Rationale: Vital registration is lacking in developing settings where health and development problems are most pressing. Policy-makers confront an “information paradox”: the critical need for information on which to base priorities and monitor progress, and the profound shortage of such information. Aims: To better understand the dynamics of mortality transition in rural South Africa over a decade of profound socio-political change coupled with emerging HIV/AIDS. Thereby to inform health and development programming, policy formulation, and the research agenda; and contribute to debate on the nature of the ‘health transition’. Methods: The Agincourt health and demographic surveillance system is based on continuous monitoring of the Agincourt sub-district population in rural north-east South Africa. This involves annual recording of all vital events, specifically deaths, births and migrations in 11,700 households comprising some 70,000 persons. A “verbal autopsy” is conducted on every death, and special modules provide additional data. Key findings: A major health transition has occurred over the past decade, with marked changes in population structure and rapidly escalating mortality particularly among children and younger adults. A quadruple burden of disease is evident with persisting infectious disease and malnutrition in children, emerging non-communicable disease in the middle-aged and older, high levels of violence in an apparently peaceful community, and rapidly escalating HIV/AIDS and tuberculosis. There is evidence of sex differences and socio-economic differentials in mortality; vulnerable sub-groups include the children of Mozambican immigrants and recently returned labour migrants. Implications: With respect to health transition, empirical data demonstrate a marked “counter transition” with mortality increasing in children and young adults; “epidemiologic polarization” is evident with the most vulnerable experiencing a higher mortality burden; and a “protracted transition” is reflected in the co-existence of persisting infectious disease and malnutrition, emerging HIV/AIDS, and increasing chronic non-communicable disease. With respect to health policy and practice there is urgent need to: strengthen HIV/AIDS prevention, treatment and care; offer effective long-term care to control the rising burden of chronic illness and related risk; maintain and improve maternal and child health services; and address differential access to care. This poses a substantial challenge to a severely stretched health system.

Thesis (M.A. (Population and Reproductive Health Research))--Mahidol University, 2003.

Background South Africa has experienced the most severe consequences of the HIV/AIDS pandemic. Every community has been affected in some way, many experiencing huge increases in mortality,particularly before antiretroviral therapies (ART) were readily available. However, the micro-level understanding of the HIV epidemic in South Africa is weak, because of a lack of detailed data for most of the population. This thesis is based on detailed individual follow-up in the Agincourt Health and Demographic Surveillance Site (HDSS) located in the Agincourt subdistrict of Mpumalanga Province and investigates micro-level determinants of HIV epidemiology and the impact of treatment provided. Methods The Agincourt HDSS has followed a geographically defined population since 1992,approximately the time when the HIV/AIDS epidemic first became apparent. This population based surveillance has included capturing details of all deaths, with cause of death determined by verbal autopsy, as well as the geographical location of individual households within the overall Agincourt area. Background information on the roll-out of ART over time was also recorded. Results A comparison immediately before and after the major roll-out of ART showed a substantial decrease in HIV-related mortality, greater in some local communities within the area than others. Individual determinants associated with a decreased risk of HIV/AIDS mortality included proximity to ART services, as well as being female, younger, and in higher socioeconomic and educational strata. There was a decrease in the use of traditional healthcare sources and an increase in the use of biomedical healthcare amongst those dying of HIV/AIDS between periods before and after the roll-out of ART. Conclusions Understanding micro-level determinants of HIV/AIDS infection and mortality was very important in terms of characterising the overall epidemic in this community. This approach will enable public health interventions to be more effectively targeted towards those who need them most in the continuing evolution of the HIV/AIDS epidemic.

Thesis (M.A. (Population and Reproductive Health Research))--Mahidol University, 2003.