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Brief Report

Cofactors of Mortality Among Hospitalized HIV-Infected Children Initiating Antiretroviral Therapy in Kenya

Njuguna, Irene N., MBChB, MSc, MPHa,b; Cranmer, Lisa M., MD, MPHc; Wagner, Anjuli D., MPH, PhDd; LaCourse, Sylvia M., MD, MPHe; Mugo, Cyrus, MBChBf; Benki-Nugent, Sarah, MS, PhDd; Richardson, Barbra A., PhDd,g; Stern, Joshua, MScd; Maleche-Obimbo, Elizabeth, MBChB, MMed, MPHf; Wamalwa, Dalton C., MBChB, MMed, MPHf; John-Stewart, Grace, MD, MPH, PhDb,d,e,h

JAIDS Journal of Acquired Immune Deficiency Syndromes: June 1, 2019 - Volume 81 - Issue 2 - p 138–144
doi: 10.1097/QAI.0000000000002012
Epidemiology
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Objectives: Identifying factors associated with mortality among acutely ill HIV-infected children presenting with advanced HIV disease may help clinicians optimize care for those at highest risk of death.

Design: Using data from a randomized controlled trial (NCT02063880), we determined baseline sociodemographic, clinical, and laboratory cofactors of mortality among HIV-infected children in Kenya.

Methods: We enrolled hospitalized, HIV-infected, antiretroviral therapy–naive children (0–12 years), initiated antiretroviral therapy, and followed up them for 6 months. We used Cox proportional hazards regression to estimate hazard ratios (HRs) for death and 95% confidence intervals (CIs).

Results: Of 181 enrolled children, 39 (22%) died. Common diagnoses at death were pneumonia or suspected pulmonary tuberculosis [23 (59%)] and gastroenteritis [7 (18%)]. Factors associated with mortality in univariate analysis included age <2 years [HR 3.08 (95% CI: 1.50 to 6.33)], orphaned or vulnerable child (OVC) [HR 2.05 (95% CI: 1.09 to 3.84)], weight-for-age Z score <−2 [HR 2.29 (95% CI: 1.05 to 5.00)], diagnosis of pneumonia with hypoxia [HR 5.25 (95% CI: 2.00 to 13.84)], oral thrush [HR 2.17 (95% CI: 1.15 to 4.09)], persistent diarrhea [HR 3.81 (95% CI: 1.89 to 7.69)], and higher log10 HIV-1 viral load [HR 2.16 (95% CI: 1.35 to 3.46)] (all P < 0.05). In multivariable analysis, age <2 years and OVC status remained significantly associated with mortality.

Conclusions: Young age and OVC status independently predicted mortality. Hypoxic pneumonia, oral thrush, and persistent diarrhea are important clinical features that predict mortality. Strategies to enhance early diagnosis in children and improve hospital management of critically ill HIV-infected children are needed.

aKenyatta National Hospital, Nairobi, Kenya;

bDepartment of Epidemiology, University of Washington, Seattle, WA;

cDepartment of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA;

Departments of dGlobal Health; and

eMedicine, University of Washington, Seattle, WA;

fDepartment of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya;

and Departments of gBiostatistics; and

hPediatrics, University of Washington, Seattle, WA.

Correspondence to: Irene N. Njuguna, MBChB, MSc, MPH, Kenyatta National Hospital, Research and Programs, P.O. Box 20723-00202 Nairobi, Kenya (e-mail: irenen@uw.edu).

Supported by the National Institute of Child Health and Human Development, National Institutes of Health, USA (R01 HD023412). This publication was supported in part by Fogarty International Center (FIC) D43TW009783 to INN and CM, the National Institute of Child Health and Human Development (NICHD) (K12 HD000850 to LMC), F32HD088204 (ADW) and (5K24HD054314‐09 to GJS), the Pediatric Scientist Development Program (PSDP) through grants from the American Pediatric Society and American Academy of Pediatrics (LMC), the https://www.niaid.nih.gov/ National Institute of Allergy and Infectious Diseases (K23AI120793 to SML), the Center for AIDS Research (CFAR) (P30 AI027757), the National Institute of Neurological Disorders and Stroke (K01 NS080637 to SBN). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Additional support was provided by the University of Washington Global Center for Integrated Health of Women, Adolescents and Children (Global WACh).

The authors have no conflicts of interest to disclose.

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Received October 09, 2018

Accepted February 11, 2019

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