Survival of HIV Infected Children Born to Mothers Enrolled in a PMTCT Program in a Resource Poor Setting

F. Z. Gumbo, G. Q. Kandawasvika, E. N. Kurewa, K. Duri, P. Chandiwana, M. P. Mapingure, M. Z. Chirenje, B. Stray-Pedersen

Department of Immunology, University of Zimbabwe, Harare, Zimbabwe.
Department of Obstetrics and Gynecology, University of Zimbabwe, Harare, Zimbabwe.
Department of Pediatrics and Child Health, University of Zimbabwe, Harare, Zimbabwe.
Division of Obstetrics and Gynecology, Faculty of Medicine, University of Oslo and Rikshospitalet, Oslo, Norway.
Letten Foundation Research Centre, Harare, Zimbabwe.

DOI: 10.4236/wja.2013.32016                

Abstract

Background: Pediatric HIV is a leading cause of morbidity and mortality worldwide. The substantial expansion in PMTCT has generated information on rates of transmission and associated factors, but there are limited studies on disease progression and mortality in vertically infected children, especially from resource poor settings. Methods: A birth cohort study was initiated in 2002 to focus on the role of a single dose of nevirapine in HIV transmission before Highly Active Antiretroviral Therapy (HAART) was readily available. The enrolment of women and subsequent follow up of the children occurred at 3 peri urban clinics around Harare. Findings: 479 women were HIV infected. From these, 93 (19%) children became HIV infected, 182 (38.0%) uninfected and 204 (43%) lost to follow up before HIV diagnosis. Of the HIV infected children, 40 (43%) died before the fifth birthday, 26 (28%) were lost to follow up and 27 (29%) were alive five years after maternal enrolment prior to availability of cART. Conclusion: In this setting, there was unacceptable high mortality from HIV infected children and loss to follow up prior to availability of HAART. A small proportion of HIV vertically infected children is surviving in resource poor settings without antiretroviral therapy.

Keywords

HIV Infected Children Outcome; Mortality; Loss to Follow Up

1. Introduction

Highly prevalent mother to child HIV transmission has given rise to pediatric AIDS mortality, especially in countries where resources are few. It has been difficult to follow up HIV exposed infants, so that timely diagnosis of HIV infection can be made which results in appropriate treatment, care and support. Several studies have reported short term survival of HIV exposed children from vertical transmission [1-4]. The substantial interest in PMTCT has generated information on short term survival of vertically infected children both in the pre Highly Active Antiretroviral Therapy (HAART) and post HAART era particularly in developed countries [3-6]. On the other hand, there is very little information on long-term survival of these children in resource poor settings where follow up is a challenge. Child mortality is independently associated with maternal HIV status and maternal death, with pediatric infection resulting in approximately a four fold increase in mortality by the age of two years compare to HIV unexposed infants [7]. To determine the proportion of children whose mothers had enrolled in the Better Health for the African Mother and Child cohort and were surviving at 5 years of age, a cross sectional study of HIV infected children was carried out between 2007 and 2008 prior to universal access of antiretroviral drugs in Zimbabwe.

2. Methods

The study was conducted at three primary maternal child health clinics in peri-urban areas around Harare (namely Epworth, Seke North and St Mary’s) in Zimbabwe.

The initial study was a cohort study of HIV infected pregnant women who had been enrolled in a PMTCT program between 2002 and 2003. The follow up of mothers and children occurred up until 15 months of post natal age and ceased. We describe cross-sectional characteristics of HIV exposed children after a five year follow up visit.

The pregnant women were enrolled into the cohort study from 36 weeks of gestation, after obtaining informed consent. The aim of the initial study was to explore the role of sexually transmitted infections in pregnancy outcome. Pre and post HIV test counseling were offered as part of the national PMTCT program. Baseline characteristics collected included sociodemographic information, medical history of sexually transmitted infections, gynecological examination findings and specimen collection for full blood counts, serology for herpes simplex type 2 and syphilis, and high vaginal swabs for culture. All HIV infected women were given a single dose of nevirapine at delivery; their infants received a single dose of nevirapine, according to the national guidelines at that time (HIVNET 012) [8]. The infants were then followed up at 6weeks, 4 months, 9 months and 15 months and HIV status determined by HIV DNA PCR (Roche Diagnostics, Indianapolis, USA) if the children were aged less than 15 months, and rapid HIV antibody tests, Determine (Abbott Diagnostics, Illinois, USA) and Oraquick (abbott before 15 months and antibody tests at 15 months. The proportion of HIV infected infants has been reported [9].

At the 5 year follow up visit, HIV infected women who had been enrolled in the BHMAC study were identified from registers and traced to their homes where information on survival of their children was collected. HIV infected children were also identified from pediatric follow up clinics and blood was collected for CD4 counts.

2.1. Data Handling and Analysis

Information was collected with the data collecting tool and results were analyzed using Stata version 10.0 (College Station, Texas, USA). Cox proportional hazard ratios were used to determine baseline factors associated with child mortality. Characteristics of survivors were also described using percentages for categorical variables and mean (standard deviations) for continuous variables.

2.2. Ethics

The mothers or legal guardians signed an informed consent. The study was approved by the Medical Research Council of Zimbabwe (MRCZ) and the Norwegian ethical review committee.

3. Results

Figure 1 shows the follow up of HIV infected infants born from the recruited mothers, 27 out of 93 (29%) HIV infected children survived. There were no significant differences in maternal baseline characteristics, notably haemoglobin p = 0.563, total lymphocyte count p = 0.557, age p = 0.067 and disclosure of HIV status to partner p = 0.733 between the 204 children who were lost before HIV diagnosis and those tested for HIV. Table 1 shows unadjusted hazard ratios for predictors of child mortality. Breast feeding at 4 months was protective of death p = 0.002, which is reflected at 6 weeks and 9 months but not statistically significant. We were able to postulate causes of mortality by verbal autopsy in 27 patients. Of these, 13 (48%) died from pneumonia, 13 (48%) from diarrhea and 1 (4%) from asthma.

Conflicts of Interest

The authors declare no conflicts of interest.

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