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Predictors of Early Mortality in a Cohort of Human Immunodeficiency Virus Type 1-Infected African Children

Obimbo, Elizabeth M. MMed, MPH; Mbori-Ngacha, Dorothy A. MMed, MPH*; Ochieng, James O. BSc*; Richardson, Barbra A. PhD*§||; Otieno, Phelgona A. MMed, MPH¶; Bosire, Rose MB, ChB*; Farquhar, Carey MD, MPH†‡; Overbaugh, Julie PhD||#; John-Stewart, Grace C. MD, PhD*†‡

Pediatric Infectious Disease Journal: June 2004 - Volume 23 - Issue 6 - pp 536-543
Original Studies

Background: Pediatric human immunodeficiency virus type 1 (HIV-1) infection follows a bimodal clinical course with rapid progression in 10–45% of children before the age of 2 years and slower progression in the remainder. A prospective observational study was undertaken to determine predictors of mortality in HIV-1-infected African infants during the first 2 years of life.

Methods: Infants in a perinatal cohort identified to be HIV-1-infected by DNA PCR were followed monthly to 1 year, then quarterly to 2 years or death.

Results: Among 62 HIV-1-infected infants, infection occurred by the age of 1 month in 56 (90%) infants, and 32 (52%) died at median age of 6.2 months. All infant deaths were caused by infectious diseases, most frequently pneumonia (75%) and diarrhea (41%). Univariate predictors of infant mortality included maternal CD4 count <200 cells/μl [hazard ratio (HR), 3.4; P = 0.008], maternal anemia (HR = 3.7; P = 0.005), delivery complications (HR = 2.7; P = 0.01), low birth weight (HR = 4.1; P = 0.001), weight, length and head circumference ≤5th percentile at age 1 month (HR = 3.7, P = 0.003; HR = 5.8, P < 0.001; and HR = 10.4, P < 0.001, respectively), formula-feeding (HR = 4.0; P = 0.01), infant CD4% ≤15% (HR = 5.5; P = 0.01), infant CD4 count <750 (HR = 9.7; P = 0.006) and maternal death (HR = 2.9, P = 0.05). In multivariate analysis, maternal CD4 count <200 (HR = 2.7; P = 0.03) and delivery complications (HR = 3.4; P = 0.005) were independently associated with infant mortality.

Conclusions: Advanced maternal HIV disease, maternal anemia, delivery complications, early growth faltering, formula-feeding and low infant CD4 were predictors of early mortality in African HIV-1-infected infants. In resource-poor settings, these predictors may be useful for early identification and treatment of high risk infants.

From the *Department of Pediatrics, University of Nairobi, Nairobi, Kenya; the Departments of †Epidemiology, ‡Medicine and §Biostatistics, University of Washington, Seattle, WA; ¶Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya; and the Divisions of ||Public Health Sciences and #Human Biology, Fred Hutchinson Cancer Research Center, Seattle, WA

Accepted for publication January 27, 2004.

Supported by National Institutes of Health grant HD 23412. E.M.O, P.A.O., C.F., and J.O.O. were scholars in the AIDS International Research and Training Program (AIRTP), supported by Fogarty International Center, National Institutes of Health, grant D43-TW00007. D.N., J.O. and G.J.-S. are Scholars of the Pediatric AIDS Foundation.

Presented in part at the Fourteenth International AIDS Conference, Barcelona, Spain, July 7–12, 2002. Abstract ThPeB7219.

Address for reprints: Grace John-Stewart, MD, PhD, 325 Ninth Avenue, Box 359909, Seattle, WA. Fax 206-731-2427. E-mail

© 2004 Lippincott Williams & Wilkins, Inc.