Victoria Hosegood

Cohort Profile: Africa Centre Demographic Information System (ACDIS) and population-based HIV survey

The health and demography of the South African population has been undergoing substantial changes as a result of the rapidly progressing HIV epidemic. Researchers at the University of KwaZulu-Natal and the South African Medical Research Council established The Africa Centre for Health and Population Studies in 1997 funded by a large core grant from The Wellcome Trust, UK. Given the urgent need for high quality longitudinal data with which to monitor these changes, and with which to evaluate interventions to mitigate impact, a demographic surveillance system (DSS) was established in a rural South African population facing a rapid and severe HIV epidemic. 1 The DSS, referred to as the Africa Centre Demographic Information System (ACDIS), started in 2000. In 2003, population-based HIV testing (also funded by the Wellcome Trust, UK) was started in ACDIS through annual surveys. In this article, we seek to describe the most salient features of ACDIS and the population-based HIV cohort and briefly present some of the most important results to date.

The socioeconomic determinants of HIV incidence: evidence from a longitudinal, population-based study in rural South Africa

Background:Knowledge of the effect of socioeconomic status on HIV infection in Africa stems largely from cross-sectional studies. Cross-sectional studies suffer from two important limitations: two-way causality between socioeconomic status and HIV serostatus and simultaneous effects of socioeconomic status on HIV incidence and HIV-positive survival time. Both problems are avoided in longitudinal cohort studies. Methods:We used data from a longitudinal HIV surveillance and a linked demographic surveillance in a poor rural community in KwaZulu-Natal, South Africa, to investigate the effect of three measures of socioeconomic status on HIV incidence: educational attainment, household wealth categories (based on a ranking of households on an assets index scale) and per capita household expenditure. Our sample comprised of 3325 individuals who tested HIV-negative at baseline and either HIV-negative or -positive on a second test (on average 1.3 years later). Results:In multivariable survival analysis, one additional year of education reduced the hazard of acquiring HIV by 7% (P = 0.017) net of sex, age, wealth, household expenditure, rural vs. urban/periurban residence, migration status and partnership status. Holding other factors equal, members of households that fell into the middle 40% of relative wealth had a 72% higher hazard of HIV acquisition than members of the 40% poorest households (P = 0.012). Per capita household expenditure did not significantly affect HIV incidence (P = 0.669). Conclusion:Although poverty reduction is important for obvious reasons, it may not be as effective as anticipated in reducing the spread of HIV in rural South Africa. In contrast, our results suggest that increasing educational attainment in the general population may lower HIV incidence.

Levels and Causes of Adult Mortality in Rural South Africa: The Impact of AIDS

Objective: To quantify the contribution that AIDS makes to adult mortality in rural South Africa. Design: Demographic surveillance of the population in a rural area of northern KwaZulu Natal province. Methods: The population and all adult deaths (n = 1021) in 2000 were enumerated. We conducted verbal autopsy interviews with the caregivers of those who died to identify the causes of adult deaths. A validation study of the verbal autopsy diagnoses was conducted on 109 individuals with hospital notes that could be located. Death rates and other mortality indices are both calculated directly and estimated indirectly by the orphanhood method. Results: Mortality in the study area rose sharply in the late-1990s. By 2000 the probability of dying between ages 15 and 60 was 58% for women and 75% for men. AIDS, with or without tuberculosis, is the leading cause of death in adulthood (48%). Injuries, mostly resulting from road traffic accidents or violence, cause 20% of deaths of men aged 15–44 years. In the age group 60 years or more, non-communicable diseases account for 76 and 71% of deaths of women and men respectively. Conclusions: This population has experienced a sudden and massive rise in adult mortality. This can be accounted for by AIDS deaths. Mortality from non-communicable disease and (among men) injuries is also high. Antenatal HIV seroprevalence continued to rise in rural KwaZulu Natal in the late 1990s, reaching 40% in some clinics in this area. Adult mortality will continue to rise unless effective treatment interventions are introduced.

The Reach and Impact of Child Support Grants: Evidence from KwaZulu-Natal

This paper examines the reach and impact of the South African Child Support Grant, using longitudinal data collected through the Africa Centre for Health and Population Studies. The grant is being taken up for a third of all age-eligible resident children, and appears to be reaching those children living in the poorer households of the demographic surveillance area (DSA). Children who received the grant are significantly more likely to be enrolled in school in the years following grant receipt than are equally poor children of the same age. However, older brothers and sisters of grant recipients, when they were observed at younger ages, were less likely than other children to be enrolled in school – perhaps reflecting the greater poverty in grant-receiving households. Thus the grant appears to help overcome the impact of poverty on school enrolment.

Dispensing with marriage: Marital and partnership trends in rural KwaZulu-Natal, South Africa 2000-2006

This paper describes marriage and partnership patterns and trends in rural KwaZulu-Natal, South Africa from 2000-2006. The study is based on longitudinal, population-based data collected by the Africa Centre demographic surveillance system. We consider whether the high rates of non-marriage among Africans in South Africa reported in the 1980s were reversed following the political transformation underway by the 1990s. Our findings show that marriage has continued to decline with a small increase in cohabitation among unmarried couples, particularly in more urbanised areas. Comparing surveillance and census data, we highlight problems with the use of the ‘living together’ marital status category in a highly mobile population.

Strengthening Families to Support Children Affected by HIV and AIDS

Abstract This paper provides an overview of the arguments for the central role of families, defined very broadly, and we emphasise the importance of efforts to strengthen families to support children affected by HIV and AIDS. We draw on work conducted in the Joint Learning Initiative on Children and AIDSs Learning Group 1: Strengthening Families, as well as published data and empirical literature to provide the rationale for family strengthening. We close with the following recommendations for strengthening families to ameliorate the effects of HIV and AIDS on children. Firstly, a developmental approach to poverty is an essential feature of responses to protect children affected by HIV and AIDS, necessary to safeguard their human capital. For this reason, access to essential services, such as health and education, as well as basic income security, must be at the heart of national strategic approaches. Secondly, we need to ensure that support garnered for children is directed to families. Unless we adopt a family oriented approach, we will not be in a position to interrupt the cycle of infection, provide treatment to all who need it and enable affected individuals to be cared for by those who love and feel responsible for them. Thirdly, income transfers, in a variety of forms, are desperately needed and positively indicated by available research. Basic economic security will relieve the worst distress experienced by families and enable them to continue to invest in the health care and education of their children. Lastly, interventions are needed to support distressed families and prevent knock-on negative outcomes through programmes such as home visiting, and protection and enhancement of childrens potential through early child development efforts.

The effects of high HIV prevalence on orphanhood and living arrangements of children in Malawi, Tanzania, and South Africa

Using longitudinal data from three demographic surveillance systems (DSS) and a retrospective cohort study, we estimate levels and trends in the prevalence and incidence of orphanhood in South Africa, Tanzania, and Malawi in the period 1988–2004. The prevalence of maternal, paternal, and double orphans rose in all three populations. In South Africa—where the HIV epidemic started later, has been very severe, and has not yet stabilized—the incidence of orphanhood among children is double that of the other populations. The living arrangements of children vary considerably between the populations, particularly in relation to fathers. Patterns of marriage, migration, and adult mortality influence the living and care arrangements of orphans and non-orphans. DSS data provide new insights into the impact of adult mortality on children, challenging several widely held assumptions. For example, we find no evidence that the prevalence of child-headed households is significant or has increased in the three study areas.

Age at first sex in rural South Africa

Objectives: To identify factors associated with sexual debut and early age at first sex (AFS) among young men and women (12–25 years) in a population with a high prevalence and incidence of HIV in rural South Africa. Methods: Longitudinal data from four rounds (2003–7) of a prospective population-based HIV and sexual behaviour survey in rural KwaZulu-Natal were used to investigate the distribution and predictors of earlier first sex. Survival analyses were used, and each analysis considered men and women separately. Results: Among the 4724 women and 4029 men who were virgins at the beginning of the period, the median AFS was 18.5 and 19.2 years, respectively. In multivariable models, factors associated with earlier AFS across gender were periurban residence (vs rural), ever use of alcohol and knowing at least one person who had HIV, while school attendance had a significant protective effect. Other factors were important for one gender only. Maternal death was significantly associated with earlier AFS for women, in the same way that paternal death was for young men, while mother’s membership of the same household significantly delayed AFS of young men. The analysis of early first sex confirmed the same factors to be important as in the overall analyses for men and women. Conclusion: Given the association of individual, household and community level factors with sexual debut, a multisectorial approach to prevention and targeting in youth programmes is recommended.

Collaboration between traditional practitioners and primary health care staff in South Africa: developing a workable partnership for community mental health services.

The majority of the black African population in South Africa utilize both traditional and public sector Western systems of healing for mental health care. There is a need to develop models of collaboration that promote a workable relationship between the two healing systems. The aim of this study was to explore perceptions of service users and providers of current interactions between the two systems of care and ways in which collaboration could be improved in the provision of community mental health services. Qualitative individual and focus group interviews were conducted with key health care providers and service users in one typical rural South African health sub-district. The majority of service users held traditional explanatory models of illness and used dual systems of care, with shifting between treatment modalities reportedly causing problems with treatment adherence. Traditional healers expressed a lack of appreciation from Western health care practitioners but were open to training in Western biomedical approaches and establishing a collaborative relationship in the interests of improving patient care. Western biomedically trained practitioners were less interested in such an arrangement. Interventions to acquaint traditional practitioners with Western approaches to the treatment of mental illness, orientation of Western practitioners towards a culture-centred approach to mental health care, as well as the establishment of fora to facilitate the negotiation of respectful collaborative relationships between the two systems of healing are required at district level to promote an equitable collaboration in the interests of improved patient care.

Gender, Migration and HIV in Rural KwaZulu-Natal, South Africa

Objectives Research on migration and HIV has largely focused on male migration, often failing to measure HIV risks associated with migration for women. We aimed to establish whether associations between migration and HIV infection differ for women and men, and identify possible mechanisms by which womens migration contributes to their high infection risk. Design Data on socio-demographic characteristics, patterns of migration, sexual behavior and HIV infection status were obtained for a population of 11,677 women aged 15–49 and men aged 15–54, resident members of households within a demographic surveillance area participating in HIV surveillance in 2003–04. Methods Logistic regression was conducted to examine whether sex and migration were independently associated with HIV infection in three additive effects models, using measures of recent migration, household presence and migration frequency. Multiplicative effects models were fitted to explore whether the risk of HIV associated with migration differed for males and females. Further modeling and simulations explored whether composition or behavioral differences accounted for observed associations. Results Relative to non-migrant males, non-migrant females had higher odds of being HIV-positive (adjusted odds ratio [aOR] = 1.72; 95% confidence interval [1.49–1.99]), but odds were higher for female migrants (aOR = 2.55 [2.07–3.13]). Female migrants also had higher odds of infection relative to female non-migrants (aOR = 1.48 [1.23–1.77]). The association between number of sexual partners over the lifetime and HIV infection was modified by both sex and migrant status: For male non-migrants, each additional partner was associated with 3% higher odds of HIV infection (aOR = 1.03 [1.02–1.05]); for male migrants the association between number of partners and HIV infection was non-significant. Each additional partner increased odds of HIV infection by 22% for female non-migrants (aOR = 1.22 [1.12–1.32]) and 46% for female migrants (aOR = 1.46 [1.25–1.69]). Conclusions Higher risk sexual behavior in the context of migration increased womens likelihood of HIV infection.