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

• Type of Material: Article
• Authors: Irene N. Njuguna, University of Washington; Lisa Cranmer, Emory University; Anjuli D. Wagner, University of Washington; Sylvia LaCourse, University of Washington; Cyrus Mugo, University of Nairobi; Sarah Benki-Nugent, University of Washington; Barbara A. Richardson, University of Washington; Joshua Stern, University of Washington; Elizabeth Maleche-Obimbo, University of Nairobi; Dalton C. Wamalwa, University of Nairobi; Grace John-Stewart, University of Washington
• Language: English
• Date: 2019-06-01
• Publisher: Lippincott Williams & Wilkins
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2019 Wolters Kluwer Health, Inc. All rights reserved.
• License: Creative Commons Attribution-NonCommercial 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1097/QAI.0000000000002012
• Title of Journal or Parent Work: JAIDS: Journal of Acquired Immune Deficiency Syndrome
• Volume: 81
• Issue: 2
• Start Page: 138
• End Page: 144
• Grant/Funding Information: 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).; 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)
• Keywords: risk factors; death; Immunology; Diagnosis; Load; Science & Technology; Disease progression; children; Tuberculosis; delayed diagnosis; Life Sciences & Biomedicine; Infectious Diseases; Association; HIV
• Research Categories: Health Sciences, Public Health; Health Sciences, Immunology; Health Sciences, Epidemiology; Biology, Biostatistics

Abstract

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.