Student Number : 0516841M - MSc research report - School of Public Health - Faculty of Health Sciences / Objective This work investigates the hypothesis that individuals recently migrating into rural areas have a higher mortality than those always resident and that migrant deaths are more likely to be HIV/AIDS related than non migrant deaths. Methods Data from the Africa Centre Demographic Surveillance System (ACDIS), South Africa, was used for the analysis. A total of 41519 adults aged 18 to 60 years since their last visit dates were categorized into three groups; internal migrants, external in migrants and always resident individuals since 2001. Follow up period was from 1st January 2001 to 31st December 2005. Cox proportional hazard regression method was used to quantify the additional risk of dying for migrants who have recently migrated into the DSS area. Logistic regression was used to examine the relationship between migration status and dying from AIDS related complications for the members in the sample whose cause of death have been identified using verbal autopsy procedures. Results External in migrants into the DSS area were 1.52 times more likely to die than those always resident. After adjusting for the effects of sex, age group, socio-economic status and educational level an external in migrant has a relative risk of 1.19, [adjusted HR=1.19, P=0.001, 95% CI (1.08,1.32)] of dying compared to those always resident. Internal migrants were 18% less likely to die compared to always resident individuals, [adjusted HR=0.82, P=0.008, 95% CI (0.71, 0.95)] and males were 1.38 times more likely to die within the follow up period compared to females, [HR=1.38, P<0.001, 95% CI (1.28, 1.49)]. These results were statistically significant at 95% confidence level. Out of a total of 1119 deaths that occurred in 2001 and 2002 whose cause of death have been identified through verbal autopsy procedures, 763 (66%) died of AIDS. The odds of dying from AIDS are 2.09 if you are an external in migrant compared to an always resident member, [unadjusted OR = 2.09, P = 0.009 95% CI (1.38, 3.16)]. After controlling for other factors in the model, the odds of dying from AIDS as an external immigrant was 1.79 times, [adjusted OR = 1.79, P = 0.009, 95% CI (1.15, 2.77)] compared to those always resident. There was no significant difference in AIDS mortality between always resident individuals and internal migrants. The odds of a female dying of AIDS was 2.33 times, [OR = 2.33, P<0.001, 95% CI (1.78, 3.06)] compared to males after controlling for migration status, age, socioeconomic status and educational level. Conclusion External in migrants have an increased risk of death among adults aged 18 to 60 years compared to those always resident. External in migrants are also more at risk of dying from AIDS related illnesses than those always resident. Internal migrants are less likely to die than those always resident. Females are more at risk of dying from AIDS than males. In resource-poor settings, especially in many parts of Africa and other developing countries with very high prevalence of HIV/AIDS and over burdened health services in rural areas, it is important to identify and quantify some of these trends contributing to high disease burdens and mortality in rural areas in order to put in place effective interventions to better the health conditions of the people in these areas.

This thesis examines the impacts of adult HIV/AIDS related mortality on elderly women and their households in Agincourt, a rural area in the north-eastern part of South Africa. It focuses specifically on demographic, socio-economic and socio-cultural impacts of adult AIDS and non-AIDS illness/death on near-old women aged 50-59 and older women aged 60 and above. The study uses the Agincourt Health and Demographic Surveillance System (AHDSS) 2004 census data which contains some history about individuals and their households (e.g. household mortality experience between 1992 and 2004). The AHDSS dataset is used to examine elderly female household headship and its relationship with, firstly, pension status and secondly, adult AIDS/non-AIDS mortality, through statistical analyses. Also, the AHDSS census data is utilised as a sampling frame to select a random sample of 60 households in which 30 women aged 50-59 and 30 women aged 60-75 lived, for the qualitative part of this study. The sample was made up of 20 women who lived in households that had experienced an HIV/AIDS death between 2001 and 2003, 20 women that lived in households where another type of adult death had occurred, and 30 women in households with no adult death during the period. The findings from the quantitative analyses of the AHDSS dataset reveal that there is no significant relationship between adult AIDS/non-AIDS death and elderly female household headship. Further findings, however, show that elderly female household headship is strongly associated with pension status, thereby suggesting that pension grant is a determining factor in the household headship status of elderly women. One implication of this is that elderly female household heads who are pensioners may be able to cope better with HIV/AIDS impacts as findings from the qualitative data demonstrate that pensioners (older women) are more likely, than non-pensioners (near-old women), to have access to coping strategies, which enable them to deal with the financial crises of adult illness/death in their households. There is, therefore, the need for programmes to target near-old women, who experience the financial impact of adult morbidity/mortality like their older peers. iii Further findings from the qualitative data explicate secondary stigma as a socio-cultural impact of adult HIV/AIDS on elderly women who are caregivers to infected children. Findings also highlight different types of secondary stigma such as physical stigma in the form of separation from family members and social stigma in the form of social isolation. The study suggests that there is need for intervention programmes that address the issue of secondary stigma as it makes caregiving responsibilities more burdensome for elderly women.