Objective: To determine clinical pattern, prevalence, and factors associated with pediatric immune reconstitution inflammatory syndrome (IRIS) in Uganda.
Design: A prospective, multicenter cross-sectional study.
Methods: We enrolled HIV-infected children receiving antiretroviral therapy (ART) between 0.5 and 6 months duration from December 2006 to October 2007 at three pediatric clinics in Uganda. Children were evaluated for IRIS at a one-time study visit by a standardized pediatric case definition.
Results: The IRIS prevalence was 38% [95% confidence interval (CI) 31–46] among 162 children (57% female) with a median age of 6 years (interquartile range 2.5–11 years). Of the IRIS events, 77% were unmasking of a new opportunistic infection and 23% were probable paradoxical IRIS events toward prior opportunistic infections. The majority of IRIS events (55%) occurred in the first month of ART. The clinical events were diverse, with tuberculosis-IRIS (29%) being the most frequent presentation. Independent risk factors for IRIS were pre-ART CD4+ cell percentage below 15% (odds ratio = 3.1, 95% CI 1.2–8.4, P = 0.027), current CD8+ cell absolute count below 1000 cells/μl (odds ratio = 4.3, 95% CI 1.8–10.4, P = 0.001), male sex (odds ratio = 2.6, 95% CI 1.06–8.4, P = 0.01), and a cough of more than 1 week duration at the current clinic visit (odds ratio = 4.3, 95% CI 1.7–10.7, P = 0.002). A more than 25 CD4+ T-cells increase at current study visit from the pre-ART baseline was associated with IRIS by univariate (P = 0.005) but not multivariate analysis.
Conclusion: IRIS events commonly occur early after ART initiation in children with advanced immunosuppression, as commonly seen in resource-limited areas. Both healthcare providers and caregivers of the children need awareness of IRIS to minimize ART nonadherence.
aDepartment of Pediatrics and Child Health, Makerere University College of Health Sciences and Mulago National Referral Hospital, Uganda
bJoint Clinical Research Center, Kampala, Uganda
cCenter for Infectious Disease and Microbiology Translational Research, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.
Received 15 February, 2010
Revised 14 April, 2010
Accepted 19 April, 2010
Correspondence to Judy Orikiiriza, MMed, Kanombe Military Hospital, P.O. Box #3377, Kigali, Rwanda. Tel: +250 783511391; fax: +250 712962843; e-mail: email@example.com
This work has been presented at the Pediatric HIV Conference in Uganda (November 2008, abstract presentation), Uganda Society of Health Scientists Conference (February 2009, oral presentation), 1st Pediatric HIV Conference in Cape Town, South Africa (July 2009, oral presentation), and 5th IAS Conference in Cape Town, South Africa (July 2009, poster presentation).