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      The compounding effect of having HIV and a disability on child mortality among mothers in South Africa

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          Abstract

          Background

          Previous research on the association between maternal HIV status and child mortality in sub–Saharan Africa was published between 2005–2011. Findings from these studies showed a higher child mortality risk among children born to HIV–positive mothers. While the population of women with disabilities is growing in developing countries, we found no research that examined the association between maternal disability in HIV–positive mothers, and child mortality in sub–Saharan Africa. This study examined the potential compounding effect of maternal disability and HIV status on child mortality in South Africa.

          Methods

          We analyzed data for women age 15–49 years from South Africa, using the nationally representative 2016 South Africa Demographic and Health Survey. We estimated unadjusted and adjusted risk ratios of child mortality indicators by maternal disability and maternal HIV using modified Poisson regressions.

          Results

          Children born to disabled mothers compared to their peers born to non-disabled mothers were at a higher risk for neonatal mortality (RR = 1.80, 95% CI:1.31–2.49), infant mortality (RR = 1.69, 95% CI:1.19–2.41), and under-five mortality (RR = 1.78, 95% CI:1.05–3.01). The joint risk of maternal disability and HIV-positive status on the selected child mortality indicators is compounded such that it is more than the sum of the risks from maternal disability or maternal HIV-positive status alone (RR = 3.97 vs. joint RR = 3.67 for neonatal mortality; RR = 3.57 vs. joint RR = 3.25 for infant mortality; RR = 6.44 vs. joint RR = 3.75 for under-five mortality).

          Conclusions

          The findings suggest that children born to HIV-positive women with disabilities are at an exceptionally high risk of premature mortality. Established inequalities faced by women with disabilities may account for this increased risk. Given that maternal HIV and disability amplify each other’s impact on child mortality, addressing disabled women’s HIV-related needs and understanding the pathways and mechanisms contributing to these disparities is crucial.

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          Most cited references37

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          World report on disability.

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            Cluster-Sample Methods in Applied Econometrics

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              Integration of postpartum healthcare services for HIV-infected women and their infants in South Africa: A randomised controlled trial

              Background As the number of HIV-infected women initiating lifelong antiretroviral therapy (ART) during pregnancy increases globally, concerns have emerged regarding low levels of retention in HIV services and suboptimal adherence to ART during the postpartum period. We examined the impact of integrating postpartum ART for HIV+ mothers alongside infant follow-up within maternal and child health (MCH) services in Cape Town, South Africa. Methods and findings We conducted a randomised trial among HIV+ postpartum women aged ≥18 years who initiated ART during pregnancy in the local antenatal care clinic and were breastfeeding when screened before 6 weeks postpartum. We compared an integrated postnatal service among mothers and their infants (the MCH-ART intervention) to the local standard of care (control)—immediate postnatal referral of HIV+ women on ART to general adult ART services and their infants to separate routine infant follow-up. Evaluation data were collected through medical records and trial measurement visits scheduled and located separately from healthcare services involved in either arm. The primary trial outcome was a composite endpoint of women’s retention in ART care and viral suppression (VS) (viral load < 50 copies/ml) at 12 months postpartum; secondary outcomes included duration of any and exclusive breastfeeding, mother-to-child HIV transmission, and infant mortality. Between 5 June 2013 and 10 December 2014, a total of 471 mother–infant pairs were enrolled and randomised (mean age, 28.6 years; 18% nulliparous; 57% newly diagnosed with HIV in pregnancy; median duration of ART use at randomisation, 18 weeks). Among 411 women (87%) with primary endpoint data available, 77% of women (n = 155) randomised to the MCH-ART intervention achieved the primary composite outcome of retention in ART services with VS at 12 months postpartum, compared to 56% of women (n = 117) randomised to the control arm (absolute risk difference, 0.21; 95% CI: 0.12–0.30; p < 0.001). The findings for improved retention in care and VS among women in the MCH-ART intervention arm were consistent across subgroups of participants according to demographic and clinical characteristics. The median durations of any breastfeeding and exclusive breastfeeding were longer in women randomised to the intervention versus control arm (6.9 versus 3.0 months, p = 0.006, and 3.0 versus 1.4 months, p < 0.001, respectively). For the infants, overall HIV-free survival through 12 months of age was 97%: mother-to-child HIV transmission was 1.2% overall (n = 4 and n = 1 transmissions in the intervention and control arms, respectively), and infant mortality was 1.9% (n = 6 and n = 3 deaths in the intervention and control arms, respectively), and these outcomes were similar by trial arm. Interpretation of these findings should be qualified by the location of this study in a single urban area as well as the self-reported nature of breastfeeding outcomes. Conclusions In this study, we found that integrating ART services into the MCH platform during the postnatal period was a simple and effective intervention, and this should be considered for improving maternal and child outcomes in the context of HIV. Trial registration ClinicalTrials.gov NCT01933477.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SoftwareRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: ValidationRole: Writing – review & editing
                Role: Funding acquisitionRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS One
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                5 May 2021
                2021
                : 16
                : 5
                : e0251183
                Affiliations
                [1 ] The Lurie Institute for Disability Policy, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, United States of America
                [2 ] UCL International Disability Research Centre, University College London, London, United Kingdom
                [3 ] National Treasury, Pretoria, South Africa
                Columbia University - MSPH, UNITED STATES
                Author notes

                Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Drs. Akobirshoev, Zandam and Nandakumar report receiving a grant from Cardno Emerging Markets, USA, Ltd., for the conduct of the study. I hereby confirm that this does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                https://orcid.org/0000-0003-0680-5101
                Article
                PONE-D-21-07389
                10.1371/journal.pone.0251183
                8099123
                33951108
                cc4cf29a-f668-4ee7-af6c-bb8b1d002134
                © 2021 Akobirshoev et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 5 March 2021
                : 22 April 2021
                Page count
                Figures: 1, Tables: 2, Pages: 12
                Funding
                Funded by: Cardno Emerging Markets USA, LTD
                Award ID: U2GGH001531
                Funding support for this research was provided by Cardno Emerging Markets, USA, Ltd, as part of the Public–Private Partnerships in PEPFAR Countries project of the Centers for Disease Control and Prevention (CDC), Division of Global HIV/AIDS and TB (DGHT) under Cooperative Agreement Number U2GGH001531. The funder did not participate in the study design; in the collection, analysis, interpretation of data; or in the writing and submission of the manuscript for publication.
                Categories
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                Medicine and Health Sciences
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                Pediatrics
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                Custom metadata
                All 2016 Demographic & Health Survey data used for this study are publicly available can be accessed from the https://dhsprogram.com/methodology/survey/survey-display-390.cfm?showall=yes after registration.

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