo, C. Zeh, A. Misore, J. Otieno, D. Jamieson, M.C. 

Thigpen, M. Bulterys, L. Slutsker, K.M. de Cock, P.N. Amornkul, A.E. Greenberg, and M.G. Fowler. 

2011. “Triple-Antiretroviral Prophylaxis to Prevent Mother-to-Child HIV Transmission through 

Breastfeeding—The Kisumu Breastfeeding Study, Kenya: A Clinical Trial.” Plos Medicine 8: e100105. 

Tonwe-Gold, B., D.K. Ekouevi, I. Viho, C. Amani-Bosse, S. Toure, P.A. Coffie, F. Rouet, R. Becquet, V. 

Leroy, W.M. El-Sadr, E.J. Abrams, and F. Dabis. 2007. “Antiretroviral Treatment and Prevention of 

Peripartum and Postnatal HIV Transmission in West Africa: Evaluation of a Two-Tiered Approach.” 

PLoS Medicine 4: e257. 

UNAIDS. 2011. Countdown to Zero: The Global Plan towards the Elimination of New HIV Infections 

among Children by 2015 and Keeping Their Mothers Alive, 2011-2015. Geneva, Switzerland: UNAIDS. 

UNAIDS. 2013. Global Report: UNAIDS Report on the Global AIDS Epidemic 2013. Geneva, 

Switzerland: UNAIDS. 

UNICEF, WHO, The World Bank, and United Nations. 2013. Levels and Trends in Child Mortality: 

Report 2013. New York, New York, USA: UNICEF. 

Wettstein, C., C. Mugglin, M. Egger, N. Blaser, L. Salazar, J. Estill, N. Bender, M.A. Davies, G. 

Wandeler, and O. Keiser. 2012. “Missed Opportunities to Prevent Mother-to-Child Transmission: 

Systematic Review and Meta-Analysis.” AIDS 26: 2361-73. 

WHO. 2004. Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants: 

Guidelines on Care, Treatment and Support for Women Living with HIV/AIDS and Their Children in 

Resource-Constrained Settings. Geneva, Switzerland: WHO. 

WHO. 2006. Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants 

in Resource-Limited Settings: Towards Universal Access. Recommendations for a Public Health 

Approach, 2006 Version. Geneva, Switzerland: WHO. 
37 

WHO. 2010a. PMTCT Strategic Vision 2010-2015: Preventing Mother-to-Child Transmission of HIV to 

Reach the UNGASS and Millennium Development Goals—Moving towards the Elimination of Pediatric 

HIV. Geneva, Switzerland: WHO. 

WHO. 2010b. Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in 

Infants in Resource-Limited Settings: Recommendations for a Public Health Approach, 2010 Version.

Geneva, Switzerland: WHO. 

WHO. 2010c. Towards Universal Access: Scaling up Priority HIV/AIDS Interventions in the Health 

Sector. Progress Report 2010. Geneva, Switzerland: WHO. 

WHO. 2013. Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing 

HIV Infection: Recommendations for a Public Health Approach. Geneva, Switzerland: WHO. 

Zaba, B., J. Whitworth, M. Marston, J. Nakiyingi, A. Ruberantwari, M. Urassa, R. Issingo, G. Mwaluko, 

S. Floyd, A. Nyondo, and A. Crampin. 2005. “HIV and Mortality of Mothers and Children: Evidence 

form Cohort Studies in Uganda, Tanzania, and Malawi.” Epidemiology 16: 275-80. 

Zaba, B., C. Calvert, M. Marston, R. Isingo, J. Nakiyingi-Miiro, T. Lutalo, A. Crampin, L. Robertson, K. 

Herbst, M.L. Newell, J. Todd, P. Byass, T. Boerma, and C. Ronsmans. 2013. “Effect of HIV Infection on 

Pregnancy-Related Mortality in Sub-Sarahan Africa: Secondary Analyses of Pooled Community-Based 

Data from the Network for Analyzing Longitudinal Population-Based HIV/AIDS Data on Africa 

(ALPHA).” The Lancet 381: 1763-71. 

Zijenah, L.S., L.H. Moulton, P. Iliff, K. Nathoo, M.W. Munjoma, K. Mutasa, L. Malaba, P. Zvandasara, 

B.J. Ward, and J. Humphrey. 2004. “Timing of Mother-to-Child Transmission of HIV-1 and Infant 

Mortality in the First 6 Months of Life in Harare, Zimbabwe.” AIDS 18: 273-80.