Predictors of Mortality and Mortality Rate in a Cohort of Children Living with HIV from India

OBJECTIVES:

To study the predictors of mortality and mortality rate in a clinical cohort of Children Living with Human Immunodeficiency Virus infection (CLHIV) from India.

METHODS:

This retrospective cohort analysis of CLHIV aged between 2 mo and 18 y registered during January 2004 through December 2014 at Pediatric Centre of Excellence (PCOE), Indira Gandhi Institute of Child Health (IGICH), was conducted using standard data collection sheet. Demographic and clinical characteristics of all eligible children were analyzed. The primary outcome measured was mortality. The authors also analyzed the cause of death and baseline parameters associated with death to study the predictors of mortality.

RESULTS:

Out of 1289 CLHIV registered in the PCOE during the study period, 834 (64.7 %) CLHIV, with or without antiretroviral therapy (ART) care, were included. The total time contributed by the study participants was 2872.8 child-years. The mortality rate in these children was 4.9/100 child-years. A significantly higher mortality rate of 28.2 % was found in children < 5 y, 38.6 % in children with advanced WHO clinical staging, 35.2 % among severely immunosuppressed children and 22.3 % in severely malnourished children. Tuberculosis accounted for 28 % of deaths. Univariate Cox regression analysis showed treatment status, age <5 y, baseline WHO clinical stage 3 and 4, severe immune suppression and severe malnutrition were strongly associated with mortality.

CONCLUSIONS:

The mortality rate in the index study cohort was 4.9/100 child-years and tuberculosis was the major cause of death. Younger age, baseline advanced clinical and immunological staging were predictors of mortality. Even though mortality was significantly higher in Pre-ART children, treatment status was not found to be an independent predictor of mortality.

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By:  Sanjeeva GN1,2, Gujjal Chebbi P3, Pavithra HB4, Sahana M4, Sunil Kumar DR5, Hande L6.

• 1Department of Pediatrics, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore, 560 029, Karnataka, India. sanju_gn@rediffmail.com.
• 2Pediatric Center of Excellence, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore, 560 029, Karnataka, India. sanju_gn@rediffmail.com.
• 3Department of Pediatrics, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore, 560 029, Karnataka, India.
• 4Pediatric Center of Excellence, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore, 560 029, Karnataka, India.
• 5CST, Ministry of Health and Family Welfare, National AIDS Control Organization, Bangalore, Karnataka, India.
• 6DD (ICTC/PPTCT), KSAPS, Bangalore, Karnataka, India. 
• Indian J Pediatr. 2016 Feb 26.

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Anemia, Diet & Therapeutic Iron among Children Living with HIV: A Prospective Cohort Study

Children living with HIV have higher-than-normal prevalence of anemia. The beneficial effect of therapeutic iron has been questioned in the setting of high prevalence of infections. This study examines anemia prevalence and effect of standard therapeutic iron on HIV disease progression among children.

Perinatally-infected children aged 2–12 years were enrolled at three sites in southern India, and were followed for 1 year with clinical assessments, dietary recall and anthropometry. Laboratory parameters included iron markers (ferritin, soluble transferrin receptor) and other micronutrient levels (vitamin A, B ₁₂ , folate). Iron was given to anemic children based on WHO guidelines. Statistical analyses including frequency distributions, chi square tests and multivariate logistic regression were performed using Stata v13.0.

Among 240 children enrolled (mean age 7.7 years, 54.6 % males), median CD4 was 25 %, 19.2 % had advanced disease, 45.5 % had malnutrition, and 43.3 % were on antiretroviral treatment (ART) at baseline. Anemia was prevalent in 47.1 % (113/240) children. Iron deficiency was present in 65.5 %; vitamin A and vitamin B ₁₂ deficiency in 26.6 % and 8.0 % respectively; and anemia of inflammation in 58.4 %. Independent risk factors for anemia were stunting, CD4 < 25 %, detectable viral load ≥400 copies/ml and vitamin A deficiency. Inadequate dietary iron was prominent; 77.9 % obtained less than two-thirds of recommended daily iron. Among clinically anemic children who took iron, overall adherence to iron therapy was good, and only minor self-limiting adverse events were reported. Median hemoglobin rose from 10.4 g/dl to 10.9 mg/dl among those who took iron for 3 months, and peaked at 11.3 mg/dl with iron taken for up to 6 months. Iron was also associated with a greater fall in clinical severity of HIV stage; however when adjusted for use of ART, was not associated with improvement in growth, inflammatory and CD4 parameters.

Children living with HIV in India have a high prevalence of anemia mediated by iron deficiency, vitamin A deficiency and chronic inflammation. The use of therapeutic iron for durations up to 6 months appears to be safe in this setting, and is associated with beneficial effects on anemia, iron deficiency and HIV disease progression.

Below:  Etiology of anemia in HIV. Proportions of micronutrient deficiency and inflammation contributing towards the etiology of anemia among HIV-infected children.

Full article at: http://goo.gl/WxLFLZ

By: Anita Shet^12*, PK Bhavani³, N. Kumarasamy⁴, Karthika Arumugam¹, S. Poongulali⁴,Suresh Elumalai⁵ and Soumya Swaminathan⁶

¹Department of Pediatrics, St. John’s Medical College Hospital, Sarjapur Road, Bangalore 560034, India

²Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden

³Department of Clinical Research, National Institute for Research in Tuberculosis, 1 Sathiyamoorthy Road, Chetput, Chennai, India

⁴YRG Center for AIDS Research and Education, Voluntary Health Services Taramani, Chennai, India

⁵Antiretroviral Treatment Center, Institute of Child Health, Egmore, Chennai, India

⁶Indian Council of Medical Research (ICMR), New Delhi, India

  

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