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

Incidence density mortality rate among HIV-positive children on antiretroviral therapy in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Human Immunodeficiency Virus (HIV) continues to be the major cause of childhood deaths, particularly in the sub-Saharan African region. In Ethiopia, though several primary studies have been conducted on the incidence of HIV-related child mortality, the pooled incidence density mortality rate among HIV-positive children is unknown. Therefore, this systematic review and meta-analysis aimed to estimate the pooled incidence density mortality rate among HIV-positive children and identify its associated factors in Ethiopia.

METHODS

We browsed PubMed, HINARI, Science Direct, Google Scholar, African Journals Online, and cross-references using different search terms to identify articles. Quality appraisal was done using the Joanna Briggs Institute checklist. Meta-package was used to estimate the pooled incidence of mortality and hazard ratio (HR) of predictors. Heterogeneity was tested using the I-square statistics. Publication bias was tested using a funnel plot visual inspection and Egger's test. Data was presented using forest plots and tables. The random effect model was used to compute the pooled estimate.

RESULTS

The overall pooled incidence density mortality rate among HIV-positive children was 2.52 (95% CI: 1.82, 3.47) per 100 child years. Advanced HIV disease (hazard ratio (HR): 3.45, 95% CI (Confidence Interval): 2.64, 4.51), tuberculosis co-infection (HR: 3.19, 95% CI: 2.08, 4.88), stunting (3.22, 95% CI: 2.46, 4.22), underweight (HR: 2.71, 95% CI: 1.72, 4.26), wasting (HR: 4.14, 95% CI: 2.27, 7.58), didn't receive Isoniazid preventive therapy (HR: 3.33, 95% CI: 2.22, 4.99), anemia (HR: 3.03, 95% CI: 2.52, 3.64), fair or poor antiretroviral therapy adherence (HR: 4.14, 95% CI: 3.28, 5.28) and didn't receive cotrimoxazole preventive therapy (HR: 3.82, 95% CI: 2.49, 5.86) were factors associated with a higher hazard of HIV related child mortality.

CONCLUSIONS

The overall pooled incidence density mortality rate among HIV-positive children was high in Ethiopia as compared to the national strategy target. Therefore, counseling on antiretroviral therapy adherence should be strengthened. Regular monitoring of hemoglobin levels and assessment of nutritional status should be done for all children living with HIV. Moreover, healthcare professionals should follow the national HIV treatment guidelines and provide cotrimoxazole preventive therapy and Isoniazid preventive therapy up on the guidelines for children living with HIV.

REGISTRATION

Registered in PROSPERO with ID: CRD42023486902.

Mortality and its predictors among human immunodeficiency virus-infected children younger than 15 years receiving antiretroviral therapy in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Despite antiretroviral treatment (ART), the human immunodeficiency virus (HIV) continues to pose a considerable health burden in resource-poor countries. This systematic review and meta-analysis aimed to determine the pooled incidence density of mortality and identify potential predictors among HIV-infected children receiving ART, from studies conducted in various parts of Ethiopia.

METHODS

A comprehensive database search was made in Excerpta Medica, PubMed, Web of Science, African Journals Online, Google Scholar, and Scopus. We reported results following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020. Excel Spreadsheet and STATA Version 14 software were used for data abstraction and meta-analysis, respectively. Statistical heterogeneity among studies was assessed using I2 statistics. Meta-regression and subgroup analysis were performed to further explore the sources of statistical heterogeneity. Moreover, publication bias and a leave-out-one sensitivity analysis were performed.

RESULTS

Twenty-two articles involving 8,731 participants met inclusion criteria and were included. The pooled incidence density of mortality was 3.08 (95% confidence interval (CI), 2.52 to 3.64) per 100 child years. Predictors of mortality were living in rural areas (hazard ratio (HR), 2.18 [95% CI, 1.20 to 3.98]), poor adherence to ART (HR, 2.85 [ 95% CI, 1.39 to 5.88]), failure to initiate co-trimoxazole preventive therapy (HR, 2.16 [95% CI, 1.52 to 3.07]), anemia (HR, 2.28 [95% CI, 1.51 to 3.45]), opportunistic infections (HR, 1.52 [ 95% CI, 1.15 to 2.00]), underweight (HR, 1.74 [95% CI, 1.26 to 2.41]), wasting (HR, 2.54 [95% CI, 1.56 to 4.16]), stunting (HR, 2.02 [95% CI, 1.63 to 2.51]), World Health Organization classified HIV clinical stages III and IV (HR, 1.71 [95% CI, 1.42 to 2.05]), and Nevirapine-based regimens (HR, 3.91 [95% CI, 3.09 to 4.95]).

CONCLUSIONS

This study found that the overall mortality rate among HIV-infected children after ART initiation was high. Therefore, high-level commitment and involvement of responsible caregivers, healthcare providers, social workers, and program managers are of paramount importance to identify these risk factors and thus enhance the survival of HIV-infected children receiving ART.

Survival status and its predictors among undernourished children on antiretroviral therapy in Bahir Dar city, Northwest Ethiopia, 2010 - 2020, a multicenter retrospective cohort study

BACKGROUND

In environments with limited resources, undernutrition is a serious public health risk. Its dual relationship to human immunodeficiency virus infection (HIV) leads to crises in a child's physical, emotional, social, and economic spheres of life. Nevertheless, little research has been done on the survival rate and risk factors that lead to poor survival outcomes in undernourished children receiving antiretroviral therapy. This study sought to evaluate survival status and its predictors among undernourished children on antiretroviral therapy (ART) in public health facilities, Bahir Dar city, September 1, 2010 - December 31, 2020.

METHODS

An institution-based retrospective cohort study design was used among 414 study participants from September 1, 2010 - December 31, 2020. A simple random sampling method was applied to select study participants. All collected data were entered into epi data version 4.6 and exported to STATA version 14.0 for analysis. Each independent predictor variable with a p-value < 0.05 in the multivariable Cox proportional hazard regression was considered statistically significant.

RESULTS

The overall incidence of mortality was 11.6 deaths per 1000 child year observation (95%CI: 7.7- 17.5). Baseline weight for age < -3 Z score (adjusted hazard ratio (AHR) = 4.9, 95% CI: 1.30-18.98), height for age < -3 Z score (AHR = 4.34, 95%CI 1.13-16.6), cotrimoxazole prophylaxis given (AHR = 0.27, 95%CI 0.08-0.87), hemoglobin level < 10 g/dl (AHR = 3.7, 95%CI 1.1-12.7), CD4 cells < threshold (AHR = 4.86, 95%CI 1.9-12.7), and WHO clinical disease stage III and IV (AHR = 8.1, 95%CI 1.97-33) were found independent predictors of mortality.

CONCLUSION AND RECOMMENDATION

The incidence of mortality was determined in the study to be 11.6 per 1000 child years. Mortality was predicted by severe stunting, severe underweight, a low hemoglobin level, a low CD4 count, and WHO clinical stages III and IV. But the risk of death is reduced by starting cotrimoxazole preventative therapy early. The risk factors that result in a low survival status should be the primary focus of all concerned bodies, and early cotrimoxazole preventive treatment initiation is strongly recommended.

Long-term effect of antiretroviral therapy on mortality among HIV-positive children and adolescents in China

Introduction

Highly active antiretroviral therapy (HAART) was piloted in 2002 and was scaled up in 2003 in mainland China. The aim of this study was to evaluate the mortality and its possible predictors based on the long-term initial antiretroviral therapy (ART) cohort among HIV positive children and adolescents.

Methods

This prospective open-labeled multicenter cohort study was conducted from January 2008 to July 2021. The participants were recruited from six representative sites in mainland China. A total of 609 participants with an HIV-positive serostatus and <18 years old were recruited and each participant was informed consent at the time of enrollment. Mortality and annual hazard were calculated, and predictors for death were analyzed using Cox regression models generating hazard ratios (HR).

Results

The results showed that the mortality was 0.721 per hundred person-years, and the annual hazard was less than 0.10 over time. Both CD4+T cell count and CD4+T cell percentage declined in the death group during the follow-up. The Cox regression model showed that the baseline low CD4+T cell count level (Low vs. High: aHR = 8.309, 95% CI: (1.093, 63.135)) and age >5 years old at HIV diagnosis (6-12 vs. 0-5: aHR = 3.140, 95%CI: (1.331, 27.411)); 13-18 vs. 0-5: aHR = 5.451, 95%CI: (1.434, 20.724)) were possible risk factors for death.

Conclusion

The longitudinal cohort study demonstrated the efficacy of China's ART program among HIV-positive children and adolescents which could be beneficial to other countries with limited resources.

Predictors of Mortality Among Children and Adolescents Living With HIV on Antiretroviral Therapy in Western Kenya

BACKGROUND

Antiretroviral therapy (ART) has decreased HIV-attributable deaths; however, children and adolescents continue to have high HIV-associated mortality.

SETTING

We determined the predictors of death among children and young adolescents living with HIV (CALWH) who died while in care in Western Kenya.

METHODS

This retrospective case-control study used electronically abstracted data of 6234 CALWH who received care in Academic Model Providing Access to Healthcare HIV clinics in Western Kenya between January 2002 and November 2022. The cases comprised CALWH who were reported dead by November 2022, while the controls constituted of matched CALWH who were alive and in care. Independent predictors of mortality were determined using univariable and multivariable Cox proportional hazard regression models. Kaplan-Meier analysis ascertained survival.

RESULTS

Of the 6234 participants enrolled, slightly more than half were male (51.7%). The mean (SD) age at the start of ART was significantly lower in cases than in controls at 6.01 (4.37) and 6.62 (4.11) ( P < 0.001), respectively. An age of 11 years or older at start of ART (adjusted Hazard Ratio [aHR]: 8.36 [3.60-19.40]), both parents being alive (aHR: 3.06 [1.67-5.60]), underweight (aHR: 1.82 [1.14-2.92]), and World Health Organization stages 3 (aHR: 2.63 [1.12-6.18]) and 4 (aHR: 2.20 [0.94-5.18]) increased mortality; while school attendance (aHR: 0.12 [0.06-0.21]), high CD4 + counts >350 cells/mm 3 (aHR: 0.79 [0.48-1.29]), and low first viral load <1000 copies/mL (aHR: 0.24 [0.14-0.40]) were protective.

CONCLUSION

Independent predictors of mortality were age 11 years or older at the start of ART, orphan status, underweight, and advanced HIV disease. Beyond the provision of universal ART, care accorded to CALWH necessitates optimization through tackling individual predictors of mortality.

Time to death and its predictors among under-five children on antiretroviral treatment in public hospitals of Addis Ababa, Addis Ababa, Ethiopia, a retrospective follow up study

BACKGROUND

Child mortality remains a global public health problem, particularly in Sub-Saharan Africa. After initiating ART, the mortality rate among HIV-infected children in Ethiopia was 12-17 deaths per 1000 child-year.

OBJECTIVE

To determine the time to death and its predictors among under-five children on antiretroviral treatment in public hospitals of Addis Ababa, Ethiopia, from April 12, 2017, to May 12, 2022.

METHOD

An institution-based retrospective follow-up study was conducted among 415 HIV-infected children at selected public hospitals of the Addis Ababa town administration. Computer generated simple random sampling technique was used to select each sampling unit. Data was extracted using a structured data extraction checklist. Data were entered into EPI data 4.2 and analyzed using STATA 14. The child mortality rate was calculated. The Cox proportional hazards regression model was fitted to identify predictor factors. The result of the study was presented using text, tables, graphs, and charts. An adjusted hazard ratio with a 95% confidence interval and a p-value less than 0.05 was used to declare the level of significance.

RESULT

A total of 415 (97.42%) of the 426 children on ART were included for analysis. Of these, 41(9.88%) children were died during the following period. The study participants were followed for a total of 8237 person- months of risk time. The overall mortality rate was 4.98 (95% CI: 3.67-6.77) per 1000 child-months. The estimated survival after starting ART was 61.42% at 56 months of follow-up. Severe underweight (AHR = 3.19; 95% CI: 1.32-7.71), tuberculosis (AHR = 3.86; CI: 1.76-8.47), low hemoglobin level (AHR = 2.51; CI: 1.02-6.20), and advanced WHO clinical stages at enrolment (AHR = 3.38; CI: 1.08-10.58) were predictors of death among HIV-infected under-five children on ART.

CONCLUSION

The incidence of mortality was 4.98 per 1000 child-months. Severe underweight, tuberculosis infection, low hemoglobin level, and advanced WHO clinical stages at enrolment were predictors of death among under-five children on ART.

Survival time and predictors of death among HIV infected under five children after initiation of anti -retroviral therapy in West Amhara Referral Hospitals, Northwest Ethiopia

BACKGROUND

Acquired immune deficiency syndrome is an infectious disease caused by the human immunodeficiency virus (HIV) that primarily targets an individual's immune system. In Ethiopia, nearly 24% of HIV-related deaths occur in children under the age of five. However, studies regarding the survival time of HIV-positive under-five children after anti-retroviral therapy initiation are limited with poor evidence of predictors of death.

OBJECTIVE

To assess survival time and predictors of death among HIV infected under-five children after initiation of anti-retroviral therapy in West Amhara Referral Hospitals, Northwest Ethiopia, 2021.

METHODS

A multicenter institution-based retrospective follow-up study was conducted among 432 HIV-positive under-five children on anti-retroviral therapy selected by simple random sampling from January 2010 to December 2019. A standardized data extraction tool was employed, which was adapted from anti-retroviral therapy entry and follow-up forms. The event of interest for this study is death, whereas the absence of experience of death is censored. Data were entered into Epi-Data version 3.1 and exported to STATA version 14. The Kaplan-Meier curve was used to estimate the survival probability. The Cox regression model was used to identify independent predictors of death.

RESULTS

Among the 415 records included in the final analysis, 25 (6.02%) of the individuals were died. The incidence rate of death was found to be 2.87 per 1000 child-months (95%CI: 1.94-4.25). The cumulative survival probabilities of children after 6, 12, 24, and 36 months were 0.97, 0.95, 0.92, and 0.85 respectively. HIV-infected under-five children who lived in rural areas (AHR 3.32:-95% CI 1.17-9.39), with poor adherence to anti-retroviral therapy (AHR = 3.36; CI: 1.06, 10.69), without Isoniazide prophylaxis (AHR = 3.15; CI: 1.11, 8.94) and with anemia (AHR: 3.05, 95% CI: 1.16, 8.03) were at higher risk of death.

CONCLUSION AND RECOMMENDATION

Death of HIV-infected under-five children on anti-retroviral therapy is high within the first one year after enrolment. Living in rural area, had poor adherence, lacked Isoniazide prophylaxis, and anemia were predictors of death. Therefore, clinicians shall emphasize for those specific risk factors of death and take action accordingly.

Effects of Undernutrition and Predictors on the Survival Status of HIV-Positive Children after Started Antiretroviral Therapy (ART) in Northwest Ethiopia

Malnutrition and human immunodeficiency virus/acquired immunodeficiency syndrome have complex and multidirectional relationships. Ethiopia is one of the countries hardest hit by the HIV epidemic as well as malnutrition. This study was aimed at assessing the effects of undernutrition on the survival status of HIV-positive children who received HIV/AIDS care in Northwest Ethiopia. Materials and Methods. A facility-based retrospective follow-up was conducted from January 1, 2009, to December 31, 2020. The data was entered into EpiData version 4.2.0. Then, the entered data was exported to STATA 14 software for further analysis, and the Kaplan-Meier survival curve was used to estimate survival time after the initiation of ART. The Bivariable and multivariable Cox regression analyses were conducted to identify predictors of mortality associated with undernutrition. Results. The mean (±SD) age of participant children was found 118.4 (±38.24) months. The overall mortality rate in this study was determined as 5.4 per 100 child-years (95% CI: 3.6, 5.8). Children with CD4 cell counts below the threshold [AHR = 1.6; 95% CI (1.19, 7.85)], advanced WHO clinical stages (III and IV) HIV [AHR = 4.5; 95% CI (2.80, 8.40)], and being severe stunting at the beginning [AHR = 2.9; 95% CI (1.80, 6.40)] were significantly associated with mortality of HIV-positive children. Conclusion. The findings of the current study indicated that HIV-positive children on ART had a high rate of mortality. Baseline undernutrition has the mortality of children who had CD4 counts below a threshold, advanced WHO HIV clinical staging (III and IV), and being severe stunting (HAZ ≤ −3 Z score) which were found to be independent predictors for mortality of undernourished HIV.

Time to death among HIV-infected under-five children after initiation of anti-retroviral therapy and its predictors in Oromiya liyu zone, Amhara region, Ethiopia: a retrospective cohort study

BACKGROUND

Human Immunodeficiency Virus (HIV) is infection which mainly attacks immune system of an individual. Its disease progress is rapid in children and if treatment is not initiated nearly half of infected children will die by the second year of infection. In Ethiopia, nearly twenty four percent of HIV related death is happen to under-five children; however studies done in this specific age group are limited are with poor evidence of predictors.

OBJECTIVES

To determine time to death and identify predictors of death in HIV infected under- five children on antiretroviral therapy in Amhara regional state, Oromia 'liyu' zone, Northeast Ethiopia, from 2014 to 2019.

METHODS

Institution based retrospective follow up study was conducted in 376 under-five HIV- infected children on antiretroviral therapy from January 2014 to December 2019 in health institutions in Oromia Liyu Zone, Amhara region, Ethiopia. Multivariable Cox-proportional hazard regression model was used to identify independent predictors of mortality in HIV- infected under-five children on antiretroviral therapy.

RESULT

At the end of follow up, 304 (80.85%) of HIV-infected children were alive, 39 (10.95%) were lost to follow up, 12 (3.19%) were transferred out and 21 (5.59%) were reported dead due to HIV/AIDS. The cumulative survival probabilities of children after 3, 6, 12, 24 and 36 months were 0.99, 0.98, 0.97, 0.89 and 0.87 respectively. The overall mean time to death was 19.7 months (95%CI = 18.74-20.67) with incidence of 5.9 deaths per 100 child-months (95%CI: 3.89-9.09). Children with severe malnutrition at baseline (AHR = 4.9; 95 CI: 1.04, 23.50), advanced WHO clinical stage at enrolment (AHR = 3.9; CI: 1.37, 10.88), poor adherence to ART (AHR = 6.56; CI: 3.33, 10.14) and with no history of Isoniazide prophylaxis were significantly associated to higher mortality events (AHR = 3.6; CI: 1.24, 10.18).

CONCLUSION

Death of HIV-infected under-five children on ART is high within the first one year after enrolment. The risk of death increased if the child was malnourished at beginning of treatment, had poor ART adherence, with advanced WHO clinical stages and lack of Isoniazide prophylaxis during their age of infancy.

Time-varying age- and CD4-stratified rates of mortality and WHO stage 3 and stage 4 events in children, adolescents and youth 0 to 24 years living with perinatally acquired HIV, before and after antiretroviral therapy initiation in the paediatric IeDEA Global Cohort Consortium

Introduction

Evaluating outcomes of paediatric patients with HIV provides crucial data for clinicians and policymakers. We analysed mortality and clinical events rates among children, adolescents, and youth with perinatally acquired HIV (PHIV) aged 0 to 24 years stratified by time‐varying age and CD4, before and after antiretroviral therapy (ART), in the paediatric IeDEA multiregional collaboration (East, West, Central and Southern Africa, Asia‐Pacific, and Central/South America and the Caribbean).

Methods

ART‐naïve children with HIV enrolled before age 10 (proxy for perinatal infection) at IeDEA sites between 2004 and 2016, with ≥1 CD4 measurement during follow‐up were included. We estimated incidence rates (IR) and 95% confidence intervals (95% CI) of mortality and first occurrence of WHO‐4 and WHO‐3 events, excluding tuberculosis, during person‐years (PY) spent within different age (<2, 2 to 4, 5 to 9, 10 to 14, 15 to 19, 20 to 24) and CD4 (percent when <5 years [<15%, 15% to 24%, ≥25%]; count when ≥5 years [<200, 200 to 499, ≥500 cells/µL]) strata. We used linear mixed models to predict CD4 evolution, with trends modelled by region.

Results

In the pre‐ART period, 49 137 participants contributed 51 966 PY of follow‐up (median enrolment age: 3.9 years). The overall pre‐ART IRs were 2.8/100 PY (95% CI: 2.7 to 2.9) for mortality, 3.3/100 PY (95% CI: 3.0 to 3.5) for first occurrence of a WHO‐4 event, and 7.0/100 PY (95% CI: 6.7 to 7.4) for first occurrence of a WHO‐3 event. Lower CD4 and younger age strata were associated with increased rates of both mortality and first occurrence of a clinical event. In the post‐ART period, 52 147 PHIVY contributed 207 945 PY (ART initiation median age: 4.5 years). Overall mortality IR was 1.4/100 PY (95% CI: 1.4 to 1.5) and higher in low CD4 strata; patients at each end of the age spectrum (<2 and >19) had increased mortality post‐ART. IRs for first occurrence of WHO‐4 and WHO‐3 events were 1.3/100 PY (95% CI: 1.2 to 1.4) and 2.1/100 PY (95% CI: 2.0 to 2.2) respectively. These were also associated with lower CD4 and younger age strata.

Conclusions

Mortality and incidence of clinical events were highest in both younger (<2 years) and older (>19 years) youth with PHIV. Scaling‐up services for <2 years (early access to HIV diagnosis and care) and >19 years (adolescent‐ and youth‐focused health services) is critical to improve outcomes among PHIVY.

[Determinants of survival of HIV-infected children aged 6 months to 15 years on follow-up in the town of Ebolowa, Cameroon from 2008 to 2018]

Introduction

la survie des enfants infectés par le VIH demeure un défi dans les pays en voie de développement. Au Cameroun, la mortalité liée au VIH chez les enfants de moins de 15 ans en 2018 était de 20%. Paradoxalement, la région du Sud Cameroun, malgré une séroprévalence élevée chez les enfants de 4,1% et une couverture en traitement antirétroviral faible de l´ordre de 64%, ne fait pas partie des régions du Cameroun les plus touchées par la mortalité pédiatrique liée au VIH/SIDA. L´objectif de ce travail était de déterminer le taux de survie et identifier ses déterminants chez les enfants âgés de 6 mois à 15 ans, infectés par le VIH.

Méthodes

une étude de cohorte à collecte de données rétrospective et prospective a été menée de janvier 2008 à décembre 2018 dans trois formations sanitaires prenant en charge les enfants VIH positifs, à Ebolowa dans la région du Sud Cameroun. L´étude s´est faite en deux temps, une phase de collecte rétrospective pour la sélection des dossiers médicaux des enfants VIH positifs répondant aux critères d´inclusion dans les registres de consultation, et une phase de collecte prospective qui nous a permis d´avoir auprès des parents, les informations sur le devenir des enfants. Un consentement éclairé parental a été obtenu au cours de cette deuxième phase. Les données sociodémographiques, cliniques, paracliniques, thérapeutiques, ainsi que le devenir des enfants ont été collectées. Les temps moyens de survie, ainsi que les facteurs associés à la survie ont été déterminés à l´aide du modèle de Kaplan Meier. La régression à risque proportionnel de Cox, nous a permis d´identifier les déterminants de la survie. Notre critère de jugement était le décès. Le niveau de significativité a été fixé à 5%.

Résultats

au total, 186 enfants ont été enrôlés. La durée médiane de suivi était de 18,5 mois. Le taux de survie était de 66,7%. La majorité des décès (67%) est survenue avant le sixième mois de suivi. Après analyse multivariée, l´âge inférieur à 2 ans [aHR: 18,6 (6,48-53,59); p=0,001], l´anémie sévère [aHR: 7,69 (1,02-57,9); p=0,04], et la présence d´infections opportunistes [aHR: 4,52 (2,51-8,14); p=0,05] étaient indépendamment et significativement associés à la survie.

Conclusion

en plus du traitement antirétroviral précoce, un bon suivi clinique et paraclinique est nécessaire pour améliorer la survie des enfants infectés par le VIH.

Mortality rate among HIV-positive children on ART in Northwest Ethiopia: a historical cohort study

Background

Though highly active antiretroviral therapy (HAART) has been available for more than a decade in Ethiopia, information regarding mortality rates of human immunodeficiency virus (HIV)-positive children after antiretroviral therapy antiretroviral therapy (ART) initiation is very scarce. Thus, this study intends to determine the predictors of mortality among HIV-positive children receiving ART in Amhara Region.

Methods

A multicenter facility-based historical cohort study was conducted in 538 HIV-positive children on ART from January 2012 to February 2017. We employed a standardized data extraction tool, adapted from ART entry and follow-up forms. Descriptive analyses were summarized using the Kaplan-Meier survival curve and log rank test. Then, the Cox-proportional hazard regression model was employed to estimate the hazard of death up to five-years after ART initiation. Variables with p-values ≤0.25 in bivariable analysis were candidates to the multivariable analysis. Finally, variables with p-values < 0.05 were considered as significant variables.

Results

The cohort contributed a total follow-up time of 14,600 child-months, with an overall mortality rate of 3.2 (95% CI: 2.3, 4.3) per 100 child-years. This study also indicated that HIV-infected children presenting with opportunistic infections (OIs) (AHR: 2.5, 95% CI: 1.04, 5.9), anemia (AHR: 3.1, 95% CI: 1.4, 6.7), severe immunodeficiency (AHR: 4.4, 95% CI: 1.7, 11.7), severe stunting (AHR: 3.3, 95% CI: 1.4, 8.0), severe wasting (AHR: 3.1, 95% CI: 1.3, 7.3), and advanced disease staging (III and IV) (AHR: 3.0, 95% CI: 1.2, 7.1) were at higher risk of mortality.

Conclusion

A higher rate of mortality was observed in our study as compared to previous Ethiopian studies. HIV-positive children presenting with anemia, OIs, severe immunodeficiency, advanced disease staging (III and IV), severe stunting, and severe wasting were at higher risk of mortality.

Mortality of children aged 5-15 years in a tertiary care center in Yaoundé, Cameroon

INTRODUCTION

Although sub-Saharan Africa accounts for only 21% of the global population of children and adolescents aged 5-15 years, 55% of deaths among children in this age group occur in this region. This seems to be related to infectious diseases. We hypothesized that besides infectious diseases, in our context, a chronic underlying condition increases mortality. Our goal was to describe the leading causes of mortality among this age group.

PATIENTS AND METHODS

We conducted a retrospective study in a tertiary care center in Yaoundé. We included the medical files of children who died between January 2013 and December 2017.

RESULTS

The in-hospital mortality rate was 10.3 per 1000. Coma and/or convulsion was the main cause of death (70.6%), followed by severe anemia (64.7%) and respiratory distress (56.8%). We identified a chronic illness in 62.2% of cases: HIV infection (39.2%) and sickle cell disease (24.5%) were the most prevalent. The main diagnoses were severe malaria, severe sepsis, and meningitis (Cryptococcus sp. included) in 25 (n=35), 16.4 (n=27), and 10.3% (n=17) of cases, respectively.

CONCLUSION

HIV infection and sickle cell disease are the most prevalent chronic diseases related to the patients' death in the age group studied. Specific interventions focusing on this age group are recommended including intensification of impregnated bednet usage as well as HIV and sickle cell disease management.

Mortality among pediatric patients on HIV treatment in sub-Saharan African countries: a systematic review and meta-analysis

Background

Despite substantial improvements in accessibility of Anti-Retroviral Treatment (ART), death of children on ART remains a prevailing challenge in sub-Saharan African (SSA) countries. However, the pooled magnitude of mortality at different ART follow-up periods remains unknown for the region. We estimated the pooled proportion of all-cause mortality for pediatric patients receiving first-line ART at 3, 6, 12, and 24 months follow-up period in SSA.

Methods

We searched for relevant articles published between January 2014 and June 2018 on PubMed, Hinari and Google scholar databases. We searched for additional articles from reference lists and 2014–2018 abstracts archived by the Conference on Retroviruses and Opportunistic Infections (CROI) and the International AIDS Society Conference on HIV Science (IAS).

Results

We reviewed 29 articles reporting mortality among pediatric ART patients at different follow-up periods in countries from 2001 to 2016. Among the 51,619 pediatric ART patients in these cohorts, studies reported 4061 (7.9%) all-cause cumulative death. The cumulative pooled proportion of mortality at 3, 6, 12 and 24 months of ART were 3% (95% CI: 3.0–4.0), 5% (95% CI: 4.0–6.0), 6% (95% CI: 5.0–7.0) and 7% (95% CI: 6.0–8.0), respectively.

Conclusions

In SSA, significant proportion of mortality among children occurs in the first 3–6 months of ART initiation. Western Africa has a little higher estimate of mortality among pediatric ART patients at 6 and 12 months of follow-up. Strategies to prevent early mortality including thorough screening and management of opportunistic infections before ART initiation are needed.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6482-1) contains supplementary material, which is available to authorized users.

Long-term survival outcomes of HIV infected children receiving antiretroviral therapy: an observational study from Zambia (2003-2015)

Background

In 2017, 64% of children living with HIV in Zambia accessed Antiretroviral Therapy (ART). Despite expanded ART coverage, there is paucity of information on effectiveness of pediatric ART in reducing mortality. The aim of this research is to describe treatment outcomes, measure mortality rates and assess predictors of mortality among children receiving ART.

Methods

Using a retrospective cohort study design, we abstracted routinely collected clinical data from medical records of children from birth to 15 years old, who had received ART for at least 6 months at Livingstone Central Hospital in Southern Province Zambia, between January 2003 and June 2015. The primary outcome was death. Cause of death was ascertained from medical records and death certificates. Distribution of survival times according to baseline covariates were estimated using Kaplan Meier and Cox Proportional Hazards methods.

Results

Overall, 1039 children were commenced on ART during the study period. The median age at treatment initiation was 3.6 years (IQR: 1.3–8.6) and 520 (50%) children were female. Of these, 71 (7%) died, 164 (16%) were lost to follow-up, 210 (20%) transferred and 594 (56%) were actively on treatment. After 4450 person years, mortality rate was 1.6/100 (95% CI: 1.4–1.8). Mortality was highest during the first 3 months of treatment (11.7/100 (95% CI: 7.6–16.3). In multivariable proportional hazards regression, the adjusted hazards of death were highest among children aged < 1 year (aHR = 3.1 (95% CI: 1.3–6.4), compared to those aged 6–15 years, WHO stage 4 (aHR =4.8 (95% CI: 2.3–10), compared to WHO stage 1 and 2. In the sensitivity analysis to address bias due to loss to follow-up, mortality increased 5 times when we assumed that all the children who were lost to follow up died within 90 days of their last visit.

Conclusion

We observed low attrition due to mortality among children on ART. Loss to follow-up was high (16%). Mortality was highest during the first 3 months of treatment. Children aged less than one year and those with advanced WHO disease stage had higher mortality. We recommend effective interventions to improve retention in care and early diagnosis of HIV in children.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6444-7) contains supplementary material, which is available to authorized users.

Effects of undernutrition on survival of human immunodeficiency virus positive children on antiretroviral therapy

Background

The relationship between undernutrition and HIV is bidirectional, ultimately contributing to quality of life and survival of affected individuals. Ethiopia is a sub-Saharan nation influenced by both undernutrition and HIV. In Ethiopia, although individuals are often dually impacted, the effect of undernutrition on the survival of HIV positive children on anti-retroviral therapy (ART) has not been well investigated. Therefore, this study assessed the effect of undernutrition on survival rates of HIV positive children on ART in Amhara Regional State of Ethiopia.

Methods

An institution-based retrospective cohort study was conducted among 390 HIV positive children on ART from the 1st of January, 2012 to the 28th of February, 2017 in Amhara Regional State Referral Hospitals. A simple random sampling technique was used to select the study participants. Data were extracted by reviewing patients’ ART intake and follow-up forms. Data were entered into Epi-Data Version 3.1, and analysis was done using STATA Version 13. The Kaplan-Meier survival curve was used to estimate the cumulative survival time of the sample. Log rank tests were employed to compare the survival time between different categories of explanatory variables. Bivariable and multivariable Cox proportional hazards models were fitted to identify predictors of mortality.

Results

Among the 390 records included in the final analysis, 9.7% of the individuals died within the follow-up period. In this study, the overall mortality rate was found to be 4.4 per 100 child-years (95% CI: 3.2, 6.0) while undernourished children had a lower survival time than well-nourished children. Low hemoglobin level (AHR: 3.2, 95% CI: 1.4, 7.4), CD4 cell count or percent below the threshold (AHR: 5.2, 95% CI: 1.9, 14.1), severe stunting (AHR: 3.9, 95% CI: 1.7, 9.4), severe wasting (AHR: 3.0, 95% CI: 1.3, 6.9) and advanced disease stage (III and IV) (AHR: 2.6, 95% CI: 1.1, 6.6) were found to be predictors of mortality.

Conclusion

There was a high rate of mortality. A significant difference was observed in the survival rate of undernourished and well-nourished children. Low hemoglobin level, CD4 count or percent below the threshold, severe wasting, severe stunting, and advanced disease stage were found to be predictors of mortality.