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Predicting Mortality in HIV-infected Children Initiating Highly Active Antiretroviral Therapy in a Resource-deprived Setting

Nugent, James MPH, MD*; Edmonds, Andrew MSPH, PhD; Lusiama, Jean MD; Thompson, Deidre MPH; Behets, Frieda MPH, PhD§for the Pediatric HIV Care and Treatment Group

The Pediatric Infectious Disease Journal: November 2014 - Volume 33 - Issue 11 - p 1148–1155
doi: 10.1097/INF.0000000000000454
HIV Reports

Background: While highly active antiretroviral therapy (HAART) programs have been scaled up across sub-Saharan Africa, no prognostic models for the prediction of mortality risk for children initiating HAART are widely available. Current clinical prediction tools for human immunodeficiency virus (HIV)-infected children are derived from pre-HAART data and therefore cannot predict mortality for children initiating HAART. The purpose of this study was to develop a mortality risk scoring system for HIV-infected children beginning HAART in a resource-deprived setting.

Methods: Observational data from HIV-infected children initiating HAART from December 2004 through March 2012 in Kinshasa, Democratic Republic of Congo, were analyzed. Cox proportional hazards models were constructed to assess associations between demographic and clinical characteristics at the time of HAART initiation and mortality. Each child received a model-based risk score predicting mortality after HAART initiation.

Results: By 31 March 2012, 1010 children had started HAART. One hundred three children (10.2%) died at a median of 5.3 months post-HAART initiation, yielding a mortality rate of 3.4 deaths per 100 child-years. The final mortality prediction model included undernutrition, low CD4 count, HIV symptoms, and low total lymphocyte count. These factors were highly predictive of mortality in the study population (C statistic = 0.79) and performed well when applied to the validation population (C statistic = 0.77).

Conclusions: Mortality among children starting HAART in resource-deprived settings can be predicted using a simple scoring system incorporating several readily available factors. Identifying predictors of mortality will help clinicians target modifiable risk factors, such as undernutrition, which are not directly addressed by HAART.

From *Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD; Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC; The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo; §Department of Epidemiology and School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC.

The authors have no conflicts of interest to disclose.

The HIV care and treatment program at Kalembe Lembe Pediatric Hospital and Bomoi Health Care Center, conducted in collaboration with the Kinshasa School of Public Health, the National AIDS Control Program, and the Salvation Army (Bomoi), was funded by the Centers for Disease Control and Prevention Global AIDS Program Grant U62/CCU422422 and the President’s Emergency Plan for AIDS Relief Grant 5U2GPS001 179-01, with additional support from the Elizabeth Glaser Pediatric AIDS Foundation, the Belgian Development Cooperation, the William J. Clinton Foundation, the United Nations Children’s Fund, and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Address for correspondence: James Nugent, MPH, MD, Department of Pediatrics, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889. E-mail:

© 2014 by Lippincott Williams & Wilkins, Inc.