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

Predictors of prolonged hospitalization among children aged 2-59 months with severe community-acquired pneumonia in public hospitals of Benishangul-Gumuz Region, Ethiopia: a multicenter retrospective follow-up study

Background

Pneumonia is a leading cause of morbidity and mortality among children aged under 5 years in Ethiopia. Prolonged hospitalization of severe community-acquired pneumonia is a significant problem in resource-limited countries. This study seeks to provide insights that can help improve the management and outcomes of severe community-acquired pneumonia, which is particularly important in the context of the Benishangul-Gumuz Region, Ethiopia, where access to quality healthcare services is limited, and childhood pneumonia is a significant health challenge.

Objective

The aim of the study was to determine the predictors of prolonged hospitalization among children aged 2-59 months admitted with severe community-acquired pneumonia between 1 January 2016 and 30 December 2020 in the public hospitals in Benishangul-Gumuz Region, Ethiopia.

Method

A retrospective follow-up study design was conducted among randomly selected samples of 526 children. Data were entered into EPI data version 4.6 and analyzed using STATA version 14.0. The Cox proportional hazard regression model was fitted to identify the independent predictors of prolonged hospitalization, and variables with a p-value <0.05 in the multivariable model were considered statistically significant.

Results

The median hospital stay was 5 days (interquartile range 2-8 = 6). Approximately 149 (28.93%) children had prolonged hospitalization (>5 days) and the recovery rate from severe community-acquired pneumonia was 19.69 per 100 person-day observations. The significant predictors of prolonged hospitalization were as follows: having facility referral sources [0.79, 95% confidence interval (CI), 0.63-0.98]; a nutritional status of wasting (0.64, 95% CI, 0.44-0.94); anemia (0.65, 95% CI, 0.46-0.90); no identified hemoglobin level (0.53, 95% CI, 0.41-0.70); no identified blood film (0.65, 95% CI, 0.53-0.80); no chest x-ray investigation (0.81, 95% CI, 0.65-0.99); pulmonary effusion (0.31, 95% CI, 0.15-0.66); and late presenters to hospital (0.67, 95% CI, 0.53-0.84) at admission.

Conclusions

The median length of stay in hospital was delayed compared to other studies. Wasting, late presenting to hospital, pulmonary effusion, anemia, absence of investigations of hemoglobin level, chest x-ray, and blood film at admission time were factors that significantly prolonged the hospitalization time. Hence, attention should be given to the prevention of malnutrition and anemia in children, increasing early health-seeking behavior in the community. Attention should be given to complications such as pleural effusion, and investigations, such as chest x-ray, hemoglobin levels, and blood films, should be performed when the child is admitted.

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.

Predictors of a high incidence of opportunistic infections among HIV-infected children receiving antiretroviral therapy at Amhara regional state comprehensive specialized hospitals, Ethiopia: A multicenter institution-based retrospective follow-up study

Introduction

Globally, opportunistic infections are the leading causes of morbidity and mortality among HIV-infected children, contributing to more than 90% of HIV-related deaths. In 2014, Ethiopia launched and began to implement a "test and treat" strategy aiming to reduce the burden of opportunistic infections. Despite this intervention, opportunistic infections continue to be a serious public health issue, with limited evidence available on their overall incidence among HIV-infected children in the study area.

Objective

The study aimed to assess the incidence of opportunistic infections and to identify predictors of their occurrence among HIV-infected children receiving antiretroviral therapy at Amhara Regional State Comprehensive Specialized Hospitals in 2022.

Methods

A multicenter, institution-based retrospective follow-up study was conducted among 472 HIV-infected children receiving antiretroviral therapy at Amhara Regional State Comprehensive Specialized Hospitals from May 17 to June 15, 2022. Children receiving antiretroviral therapy were selected using a simple random sampling technique. Data were collected using national antiretroviral intake and follow-up forms via the KoBo Toolbox. STATA 16 was used for data analyses, and the Kaplan-Meier method was used to estimate probabilities of opportunistic infection-free survival. Both bi-variable and multivariable Cox proportional hazard models were employed to identify significant predictors. A P-value <0.05 was taken to indicate statistical significance.

Results

Medical records from a total of 452 children (representing a completeness rate of 95.8%) were included and analyzed in the study. The overall incidence of opportunistic infections among children receiving ART was 8.64 per 100 person-years of observation. The predictors of elevated incidence of opportunistic infections were: a CD4 cell count below a specified threshold [AHR: 2.34 (95% CI: 1.45, 3.76)]; co-morbidity of anemia [AHR: 1.68 (95% CI: 1.06, 2.67)]; ever having exhibited only fair or poor adherence to ART drugs [AHR: 2.31 (95% CI: 1.47, 3.63)]; never having taken tuberculosis-preventive therapy [AHR: 1.95 (95% CI: 1.27, 2.99)]; and not having initiated antiretroviral therapy within 7 days of HIV diagnosis [AHR: 1.82 (95% CI: 1.12, 2.96)].

Conclusion

In this study, the incidence of opportunistic infections was high. Early initiation antiretroviral therapy has direct effect on boosting the immunity, suppressing viral replications and increases the CD4 count, so that the occurrence of opportunistic infection will reduce the incidence of OIs.

Survival rate and predictors of mortality among TB/HIV co-infected adult patients: retrospective cohort study

Nowadays, Tuberculosis remains the major cause of HIV-associated mortality, which accounts for 1 out of every 5 HIV-related mortality worldwide. This study aimed to determine the survival rate and predictors of mortality among TB/HIV co-infected patients. An institution-based retrospective cohort study was undertaken on adult TB/HIV co-infected individuals between 1st February 2014 and 30th January 2022 at Mettu Karl Referral Hospital. A Cox regression model was used to identify predictors of survival time to death among TB/HIV co-infected patients. This study comprised 402 TB and HIV co-infected adult patients. Among these, 84 (20.9%) died, and 318 (79.1%) were censored. The study subjects have been followed up for 6920 person-months with an overall median survival time of 17.6 months. The overall incidence rate was 12.1 per 1000 person months [95% CI: 9.77-14.98]. The results of a multivariable Cox regression analysis showed that being at an older age, urban residence, WHO clinical stage II & IV, CD4 count of ≥ 200 cells/mm³, bedridden functional status, using INH, and using CPT were associated with the survival time of TB and HIV co-infected patients at a significance level of alpha = 0.05. This retrospective study found that high mortality of TB/HIV co-infected patients occurred in the earlier months of treatment initiation. Close monitoring of patients with low CD4, who do not utilize CPT, who are in advanced WHO stages, and who have poor functional levels can help them improve their health and live longer.

Incidence of Pneumonia and Predictors Among Human Immunodeficiency Virus Infected Children at Public Health Institutions in the Northwest Part of Ethiopia: Multicenter Retrospective Follow-Up Study

Introduction

Pneumonia is an inflammation of the lung parenchymal structure secondary to hematogens spread of pathogens, inhalation, or aspiration. It is also one of the most frequently occurring opportunistic infections in HIV-infected children. In Ethiopia, data on the incidence and predictors of opportunistic infection, especially pneumonia, among HIV-infected children is very limited. Hence, this study aimed to assess the incidence of pneumonia and predictors among HIV-infected children at public health institutions in the Northwest part of Ethiopia.

Methods

An institution-based retrospective cohort study was conducted among 342 HIV-infected children at public health institutions from January 1, 2013 to December 30, 2020. Log rank test was used to compare the survival curves between different explanatory variables. Bivariable Cox proportional hazards regression model was employed for each explanatory variable to check the association with the outcome variable. Variables found to have a p-value of < 0.25 in the bivariable analysis were candidates for the multi-variable proportional hazard model. Cox proportional hazards model was used at 5% level of significance to identify predictors of pneumonia.

Results

This study included 342 records of HIV-infected children who started antiretroviral therapy between the periods of January 1, 2013 to December 30, 2020. The overall incidence rate of pneumonia during the follow-up time was 5.57 (95% CI: 4.4, 7.0) per 100 child-years of observation. Those children who did not take cotrimoxazole preventive therapy (AHR: 3, 95% CI: 1.40, 6.44), being underweight at baseline (AHR: 2.6, 95% CI: 1.41, 4.86), having baseline advanced disease (clinical stages III and IV) (AHR: 2.8, 95% CI: 1.30, 6.04), and presenting with recently detected viral load (AHR: 5.9, 95% CI: 2.53, 14.06), were more likely to develop pneumonia.

Conclusion

Pneumonia incidence rate was high. Providing prophylaxis and nutritional supplementation for those children with baseline advanced disease stage, low weight for age and detectable viral load would reduce pneumonia occurrence.

HIV/AIDS treatment failure and associated factors in Ethiopia: meta-analysis

Background

The national burden of human immunodeficiency virus treatment failure and associated factors in the Ethiopian context is required to provide evidence towards a renewed ambitious future goal.

Methods

We accessed Ethiopian Universities’ online repository library, Google Scholar, PubMed, Web of Science, and Scopus to get the research articles. We run I-squared statistics to see heterogeneity. Publication bias was checked by using Egger’s regression test. The pooled prevalence was estimated using the DerSimonian-Laird random-effects model. We employed the sensitivity analysis to see the presence of outlier result in the included studies.

Results

The overall human immunodeficiency treatment failure was 15.9% (95% confidence interval: 11.6–20.1%). Using immunological, virological, and clinical definition, human immunodeficiency treatment failure was 10.2% (95% confidence interval: 6.9–13.6%), 5.6% (95% confidence interval: 2.9–8.3%), and 6.3% (95% confidence interval: 4.6–8.0%), respectively. The pooled effects of World Health Organization clinical stage III/IV (Adjusted Odd Ratio = 1.9; 95% CI: 1.3–2.6), presence of opportunistic infections (Adjusted Odd Ratio = 1.8; 95% CI: 1.2–2.4), and poor adherence to highly active antiretroviral therapy (Adjusted Odd Ratio = 8.1; 95% CI: 4.3–11.8) on HIV treatment failure were estimated.

Conclusions

Human immunodeficiency virus treatment failure in Ethiopia found to be high. Being on advanced clinical stage, presence of opportunistic infections, and poor adherence to highly active antiretroviral therapy were the contributing factors of human immunodeficiency virus treatment failure. Human immunodeficiency virus intervention programs need to address the specified contributing factors of human immunodeficiency virus treatment failure. Behavioral intervention to prevent treatment interruption is required to sustain human immunodeficiency virus treatment adherence.

Protocol registration

It has been registered in the PROSPERO database with a registration number of CRD42018100254.

Incidence of common opportunistic infections among HIV-infected children on ART at Debre Markos referral hospital, Northwest Ethiopia: a retrospective cohort study

Background

Opportunistic infections (OIs) are the leading cause of morbidity and mortality among children living with human immunodeficiency virus (HIV). For better treatments and interventions, current and up-to-date information concerning occurrence of opportunistic infections in HIV-infected children is crucial. However, studies regarding the incidence of common opportunistic infections in HIV-infected children in Ethiopia are very limited. Hence, this study aimed to determine the incidence of opportunistic infections among HIV-infected children on antiretroviral therapy (ART) at Debre Markos Referral Hospital.

Methods

A facility-based retrospective cohort study was undertaken at Debre Markos Referral Hospital for the period of January 1, 2005 to March 31, 2019. A total of 408 HIV-infected children receiving ART were included. Data from HIV-infected children charts were extracted using a data extraction form adapted from ART entry and follow-up forms. Data were entered using Epi-data™ Version 3.1 and analyzed using Stata™ Version 14. The Kaplan Meier survival curve was used to estimate the opportunistic infections free survival time. Both bi-variable and multivariable Cox proportional hazard models were fitted to identify the predictors of opportunistic infections.

Results

This study included the records of 408 HIV-infected children-initiated ART between the periods of January 1, 2005 to March 31, 2019. The overall incidence rate of opportunistic infections during the follow-up time was 9.7 (95% CI: 8.13, 11.48) per 100 child-years of observation. Tuberculosis at 29.8% was the most commonly encountered OI at follow-up. Children presenting with advanced disease stage (III and IV) (AHR: 1.8, 95% CI: 1.2, 2.7), having “fair” or “poor” ART adherence (AHR: 2.6, 95% CI: 1.8, 3.8), not taking OI prophylaxis (AHR:1.6, 95% CI: 1.1, 2.4), and CD4 count or % below the threshold (AHR:1.7, 95% CI: 1.1, 2.6) were at a higher risk of developing opportunistic infections.

Conclusions

In this study, the incidence rate of opportunistic infections among HIV-infected children remained high. Concerning predictors, such as advanced disease stage (III and IV), CD4 count or % below the threshold, “fair” or “poor” ART adherence, and not taking past OI prophylaxis were found to be significantly associated with OIs.

Prevalence of chronic ear disease among HIV+ children in Sub-Saharan Africa

OBJECTIVES

To determine the prevalence of chronic ear disease in HIV+, highly active anti-retroviral therapy (HAART)-treated children and compare this to the prevalence in healthy children of similar age living in a similar setting.

INTRODUCTION

From previous clinical work in Ethiopia, we suspected that chronic middle ear disease was common both in the general pediatric population and especially among children with HIV/AIDS. Few studies have examined the prevalence of chronic ear disease in HIV + children, particularly in those treated with HAART.

METHODS

Full examination of the head and neck was performed by otolaryngologists. This including cleaning of cerumen, otoscopy and microscopic otoscopy when needed. Patient's medical records were reviewed. Presence or absence of tympanic membrane (TM) perforation (unilateral or bilateral), tympanosclerosis, TM atrophy, otorrhea and/or cholesteatoma was documented.

RESULTS

112 HIV+ and 162 healthy (HIVU) children were included. Prevalence of TM perforations was 17% in the HIV + infected versus 3% in the HIVU (Fisher's-Exact-Test; OR: 7.2, 95% CI 2.5-20, p-value <0.0001). Presence of unilateral TM perforations was 12% in the HIV + population and 2% in the HIVU population (Fisher's-Exact-Test; OR: 6.8, 95% CI 2.0-22, p-value 0.002). The presence of bilateral perforations was 4% in the HIV + population and 1% in the HIVU population (Fisher's-Exact-Test; OR: 6.8, 95% CI 1.1-42, p-value 0.088). In the HIV + cohort, 2% were diagnosed with cholesteatoma compared to 0% in the HIVU population (95% CI HIV+ 0.002-0.06; HIVU 0.0-0.02) and 8% of HIV + subjects had active middle ear discharge, compared to 0% in the HIVU population (95% CI HIV+ 0.04-0.1; HIVU 0.0-0.02). Neither tympanosclerosis nor tympanic membrane atrophy was more frequent in the HIV + population compared to the HIVU population. Persistent or recurrent TM perforation was not more frequent in children with prior tympanoplasty in the HIV + population compared to the HIVU population.

CONCLUSION

TM perforations are significantly more common in HAART-treated HIV + children than in healthy, age-matched HIVU population. Otorrhea and cholesteatoma were found only in the HIV + cohort.