Reasons for hospitalization in HIV-infected children in West Africa

Self-transfers, Hospital Admissions and Mortality Among Children and Adolescents Lost to Follow-up From Antiretroviral Therapy Programs in the Western Cape, South Africa Between 2004 and 2019: Linkage to Provincial Records

BACKGROUND

Pediatric programs face a high rate of loss to follow-up (LTFU) among children and adolescents living with HIV (CAHIV). We assessed true outcomes and predictors of these among CAHIV who were LTFU using linkage to the Western Cape Provincial Health Data Centre at Western Cape sites of the International epidemiology Databases to Evaluate AIDS-Southern Africa collaboration.

METHODS

We examined factors associated with self-transfer, hospital admission and mortality using competing risks regression in a retrospective cohort of CAHIV initiating antiretroviral therapy <15 years old between 2004 and 2019 and deemed LTFU (no recorded visit at the original facility for ≥180 days from the last visit date before database closure and not known to have officially transferred out or deceased).

RESULTS

Of the 1720 CAHIV deemed LTFU, 802 (46.6%) had self-transferred and were receiving care elsewhere within the Western Cape, 463 (26.9%) had been hospitalized and 45 (2.6%) CAHIV had died. The overall rates of self-transfer, hospitalization, mortality and LTFU were 9.4 [95% confidence interval (CI): 8.8-10.1], 5.4 (95% CI: 5.0-6.0), 0.5 (95% CI: 0.4-0.7) and 4.8 (95% CI: 4.4-5.3) per 100 person-years respectively. Increasing duration on antiretroviral therapy before LTFU was associated with self-transfers while male sex, older age at last visit (≥10 years vs. younger) were associated with hospital admission and immune suppression at last visit was associated with 5 times higher mortality.

CONCLUSIONS

Nearly half of CAHIV classified as LTFU had self-transferred to another health facility, a quarter had been hospitalized and a small proportion had died.

Adverse Drug Reactions to Antiretroviral Therapy: Frequency, Type, and Risk Factors in Children in Mali

OBJECTIVE

The aim of our study was to evaluate the frequency, type, and risk factors associated with adverse drug reactions (ADRs) in HIV-positive children with adherence to antiretroviral therapy (ART) at the Unit of Care and Accompaniment for People Living With HIV (USAC) of Bamako.

METHODS

A cross-sectional study was conducted at USAC of Bamako from May 1, 2014, to July 31, 2015. We included children aged 1 to 14 years with at least 6 months of ARV treatment initiated at USAC, with or without ADRs. Data collection was based on information collected from parents and clinical/biological assessments.

RESULTS

Median age of participants was 36 months and female sex was predominant (54.8%). Poor adherence during the study was observed in 15% of cases. Of patients in the study, 52% had a CD4 count less than 350 cells/mm³ at the time of adverse events. In bivariate analysis, we found that participants with adherence to ART tended to be younger than those with non-adherence to ART (36 vs 72 months, p = 0.093). In multivariable analysis, prophylactic treatment was the only factor marginally associated with ART adherence in HIV patients (p = 0.09). No other adverse biological effects or clinical conditions were associated with ART adherence in this study.

CONCLUSIONS

In this study we found that ADRs were frequent in HIV-positive patients but less frequent in ART-adherent HIV-positive children. Therefore, it is essential to regularly monitor children receiving ARVs to detect and treat the complications associated with these therapies according to ART adherence.

Hospitalization among infants who initiate antiretroviral therapy before 3 months of age

INTRODUCTION

Studies examining hospitalization among infants with HIV in resource-limited settings, in the context of early infant diagnosis and early antiretroviral therapy (ART) initiation, are limited.

METHODS

We used routinely collected data on infants who initiated ART aged <3 months (Western Cape province, South Africa; 2013-2017) to describe hospitalization from birth until 12 months post-ART initiation. Record reviews were additionally performed at three tertiary-level facilities. We used mixed-effects Poisson regression to examine factors associated with hospitalization.

RESULTS

Among 840 infants, 579 (69%) were hospitalized; 36% had >1 hospitalization. Median age at ART initiation decreased from 57 days (interquartile range [IQR] 22-74; 2013-2015) to 19 days (IQR 5-54; 2016-2017). Early neonatal hospitalization (age <7 days) occurred in 271 infants (32%) and represented 24% of hospitalizations (272/1131). Overall, 443 infants (53%) were hospitalized at age ≥7 days, including 13% with hospitalizations pre-ART initiation, 15% pre and post-ART initiation and 25% post-ART initiation. Excluding early neonatal hospitalizations, initiating ART at older age vs. age <1 week was associated with higher hospitalization rates: adjusted incidence rate ratios (95% confidence interval) were 1.86 (1.31-2.64); 2.31 (1.62-3.29) and 2.47 (1.76-3.46) if ART initiation age was 1-4 weeks; 5-8 weeks and 9-12 weeks respectively. Among infants whose hospital records were reviewed, reasons for early neonatal hospitalizations mostly related to prematurity or low birthweight (n = 46/60; 77%) whereas hospitalizations at age ≥7 days were mostly due to infections (n = 206/243; 85%).

CONCLUSIONS

Earlier ART initiation is associated with lower hospitalization rates. High hospitalization rates, despite initiation age <3 months, is concerning.

Cytomegalovirus Viremia and Clinical Outcomes in Kenyan Children Diagnosed With Human Immunodeficiency Virus (HIV) in Hospital

BACKGROUND

Cytomegalovirus (CMV) viremia is common in human immunodeficiency virus (HIV) infection and is associated with worse long-term outcomes. To date, no studies have assessed CMV viremia in children diagnosed with HIV in hospital.

METHODS

We studied CMV viremia and clinical outcomes in 163 Kenyan children aged 2 months to 12 years, diagnosed with HIV in hospital. CMV DNA levels in plasma were measured using quantitative polymerase chain reaction (PCR). Regression models were used to assess associations between CMV viremia ≥1000 IU/mL and the risk of continued hospitalization or death at 15 days, duration of hospitalization, and 6-month mortality.

RESULTS

At enrollment, 62/114 (54%) children had CMV viremia, and 20 (32%) were ≥1000 IU/mL. Eleven CMV reactivations were observed after admission. The prevalence and level of CMV viremia were highest in children <2 years and lowest in children ≥5 years old. CMV viremia ≥1000 IU/mL was independently associated with age <2 years (P = .03), higher log10 HIV RNA level (P = .01), and height-for-age z score >-2 (P = .02). Adjusting for age and log10 HIV RNA, the relative risk of death or continued hospitalization at 15 days was 1.74 (95% confidence interval [CI] = 1.04, 2.90), and the hazard ratio of 6-month mortality was 1.97 (95% CI = .57, 5.07) for children with CMV DNA ≥1000 IU/mL compared to lower-level or undetectable CMV DNA. Children with CMV DNA ≥1000 IU/mL were hospitalized a median ~5 days longer than children with lower-level or undetectable CMV DNA (P = .002).

CONCLUSIONS

In this nested observational study, CMV viremia was common in hospitalized children with HIV, and levels ≥1000 IU/mL were associated with increased risk of mortality and longer hospitalization.

Spectrum of disease in HIV-positive patients presenting to a tertiary care hospital: a retrospective, cross-sectional review in Kumasi, Ghana

Background

HIV remains a significant public health dilemma in West and Central Africa. HIV-related morbidity and mortality are unjustly high, yet little is known about the spectrum of complicating comorbidities in HIV-positive patients who are admitted to hospitals in these regions.

Methods

This study involved a retrospective chart review to determine the common comorbidities and mortality rate of HIV-infected patients admitted over a six month period to the internal medicine service at the Komfo Anokye Teaching Hospital (KATH), a tertiary care center in Ghana. Patients admitted with a known or new HIV diagnosis from January to July 2016 were included. Data were collected regarding the number of new versus known cases admitted, the most common presenting complaints, final admitting diagnoses, and causes of mortality in these patients.

Results

During the six-month study period, 250 HIV-positive patients were admitted to KATH, and 245 of these individuals had valid survival time recorded. Of these patients, 145/245 (59.2%) were female. Median age of patients included in the study was 42 years old (IQR 35–51). The mortality rate for HIV patients admitted to the hospital was 35.5% (87 patients). One hundred and forty-five (59.4%) patients had a known history of HIV documented in their patient charts, while the remaining patients were newly diagnosed with HIV during their inpatient stay. Pulmonary tuberculosis predominated among diagnostic findings, with 40.4% of HIV-infected patients diagnosed with the condition while admitted. Patients presenting with neurological symptoms on admission were 2.14 (95% CI: 1.27–3.61) times more likely to die than those without neurological symptoms (p = .004).

Conclusions

Over 40% of HIV-positive patients admitted to KATH were newly diagnosed with HIV at admission. While pulmonary tuberculosis was the most common co-morbidity, patients presenting with neurological symptoms were at higher risk of death. This study suggests that enhanced outpatient screening is needed for early diagnosis and prompt HAART initiation, as well as increased access to diagnostic modalities and treatment for HIV-positive patients with neurological symptoms.

Feasibility and utility of active case finding of HIV-infected children and adolescents by provider-initiated testing and counselling: evidence from the Laquintinie hospital in Douala, Cameroon

BACKGROUND

Universal HIV testing and treatment of infected children remain challenging in resource-limited settings (RLS), leading to undiagnosed children/adolescents and limited access to pediatric antiretroviral therapy (ART). Our objective was to evaluate the feasibility of active cases finding of HIV-infected children/adolescents by provider-initiated testing and counseling in a health facility.

METHODS

A cross-sectional prospective study was conducted from January through April 2016 at 6 entry-points (inpatient, outpatient, neonatology, immunization/family planning, tuberculosis, day-care units) at the Laquintinie Hospital of Douala (LHD), Cameroon. At each entry-point, following counseling with consenting parents, children/adolescents (0-19 years old) with unknown HIV status were tested using the Rapid Diagnostic Test (RDT) (Determine®) and confirmed with a second RDT (Oraquick®) according to national guidelines. For children less than 18 months, PCR was performed to confirm every positive RDT. Community health workers linked infected participants by accompanying them from the entry-point to the treatment centre for an immediate ART initiation following the « test and treat » strategy. Statistical analysis was performed, with p < 0.05 considered significant.

RESULTS

Out of 3439 children seen at entry-points, 2107 had an unknown HIV status (61.3%) and HIV testing acceptance rate was 99.9% (2104). Their mean age was 2.1 (Sd = 2.96) years, with a sex ratio boy/girl of 6/5. HIV prevalence was 2.1% (44), without a significant difference between boys and girls (p = 0.081). High rates of HIV-infection were found among siblings/descendants (22.2%), TB treatment unit attendees (11.4%) and hospitalized children/adolescents (5.6%); p < 0.001. Up to 95.4% (42/44) of those infected children/adolescents were initiated on ART. Overall, 487 (23.2%) deaths were registered (122 per month) and among them, 7 (15.9%) were HIV-positive; mainly due to tuberculosis and malnutrition.

CONCLUSION

The consistent rate of unknown HIV status among children/adolescents attending health facilities, the high acceptability rates of HIV testing and linkage to ART, underscore the feasibility and utility of an active case finding model, using multiple entry-points at the health facility, in achieving the 90-90-90 targets for paediatric HIV/AIDS in RLS.

Predictors of Hospitalization among Children on ART in Ethiopia: a Cohort study

BACKGROUND

Substantial progress has been made in the management of pediatric HIV infection in Ethiopia with the implementation of mother-to-child-prevention programs. Since the introduction of HAART in 2005, mortality among HIV-infected children has reduced while the rate of hospitalization was expected to rise. The purpose of this study, therefore, was to assess predictors of hospitalization in children on ART in seven university referral hospitals in Ethiopia.

METHODS

A prospective cohort study design was employed on children age 0-18 years as part of a multisite observational study. ART-experienced eligible and ART-naïve children with HIV/AIDS were enrolled into the Advanced Clinical Monitoring (ACM) till December 31, 2012 were included. From the database, information on hospitalization and other independent variables were extracted. Analysis was done using both SPSS for Windows version 16.0 and STATA. Descriptive analyses and modeling was done using logistic regression.

RESULTS

Of the 405 children on ART (174 experienced, 231 naive), 86 (20.7%) were hospitalized for various reasons; two children were excluded since they were hospitalized for unrelated conditions (appendicitis and burn). Fifty one (60.7%) of the eighty four admitted children were hospitalized in the first six months of ART initiation. Of the independent variables, only the presence of opportunistic infections and duration on ART were significantly associated with hospitalization both on bi-variable and multivariable analyses (P-value <0.05). As the duration on ART increased by one month, the risk of hospitalization decreased by 5.4%, which is statistically significant (P < 0.001). Whereas the incidence (number) of OI's increased by one, the risk of being hospitalized increased by 35.2% (P = 0.002). Of the individual opportunistic infections, pneumonia was found to be the only predictor of hospitalization (P-value = 0.002).

CONCLUSION

This study showed that nearly two-third of the hospitalization was within 6 months of initiation of ART; and presence of OI and duration on ART were the only predictors of hospitalization.

Acute kidney injury in HIV-infected children: comparison of patients according to the use of highly active antiretroviral therapy

OBJECTIVE

To assess clinical and laboratory data, and acute kidney injury (AKI) in HIV-infected children using and not using highly active antiretroviral therapy (HAART) prior to admission.

METHODS

A retrospective study was conducted with HIV-infected pediatric patients (<16 years). Children who were using and not using HAART prior to admission were compared.

RESULTS

Sixty-three patients were included. Mean age was 5.3±4.27 years; 55.6% were females. AKI was observed in 33 (52.3%) children. Patients on HAART presented lower levels of potassium (3.9±0.8 vs. 4.5±0.7mEq/L, p=0.019) and bicarbonate (19.1±4.9 vs. 23.5±2.2mEq/L, p=0.013) and had a higher estimated glomerular filtration rate (102.2±36.7 vs. 77.0±32.8mL/min/1.73m², p=0.011) than those not on HAART. In the multivariate analysis, the use of HAART prior to the admission was a protective factor for AKI (p=0.036; OR=0.30; 95% CI=0.097-0.926).

CONCLUSION

AKI is a common complication of pediatric HIV infection. Use of HAART prior to the admission preserved glomerular filtration and was a protective factor for AKI, but increased medication side effects, such as hypokalemia and renal metabolic acidosis.

Predictors of mortality among HIV-infected children receiving highly active antiretroviral therapy

BACKGROUND AND OBJECTIVES

The mortality rate of HIV-infected children can be reversed under highly active antiretroviral therapy (HAART). The impact of HAART on the mortality of HIV-infected children in Cameroon has not been extensively documented. We aimed to measure the mortality rate of HIV-infected children under HAART and to identify predictive factors of mortality.

METHODS

Retrospective cohort study of 221 children initiated on HAART from 2005 to 2009 and followed-up until 2013. Survival data was analyzed using Kaplan Meier method and Cox regression model to identify independent predictors of child mortality on HAART.

RESULTS

Overall, 9.9% of children (n=22) died over a follow-up period of 755 child-years (mortality of 2.9 per 100 child-years); 70% of deaths occurred during the first six months of HAART. The probability of survival after four years of treatment was 88.7% (95% CI=[84.2-93.3]). During the multivariate analysis of baseline variables, we observed that the WHO clinical stages III and IV (HR: 3.55 [1.09-13.6] and HR: 7.7 [3.07-31.2]) and age≤1year at HAART initiation were independently associated with death (HR: 2.1 [1.01-5.08]). Neither orphanhood, baseline CD4 count or hemoglobin level nor low nutritional status predicted death in this cohort.

CONCLUSION

The mortality of children receiving HAART was low after five years of follow-up and it was strongly associated with WHO stages III and IV and a younger age at treatment initiation.