Elsevier

The Journal of Pediatrics

Volume 159, Issue 3, September 2011, Pages 484-489
The Journal of Pediatrics

Original Article
Pneumonia and Malnutrition are Highly Predictive of Mortality among African Children Hospitalized with Human Immunodeficiency Virus Infection or Exposure in the Era of Antiretroviral Therapy

https://doi.org/10.1016/j.jpeds.2011.02.033Get rights and content

Objective

To identify clinical characteristics predicting death among inpatients who are infected with or exposed to human immunodeficiency virus (HIV) during a period of pediatric antiretroviral therapy scale-up in sub-Saharan Africa.

Study design

Retrospective review of medical records from every child with HIV infection (n = 834) or exposure (n = 351) identified by routine inpatient testing in Kamuzu Central Hospital, Lilongwe, Malawi, September 2007 through December 2008.

Results

The inpatient mortality rate was high among children with HIV infection (16.6%) and exposure (13.4%). Clinically diagnosed Pneumocystis pneumonia or very severe pneumonia independently predicted death in inpatients with HIV infection (OR 14; 95% CI 8.2 to 23) or exposure (OR 21; CI 8.4 to 50). Severe acute malnutrition independently predicted death in children who are HIV infected (OR 2.2; CI 1.7 to 3.9) or exposed (OR 5.1; CI 2.3 to 11). Other independent predictors of death were septicemia, Kaposi sarcoma, meningitis, and esophageal candidiasis for children infected with HIV, and meningitis and severe anemia for inpatients exposed to HIV.

Conclusions

Severe respiratory tract infections and malnutrition are both highly prevalent and strongly associated with death among hospitalized children who are HIV infected or exposed. Novel programmatic and therapeutic strategies are urgently needed to reduce the high mortality rate among inpatients with HIV infection and HIV exposure in African pediatric hospitals.

Section snippets

Methods

The KCH pediatric ward is a crowded 215-bed referral facility averaging 42 and 34 daily admissions during the malaria and non-malaria seasons, respectively, for children <14 years of age. Data from every hospitalized inpatient with HIV infection and HIV exposure evaluated by an HIV-trained KCH clinician between September 1, 2007, and December 31, 2008, were recorded by COE pediatricians. The study was approved by the Malawi National Health Sciences Research Committee and Baylor College of

Results

During the 16-month study period, 15 271 children were admitted to KCH, and routine HIV testing identified 884 inpatients with HIV infection and 351 inpatients with HIV exposure (Table I). Although the overall mortality rate at KCH was 7.3%, the mortality rate was especially high in children who were HIV infected (16.6%) and HIV exposed (13.4%), and although the median duration between hospital admission and death at KCH was 2 days, most deaths in cohorts with HIV infection and HIV exposure

Discussion

From the beginning of the global scale-up of ART, children have been underrepresented as recipients of both HIV care and treatment.8 Most African children first gain access to HIV care in pediatric hospitals,4, 9 which face high burdens of HIV-related admissions and death.10 However, little is known about pediatric inpatients in the era of ART, and it is not yet known whether specific clinical features might predict which children who were infected or exposed to HIV are at especially high risk

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    Supported by Baylor International Pediatric AIDS Initiative, Bristol Myers Squibb, Abbott Fund, Texas Children’s Hospital, UNICEF, and the Malawi Ministry of Health. The funders had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; and in the preparation, review or approval of the manuscript. The authors declare no conflicts of interest.

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