Mortality variability and differentials by age and causes of death in rural South Africa, 1994-2018.

INTRODUCTION: Understanding mortality variability by age and cause is critical to identifying intervention and prevention actions to support disadvantaged populations. We assessed mortality changes in two rural South African populations over 25 years covering pre-AIDS and peak AIDS epidemic and subsequent antiretroviral therapy (ART) availability. METHODS: Using population surveillance data from the Agincourt Health and Socio-Demographic Surveillance System (AHDSS; 1994-2018) and Africa Health Research Institute (AHRI; 2000-2018) for 5-year periods, we calculated life expectancy from birth to age 85, mortality age distributions and variation, and life-years lost (LYL) decomposed into four cause-of-death groups. RESULTS: The AIDS epidemic shifted the age-at-death distribution to younger ages and increased LYL. For AHDSS, between 1994-1998 and 1999-2003 LYL increased for females from 13.6 years (95% CI 12.7 to 14.4) to 22.1 (95% CI 21.2 to 23.0) and for males from 19.9 (95% CI 18.8 to 20.8) to 27.1 (95% CI 26.2 to 28.0). AHRI LYL in 2000-2003 was extremely high (females=40.7 years (95% CI 39.8 to 41.5), males=44.8 years (95% CI 44.1 to 45.5)). Subsequent widespread ART availability reduced LYL (2014-2018) for women (AHDSS=15.7 (95% CI 15.0 to 16.3); AHRI=22.4 (95% CI 21.7 to 23.1)) and men (AHDSS=21.2 (95% CI 20.5 to 22.0); AHRI=27.4 (95% CI 26.7 to 28.2)), primarily due to reduced HIV/AIDS/TB deaths in mid-life and other communicable disease deaths in children. External causes increased as a proportion of LYL for men (2014-2018: AHRI=25%, AHDSS=17%). The share of AHDSS LYL 2014-2018 due to non-communicable diseases exceeded pre-HIV levels: females=43%; males=40%. CONCLUSIONS: Our findings highlight shifting burdens in cause-specific LYL and persistent mortality differentials in two populations experiencing complex epidemiological transitions. Results show high contributions of child deaths to LYL at the height of the AIDS epidemic. Reductions in LYL were primarily driven by lowered HIV/AIDS/TB and other communicable disease mortality during the ART periods. LYL differentials persist despite widespread ART availability, highlighting the contributions of other communicable diseases in children, HIV/AIDS/TB and external causes in mid-life and non-communicable diseases in older ages.

Understanding Household Dynamics From the Ground Up: A Longitudinal Study From a Rural South African Setting.

Investigations into household structure in low- and middle-income countries (LMICs) provide important insight into how families manage domestic life in response to resource allocation and caregiving needs during periods of rapid sociopolitical and health-related challenges. Recent evidence on household structure in many LMICs contrasts with long-standing viewpoints of worldwide convergence to a Western nuclearized household model. Here, we adopt a household-centered theoretical and methodological framework to investigate longitudinal patterns and dynamics of household structure in a rural South African setting during a period of high AIDS-related mortality and socioeconomic change. Data come from the Agincourt Health and Socio-Demographic Surveillance System (2003-2015). Using latent transition models, we derived six distinct household types by examining conditional interdependency between household heads' characteristics, members' age composition, and migration status. More than half of households were characterized by their complex and multigenerational profiles, with considerable within-typology variation in household size and dependency structure. Transition analyses showed stability of household types under female headship, while higher proportions of nuclearized household types dissolved over time. Household dissolution was closely linked to prior mortality experiences-particularly, following death of a male head. Our findings highlight the need to better conceptualize and contextualize household changes across populations and over time.

Gender inequities in women's access to maternal health care utilisation in Zambia: a qualitative analysis.

BACKGROUND: The role of gender inequities in women's ability to access maternal health care has mainly been analysed from either women's or men's perspective only. In this article, we explore the role of gender inequities in maternal health care utilisation from both men's and women's perspectives. METHODS: Thirty-six interviews were conducted with reproductive age women (n = 24), and men whose wives/partners gave birth within the last three years prior to our study in Zambia (n = 12). Our study sought to improve understanding of the normative environment in which women and men make decisions on maternal health care utilisation in Zambia. RESULTS: We found that men and women had different expectations regarding their gender roles in maternal health care utilisation, which created inequities reinforced by societal norms and traditions. Men make most household decisions including those related to reproductive health and they often have the major say in access to maternal health services despite not having holistic maternal health information which creates challenges in maternal health care utilisation. CONCLUSION: The study highlights the need for maternal health care utilisation decisions to be made by both men and women and that men should be fully involved in maternal health care from pregnancy until after child birth. Further, there is urgent need for concerted and sustained efforts to change traditional norms that reinforce these inequities and affect maternal health care utilisation if Zambia is to meet Sustainable Development Goal-3.1.

The effects of HIV and systolic blood pressure on mortality risk in rural South Africa, 2010-2019: a data note.

OBJECTIVES: South Africa is experiencing both HIV and hypertension epidemics. Data were compiled for a study to identify effects of HIV and high systolic blood pressure on mortality risk among people aged 40-plus in a rural South African area experiencing high prevalence of both conditions. We aim to release the replication data set for this study. DATA DESCRIPTION: The research data comes from the 2010-11 Ha Nakekela (We Care) population-based survey nested in the Agincourt Health and socio-Demographic Surveillance System (AHDSS) located in the northeast region of South Africa. An age-sex-stratified probability sample was drawn from the AHDSS. The public data set includes information on individual socioeconomic characteristics and measures of HIV status and blood pressure for participants aged 40-plus by 2019. The AHDSS, through its annual surveillance, provided mortality data for nine years subsequent to the survey. These data were converted to person-year observations and linked to the individual-level survey data using participants' AHDSS census identifier. The data can be used to replicate Houle et al. (2022) - which used discrete-time event history models stratified by sex to assess differential mortality risks according to Ha Nakekela measures of HIV-infection, HIV-1 RNA viral load, and systolic blood pressure.

Effect of the COVID-19 pandemic on life expectancy in Australia, 2020-22.

BACKGROUND: Australia provides a valuable international case study of life expectancy during the pandemic. In contrast to many other countries, it experienced relatively stringent restrictions and low COVID-19 mortality during 2020-21, followed by relaxation of these restrictions when high vaccination rates were achieved. This study measures Australia's life expectancy trends and the contributions of age group and causes of death, during the pandemic. METHODS: Trends in life expectancy at birth in Australia and its states and territories were measured from 2020 to 2022. The contributions of age group and cause of death to these trends were measured using decomposition methods. Life expectancy was compared with other high-income countries. RESULTS: Australia's life expectancy fell by more than half a year in 2022, following a sharp increase in 2020 and moderate decline in 2021. For the 3 years 2020 to 2022, life expectancy was 0.13 years (95% confidence interval 0.07-0.19) higher for males and 0.09 years (0.03-0.14) higher for females versus 2017-19. Australia's life expectancy increase in 2020 was larger than that in the vast majority of other high-income countries, but its decline in 2022 was greater than in other countries whose life expectancy rose in the first year of the pandemic. The small negative contribution of COVID-19 deaths to life expectancy in Australia was more than offset by lower non-communicable disease mortality. There were only small differences in life expectancy change between the states with the most stringent restrictions (Victoria and New South Wales) and the rest of Australia. CONCLUSIONS: Australia's life expectancy trends during 2020-22 were relatively favourable compared with other high-income countries, with the exception of its sharp decline in 2022 once restrictions were loosened.

Parental imprisonment, delinquent behavior, and BMI gain in a U.S. nationally representative cohort study of adolescents and adults ages 12-32.

Children who experience parental imprisonment report greater mental and physical health adversities in adolescence and adulthood relative to comparable individuals whose parents did not serve time in prison. Research has linked BMI gain with parental imprisonment among females, but other studies have shown null or negative associations between parental imprisonment and weight increases for their offspring. Using longitudinal data from the National Longitudinal Study of Adolescent to Adult Health, this study attempts to resolve these differential findings by examining the interrelationship between delinquent behavior and BMI associated with parental imprisonment as individuals progress from adolescence into adulthood (ages 12-32). We show that higher delinquency levels are associated with lower BMI among men and women. With the transition from adolescence to adulthood, parental imprisonment is linked with increased BMI gain and obesity among females who are not delinquent. These findings highlight the need to consider how the decline in delinquent behavior and increasing health disparities between adolescence and adulthood may intersect as individuals experiencing parental imprisonment transition from adolescence to adulthood.

Household structure, composition and child mortality in the unfolding antiretroviral therapy era in rural South Africa: comparative evidence from population surveillance, 2000-2015.

OBJECTIVES: The structure and composition of the household has important influences on child mortality. However, little is known about these factors in HIV-endemic areas and how associations may change with the introduction and widespread availability of antiretroviral treatment (ART). We use comparative, longitudinal data from two demographic surveillance sites in rural South Africa (2000-2015) on mortality of children younger than 5 years (n=101 105). DESIGN: We use multilevel discrete time event history analysis to estimate children's probability of dying by their matrilineal residential arrangements. We also test if associations have changed over time with ART availability. SETTING: Rural South Africa. PARTICIPANTS: Children younger than 5 years (n=101 105). RESULTS: 3603 children died between 2000 and 2015. Mortality risks differed by co-residence patterns along with different types of kin present in the household. Children in nuclear households with both parents had the lowest risk of dying compared with all other household types. Associations with kin and child mortality were moderated by parental status. Having older siblings lowered the probability of dying only for children in a household with both parents (relative risk ratio (RRR)=0.736, 95% CI (0.633 to 0.855)). Only in the later ART period was there evidence that older adult kin lowered the probability of dying for children in single parent households (RRR=0.753, 95% CI (0.664 to 0.853)). CONCLUSIONS: Our findings provide comparative evidence of how differential household profiles may place children at higher mortality risk. Formative research is needed to understand the role of other household kin in promoting child well-being, particularly in one-parent households that are increasingly prevalent.

Significant Improvement in Blood Pressure Levels Among Older Adults With Hypertension in Rural South Africa.

BACKGROUND: Sub-Saharan Africa is undergoing an epidemiologic transition from infectious diseases to cardiovascular diseases. From 2014 to 2019, sociodemographic surveillance was performed in a large cohort in rural South Africa. METHODS: Disease prevalence and incidence were calculated using inverse probability weights. Poisson regression was used to identify disease predictors. The percentage of individuals with controlled (<140/90 mm Hg) versus uncontrolled hypertension was compared between 2014 and 2019. RESULTS: Compared with 2014 (n=5059), study participants in 2019 (n=4176) had similar rates of obesity (mean body mass index, 27.5±10.0 versus 27.0±6.5) but higher smoking (9.1% versus 11.5%) and diabetes (11.1% versus 13.9%). There was no significant increase in hypertension prevalence (58.4% versus 59.8%; age adjusted, 64.3% versus 63.3%), and there was a significant reduction in mean systolic blood pressure (138.0 versus 128.5 mm Hg; P<0.001). Among hypertensive individuals who reported medication use in 2014 and 2019 (n=796), the proportion with controlled hypertension on medication increased from 44.5% to 62.3%. Hypertension incidence was 6.2 per 100 person-years, and age was the only independent predictor. Among normotensive individuals in 2014 (n=2257), 15.2% developed hypertension by 2019, with the majority already controlled on medications by 2019. CONCLUSIONS: The hypertension prevalence and incidence are plateauing in this aging cohort. There was a statistically and clinically significant decline in mean blood pressure and a substantial increase in individuals with controlled hypertension on medication. The prevalence of cardiometabolic risk factors did not decrease over time, suggesting that the blood pressure decrease is likely due to increased medication access and adherence, promoted by local health systems.

Impact of diabetes on longevity and disability-free life expectancy among older South African adults: A prospective longitudinal analysis.

AIMS: We seek to understand the coexisting effects of population aging and a rising burden of diabetes on healthy longevity in South Africa. METHODS: We used longitudinal data from the 2015 and 2018 waves of the "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI) study to explore life expectancy (LE) and disability-free life expectancy (DFLE) of adults aged 45 and older with and without diabetes in rural South Africa. We estimated LE and DFLE by diabetes status using Markov-based microsimulation. RESULTS: We find a clear gradient in remaining LE and DFLE based on diabetes status. At age 45, a man without diabetes could expect to live 7.4 [95% CI 3.4 - 11.7] more years than a man with diabetes, and a woman without diabetes could expect to live 3.9 [95% CI: 0.8 - 6.9] more years than a woman with diabetes. Individuals with diabetes lived proportionately more years subject to disability than individuals without diabetes. CONCLUSIONS: We find large and important decrements in disability-free aging for people with diabetes in South Africa. This finding should motivate efforts to strengthen prevention and treatment efforts for diabetes and its complications for older adults in this setting.

Differences in healthy longevity by HIV status and viral load among older South African adults: an observational cohort modelling study.

BACKGROUND: The population of people living with HIV in South Africa is rapidly ageing due to increased survivorship attributable to antiretroviral therapy (ART). We sought to understand how the combined effects of HIV and ART have led to differences in healthy longevity by HIV status and viral suppression in this context. METHODS: In this observational cohort modelling study we use longitudinal data from the 2015 baseline interview (from Nov 13, 2014, to Nov 30, 2015) and the 2018 longitudinal follow-up interview (from Oct 12, 2018, to Nov 7, 2019) of the population-based study Health and Ageing in Africa: a Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) to estimate life expectancy and disability-free life expectancy (DFLE) of adults aged 40 years and older in rural South Africa. Respondents who consented to HIV testing, responded to survey questions on disability, and who were either interviewed in both surveys or who died between survey waves were included in the analysis. We estimate life expectancy and DFLE by HIV status and viral suppression (defined as <200 copies per mL) using Markov-based microsimulation. FINDINGS: Among the 4322 eligible participants from the HAALSI study, we find a clear gradient in remaining life expectancy and DFLE based on HIV serostatus and viral suppression. At age 45 years, the life expectancy of a woman without HIV was 33·2 years (95% CI 32·0-35·0), compared with 31·6 years (29·2-34·1) a woman with virally suppressed HIV, and 26·4 years (23·1-29·1) for a woman with unsuppressed HIV; life expectancy for a 45 year old man without HIV was 27·2 years (25·8-29·1), compared with 24·1 years (20·9-27·2) for a man with virally suppressed HIV, and 17·4 years (15·0-20·3) for a man with unsuppressed HIV. Men and women with viral suppression could expect to live nearly as many years of DFLE as HIV-uninfected individuals at ages 45 years and 65 years. INTERPRETATION: These results highlight the tremendous benefits of ART for population health in high-HIV-prevalence contexts and reinforce the need for continued work in making ART treatment accessible to ageing populations. FUNDING: National Institutes of Health.

The double-edged role of accessed status on health and well-being among middle- and older-age adults in rural South Africa: The HAALSI study.

Background: Social capital theory conceptualizes accessed status (the socioeconomic status of social contacts) as interpersonal resources that generate positive health returns, while social cost theory suggests that accessed status can harm health due to the sociopsychological costs of generating and maintaining these relationships. Evidence for both hypotheses has been observed in higher-income countries, but not in more resource-constrained settings.We therefore investigated whether the dual functions of accessed status on health may be patterned by its interaction with network structure and functions among an older population in rural South Africa. Method: We used baseline survey data from the HAALSI study ("Health and Aging in Africa: a Longitudinal Study of an INDEPTH Community in South Africa") among 4,379 adults aged 40 and older. We examined the direct effect of accessed status (measured as network members' literacy), as well as its interaction with network size and instrumental support, on life satisfaction and self-rated health. Results: In models without interactions, accessed status was positively associated with life satisfaction but not self-rated health. Higher accessed status was positively associated with both outcomes for those with fewer personal contacts. Interaction effects were further patterned by gender, being most health-protective for women with a smaller network and most health-damaging for men with a larger network. Conclusions: Supporting social capital theory, we find that having higher accessed status is associated with better health and well-being for older adults in a setting with limited formal support resources. However, the explanatory power of both theories appears to depending on other key factors, such as gender and network size, highlighting the importance of contextualizing theories in practice.

Parental imprisonment as a risk factor for cardiovascular and metabolic disease in adolescent and adult offspring: A prospective Australian birth cohort study.

Objectives: Parental imprisonment is linked with child health in later life. The present study provides the first prospective cohort analysis and non-U.S. based study examining parental imprisonment and cardiometabolic risk factors in adolescence and adulthood. Methods: The study followed 7,223 children born from live, singleton births from 1981 to 1984 in Brisbane, Australia. Data on parental imprisonment was collected at mother interview when the children were ages 5 and 14. Our sample analyzes offspring with biometric data collected by health professionals, including 3,794 at age 14, 2,136 at age 21, and 1,712 at age 30. Analyses used multivariate linear and logistic regression, and time-varying growth curve models. Results: Among female respondents, parental imprisonment at ages ≤5 was associated with higher body-mass index (BMI) at ages 14, 21, and 30; higher systolic blood pressure (SBP) and diastolic blood pressure (DBP) at age 30; and increased sedentary hours, larger waist circumference, and odds of a high-risk waist circumference at age 30. Parental imprisonment when the child was aged ≤14 was associated with increased BMI and SBP at age 30 for females. In growth-curve models, parental imprisonment when the child was aged ≤5 and ≤ 14 among females was linked with increased BMI; parental imprisonment when the child was aged ≤5 was associated with increased SBP and DBP. No significant associations were observed for males. Conclusions: Using prospective cohort data, our results support research showing that parental imprisonment, particularly in early childhood, is associated with increased BMI, blood pressure, sedentary hours, and waist circumference in females in early adulthood. These findings implicate parental imprisonment as a risk factor for cardiometabolic health issues in later life among females.

Twin epidemics: the effects of HIV and systolic blood pressure on mortality risk in rural South Africa, 2010-2019.

BACKGROUND: Sub-Saharan African settings are experiencing dual epidemics of HIV and hypertension. We investigate effects of each condition on mortality and examine whether HIV and hypertension interact in determining mortality. METHODS: Data come from the 2010 Ha Nakekela population-based survey of individuals ages 40 and older (1,802 women; 1,107 men) nested in the Agincourt Health and socio-Demographic Surveillance System in rural South Africa, which provides mortality follow-up from population surveillance until mid-2019. Using discrete-time event history models stratified by sex, we assessed differential mortality risks according to baseline measures of HIV infection, HIV-1 RNA viral load, and systolic blood pressure. RESULTS: During the 8-year follow-up period, mortality was high (477 deaths). Survey weighted estimates are that 37% of men (mortality rate 987.53/100,000, 95% CI: 986.26 to 988.79) and 25% of women (mortality rate 937.28/100,000, 95% CI: 899.7 to 974.88) died. Over a quarter of participants were living with HIV (PLWH) at baseline, over 50% of whom had unsuppressed viral loads. The share of the population with a systolic blood pressure of 140mm Hg or higher increased from 24% at ages 40-59 to 50% at ages 75-plus and was generally higher for those not living with HIV compared to PLWH. Men and women with unsuppressed viral load had elevated mortality risks (men: adjusted odds ratio (aOR) 3.23, 95% CI: 2.21 to 4.71, women: aOR 2.05, 95% CI: 1.27 to 3.30). There was a weak, non-linear relationship between systolic blood pressure and higher mortality risk. We found no significant interaction between systolic blood pressure and HIV status for either men or women (p>0.05). CONCLUSIONS: Our results indicate that HIV and elevated blood pressure are acting as separate, non-interacting epidemics affecting high proportions of the older adult population. PLWH with unsuppressed viral load were at higher mortality risk compared to those uninfected. Systolic blood pressure was a mortality risk factor independent of HIV status. As antiretroviral therapy becomes more widespread, further longitudinal follow-up is needed to understand how the dynamics of increased longevity and multimorbidity among people living with both HIV and high blood pressure, as well as the emergence of COVID-19, may alter these patterns.

Hypertension incidence among middle-aged and older adults: findings from a 5-year prospective study in rural South Africa, 2010-2015.

OBJECTIVES: There is a scarcity of longitudinal cohort studies in sub-Saharan Africa to understand the epidemiology of cardiovascular disease as a basis for intervention. We estimated incident hypertension and associated sociodemographic, health and behavioural risk factors in a population aged 40 years and older over a 5-year period. DESIGN: We assessed the association between incident hypertension and sociodemographic, health and behavioural factors using Poisson regression. We adjusted for non-response in 2015 using inverse probability sampling weights from a logistic regression including sex and age at baseline. SETTING: Rural South Africa. PARTICIPANTS: We used a population-based cohort of normotensive adults in 2010 who were aged 40 years and older at retest in 2015. RESULTS: Of 676 individuals completing baseline and 5-year follow-up, there were 193 incident cases of hypertension. The overall hypertension incidence rate was 8.374/100 person-years. In multivariable analyses, those who became hypertensive were more likely to be older, have a high waist circumference (incidence rate ratio (IRR): 1.557, 95% CI: 1.074 to 2.259) and be employed (IRR: 1.579, 95% CI: 1.071 to 2.329) at baseline. Being HIV positive and not on antiretroviral therapy at baseline was associated with lower risk of incident hypertension. CONCLUSIONS: Over a 5-year period, 29% of respondents developed hypertension. Given the high burden of hypertension in South Africa, continued longitudinal follow-up is needed to understand the complex interplay of non-communicable and infectious diseases and their underlying and modifiable risk factors to inform public health prevention strategies and programmes.

Assessing the relationship between parental imprisonment in childhood and risk of sexually transmitted infections: a cohort study of US adults in early adulthood.

OBJECTIVES: One in six young adults in the USA experiences parental imprisonment in childhood. Prior studies have associated parental imprisonment with risk of sexually transmitted infection (STI); however, potential data and methodological issues may have limited the reliability and accuracy of prior findings. Examining cumulative and longitudinal risk, we address several methodological limitations of prior studies and also examine comparative risk by respondent sex and ethnicity. We assess these associations using a range of control variables. DESIGN: A national cohort study from the National Longitudinal Study of Adolescent to Adult Health using (1) a cross-sectional sample of adults at ages 24-32 years and (2) a longitudinal sample between ages 18 and 32 years. Both analyses estimate ORs for STI associated with parental imprisonment and examine variation by parent/child gender and respondent ethnicity. SETTING: In-home interviews in the USA at wave 1 (1994-1995), wave 3 (2001-2003) and wave 4 (2007-2009). PARTICIPANTS: 15 684 respondents completing interviews at wave 1 (ages 12-18 years) and wave 4 (ages 26-32 years), including 8556 women, 3437 black and 2397 respondents reporting parental imprisonment. RESULTS: Father-only imprisonment is associated with 1.22 higher odds (95% CI: 1.09 to 1.37) of lifetime STI and 1.19 higher odds (95% CI: 1.01 to 1.41) of STI in the past 12 months between ages 18 and 32 years, adjusting for familial, neighbourhood, individual and sexual risk factors. Maternal imprisonment is not associated with higher risk of lifetime STI after adjusting for confounders (95% CI: 0.90 to 1.61). Examining predicted probabilities of STI, our findings show additive risks for women, black people and parental imprisonment. CONCLUSION: Adjusting for confounders, only paternal imprisonment is associated with slightly elevated risk of annual and lifetime risk of STI. Additive effects show that parental imprisonment modestly increases ethnic and female risk for STI.

Linking the timing of a mother's and child's death: Comparative evidence from two rural South African population-based surveillance studies, 2000-2015.

BACKGROUND: The effect of the period before a mother's death on child survival has been assessed in only a few studies. We conducted a comparative investigation of the effect of the timing of a mother's death on child survival up to age five years in rural South Africa. METHODS: We used discrete time survival analysis on data from two HIV-endemic population surveillance sites (2000-2015) to estimate a child's risk of dying before and after their mother's death. We tested if this relationship varied between sites and by availability of antiretroviral therapy (ART). We assessed if related adults in the household altered the effect of a mother's death on child survival. FINDINGS: 3,618 children died from 2000-2015. The probability of a child dying began to increase in the 7-11 months prior to the mother's death and increased markedly in the 3 months before (2000-2003 relative risk = 22.2, 95% CI = 14.2-34.6) and 3 months following her death (2000-2003 RR = 20.1; CI = 10.3-39.4). This increased risk pattern was evident at both sites. The pattern attenuated with ART availability but remained even with availability at both sites. The father and maternal grandmother in the household lowered children's mortality risk independent of the association between timing of mother and child mortality. CONCLUSIONS: The persistence of elevated mortality risk both before and after the mother's death for children of different ages suggests that absence of maternal care and abrupt breastfeeding cessation might be crucial risk factors. Formative research is needed to understand the circumstances for children when a mother is very ill or dies, and behavioral and other risk factors that increase both the mother and child's risk of dying. Identifying families when a mother is very ill and implementing training and support strategies for other members of the household are urgently needed to reduce preventable child mortality.

"A NOWADAYS DISEASE": HIV/AIDS AND SOCIAL CHANGE IN A RURAL SOUTH AFRICAN COMMUNITY.

Why do some people adapt successfully to change while others do not? We examine this question in the context of a severe HIV/AIDS epidemic in South Africa, where adapting (or not) to social change has borne life and death consequences. Applying an age-period-cohort lens to the analysis of qualitative life history interviews among middle-aged and older adults, we consider the role of the life course and gendered sexuality in informing Africans' strategies of action, or inaction, and in differentially driving and stalling change in each cohort in response to the HIV/AIDS epidemic. Our study illuminates the unique challenges of adapting to social change that result from dynamic interactions among aging, prevailing social structures, and a cohort's socio-historical orientation to a new period.

Mortality transition over a quarter century in rural South Africa: findings from population surveillance in Agincourt 1993-2018.

BACKGROUND: Mortality burden in South Africa since the mid-1990s has been characterized by a quadruple disease burden: HIV/AIDS and tuberculosis (TB); other communicable diseases (excluding HIV/AIDS and TB), maternal causes, perinatal conditions and nutritional deficiencies; non-communicable diseases (NCDs); and injuries. Causes from these broad groupings have persistently constituted the top 10 causes of death. However, proportions and rankings have varied over time, alongside overall mortality levels. OBJECTIVE: To provide evidence on the contributions of age and cause-of-death to changes in mortality levels in a rural South African population over a quarter century (1993-2018). METHODS: Using mortality and cause-of-death data from the Agincourt Health and Socio-Demographic Surveillance System (HDSS), we derive estimates of the distribution of deaths by cause, and hazards of death by age, sex, and time period, 1993-2018. We derive estimates of life expectancies at birth and years of life expectancy gained at age 15 if most common causes of death were deleted. We compare mortality indicators and cause-of-death trends from the Agincourt HDSS with South African national indicators generated from publicly available datasets. RESULTS: Mortality and cause-of-death transition reveals that overall mortality levels have returned to pre-HIV epidemic levels. In recent years, the concentration of mortality has shifted towards older ages, and the mortality burden from cardiovascular diseases and other chronic NCDs are more prominent as people living with HIV/AIDS access ART and live longer. Changes in life expectancy at birth, distribution of deaths by age, and major cause-of-death categories in the Agincourt population follow a similar pattern to the South African population. CONCLUSION: The Agincourt HDSS provides critical information about general mortality, cause-of-death, and age patterns in rural South Africa. Realigning and strengthening the South African public health and healthcare systems is needed to concurrently cater for the prevention, control, and treatment of multiple disease conditions.

Antenatal depression and anxiety across pregnancy in urban South Africa.

BACKGROUND: Depression and anxiety in pregnancy have negative consequences for women and their offspring. High adversity places pregnant women at increased mental health risk, yet there is a dearth of longitudinal research in these settings. Little is known about the pathways by which these problems emerge or persist in pregnancy. METHODS: Women were enrolled in a prospective pregnancy cohort in Soweto, South Africa (2014-2016) and assessed using validated measures (Edinburgh Postnatal Depression Scale EPDS ≥13; State Trait Anxiety Index STAI ≥12) in early (T1) and later pregnancy (T2). Data was available for n = 649 women. Multinominal regression modelling was used to determine factors associated with transient versus persistent depression and anxiety across pregnancy. Cross-lagged panel modelling explored direction of effect between depression and anxiety, and stressors. RESULTS: We found high rates of depression (T1: 27%; T2: 25%) and anxiety (T1: 15%; T2: 17%). Perceiving a partner made one's life harder increased risk of persistent depression (RR 5.92 95% CI [3.0-11.8] p<0.001); family stress increased risk for persistent anxiety (RR 1.71 95% CI [1.1-2.7] p = 0.027). We find evidence of a direct effect of early depression (T1) on later family stress (T2); and early family stress (T1) on later anxiety (T2). LIMITATIONS: We used screening measures of depression and anxiety rather than clinical interviews. CONCLUSIONS: Studies which focus only on late pregnancy may underestimate risk. Early identification, in the first trimester, is critical for prevention and treatment. Partner and family stressors are a key intervention target.