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HIV Morbidity and Mortality in the Pediatric Population of Cote d’Ivoire

Folquet AM1,2*, Dainguy ME1, Kangouté M1, Kouakou C1, Kouadio E1, Zobo Konan N1, Oka Bérété G1, Kouadio Yapo G1, Gro Bi A1, Djivohessoun A1, Djoman I1 and Jaeger FN3,4,5

1Pediatrics department of Cocody Teaching Hospital, Abidjan, Côte d’Ivoire

2Felix Houphouët Boigny University, Abidjan, Côte d’Ivoire

3Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Abidjan, Côte d'Ivoire

4Swiss Tropical and Public Health Institute, Basel, Switzerland

5University of Basel, Basel, Switzerland

Corresponding Author:
Folquet AM
Pediatrics department of Cocody Teaching Hospital
Abidjan, 25 BP 567 Abidjan 25, Côte d’Ivoire
Tel: 00 225 07 84 83 17
E-mail: [email protected]

Received date June 02, 2014; Accepted date October 29, 2014; Published date November 07, 2014

Citation: Folquet AM, Dainguy ME, Kangouté M, Kouakou C, Kouadio E, et al. (2014) HIV Morbidity and Mortality in the Pediatric Population of Côte d’Ivoire. Clinics Mother Child Health 11:162. doi: 10.4172/2090-7214.1000162

Copyright: © 2014 Folquet AM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Keywords

HIV/AIDS; ARVs; Morbidity; Mortality; Child

Introduction

According to the 2010 World UNAIDS report, expanding access to antiretroviral therapy has helped reducing the number of deaths among people living with HIV by 19% between 2004 and 2009 [1]. Definitely, major progress has been made concerning the HIV pandemic, as demonstrated by the >25% decline of the incidence of infection between 2001 and 2009 in 33 countries [1]. Still, HIV infection remains one of the leading causes of morbidity in childhood. It has increased infant mortality in the most affected countries and threatens to wipe out years of progress in the fight for child survival [2].

According to the AIDS Indicator survey of 2005 in Côte d'Ivoire, a country much affected by the HIV/AIDS pandemic in West Africa, HIV infection prevalence was estimated at 4.7% with 2.9% of men and 6.4% of women infected. This corresponds to 570,000 adults and children infected by the virus, including 350,000 females (61.4%) [3]. The number of children under 15 years old infected has increased from 50,000 in 2005 to 74,000 in 2013. Currently HIV prevalence in Côte d’Ivoire is estimated at 3.4% in children and adolescents <15 years. Only 15% of them are under ARV treatment [4].

Efforts to fight this pandemic were undertaken by the public pediatric healthcare services and included the provision of free antiretroviral treatment. In 2001, the first national evaluation of the situation of pediatric HIV took place. In 2005, decentralization of the health care activities allowed an increase from previously four to 175 pediatric HIV treatment sites in 2010 [5].

Wishing to provide care for HIV infected children, the Pediatrics Department of Cocody University Teaching Hospital (Centre Hospitalier Universitaire de Cocody, CHU-Cocody), one of the three teaching hospitals in the country’s economic capital, Abidjan, and the Elisabeth Glazer Pediatric AIDS Foundation (EFPAF) united forces to provide care. In this paper we shall give an overview of work conducted in this spirit and describe morbidity and mortality of the pediatric HIV-patients the department cared for.

Resources and Methods

Framework

The study has been conducted within the unit in charge of pediatric HIV in the CHU-Cocody in Abidjan. Since November 2005, a multi-disciplinary team involved in health care activities and in support of children living with HIV is in charge of the unit. The treatment of the pediatric HIV/AIDS is carried out according to national guidelines.

Type and method of study

This retrospective study investigated care and outcomes of pediatric HIV-patients followed at the CHU-Cocody from November 28th 2005 to June 30th 2010 (5 years). HIV positive children- living or deceased with an exploitable patient file (file comprising the primary check-up and including all mentioned follow-up consultations) were included. Children lost to follow-up, thus who have not had contact with the center for at least 90 days and for which therefore outcomes cannot be defined, and those who have been transferred to other health care centers were excluded from analysis. The studied population was divided into two groups: Group A: all children under antiretroviral therapy and group B: all children without antiretroviral therapy, because they were still immune-competent, disqualified for the treatment for social reasons or had contraindications such as transaminases 10x higher than normal. According to the Ivorian national consensus in use from 2005 to 2010, the following children were eligible for ARV treatment:

- Children under 5 years old with a percentage of CD4<25% regardless of the WHO clinical state (CDC or WHO) or having a WHO clinical state 3-4 or CDC B-C and this regardless of the percentage of CD4.

- Children of 5 years and older who have a rate of CD4<15% or <200 cells/mm3regardless of clinical state (CDC or WHO) or WHO clinical state 3-4, CDC B and C regardless of CD4.

The clinical monitoring was conducted quarterly. The initial assessment at admission and the semi-annual monitoring assessments covered full blood count, transaminases, creatin, glycemia and were carried out free of charge. Additionally, children were seen whenever they were sick.

Data collection

Data were collected using a survey form including the following parameters: socio-demographic (sex, age, nationality, place of residence); clinical (reason for medical examination, medical history, physical examination at entry, nutritional status, CDC classification, diagnosis at admission), laboratory work-up information (Type of HIV, lymphocyte count, blood count), therapeutic (treatment regimens, Cotrimoxazole); and evolution and outcomes (Pathology during follow-up, severe morbidity which caused hospitalization or death).

Data processing and analysis

Data entry was performed using MS Excel 2007. Data were analyzed with EPI Info 6.0. The population of children under ARV was compared to that of children without ARVs. Statistical tests used were the Chi 2, the Fisher exact test and Odds ratio. The significance level chosen was 5% and the confidence interval 95%.

Results

Of the 336 children followed during the study period, 37 (11.0%) were transferred to another health care center, 81 (24.1%) children were lost to follow-up. 218 (64.9%) patient-files were selected meeting the inclusion criteria. Group A was made-up of 198 children and group B of 28 children.

Characteristics of children at admission

The average age of children in group A was 66.11 months. These children were symptomatic in 84.74% of cases, presenting severe immunodeficiency in 54.74% and were under first line therapy combining 2IN (nucleotide inhibitors) + 1INN (non nucleotide inhibitors) in 86.31% of cases.

The children in the group B were younger with a mean age of 48.14 months, slightly symptomatic (60.7%) in the majority of cases and did not present with severe immunodeficiency.

The majority of children in both groups were infected with HIV-1. All children in group B (100%) and only 85.26% in group A received cotrimoxazole.

Patient history upon admission reviled different patterns in both groups. In Group A previous history of digestive problems (52.63%), dermatological concerns (46.84%) and tuberculosis (19.47%) were encountered, while previous pulmonary affections were more frequent in group B. The most frequent reasons for medical consultation at first presentation in group B were fever (57.86%) and coughing (55.26%). Physical examination mainly revealed pulmonary signs (54.21%) and alteration of general state (43.15%) in group A and oral candidiasis for children in group B. Bacterial pneumonia in addition to HIV was the most frequent medical diagnoses in both groups upon inclusion into the HIV-care-program. Table 1 and 2 show the main characteristics of children.

Characteristics at the admission Group A (n=190) Group B (n=28)
Amount Percentage Amount Percentage
Age (months)
<24 66 34.73 8 28.57
[24-60] 32 16.84 5 17.86
>60 92 48.42 15 53.57
Sex
Male 93 48.94 15 53.57
Female 97 51.05 13 46.42
Type of HIV
HIV1 184 96.94 28 100
HIV2 4 2.10 0 0
HIV1 + 2 2 1.05 0 0
Clinical stage (CDC)
N 10 5.26 8 28.57
A 19 10.00 9 32.15
B 60 31.59 7 25.00
C 101 53.15 4 14.28
Immunodeficiency
Absent 21 11.05 18 64.29
Moderate 65 34.21 10 35.71
Severe 104 54.74 0 0
ART
First line 164 86.31 - -
Second  line 28 13.69 - -
Cotrimoxazole
Yes 162 85.26 28 100
No 28 14.73 0 0

Table 1: Characteristics of HIV-positive children at the admission.

Clinical characteristics Group A (n=190) Group B (n=28) OR [CI] P
Amount Percentage Amount Percentage
Clinical History
Pulmonary 37 19.47 13 46.42 0.07 -  
Digestive 100 52.63 8 28.57 2.78 [1.09 to 7.26] 0.001
Dermatological 89 46.84 2 7.14 11.46 [0.02 to 0.28] 0
Tuberculosis 37 19.47 0 0 - - -
Neurological 2 1.05 0 0 - - -
Fever-going 35 18.42 4 14.28 1.35   0.78
No medical history 0 0 6 21.42 - - -
Reason for check-up
Hyperthermia 110 57.86 6 21.42 5.04 [1.83 to 14.61] 0
Coughing 105 55.26 8 28.57 3.09 [1.21 to 8.08] 0
Emaciation 68 35.79 6 21.42 2.04 [0.74 to 5.94] 0.134
Diarrhea 49 25.79 3 10.71 2.90 [0.78 to 12.62] 0.131
Paleness 40 25.79 3 10.71      
Rash 39 20.52 5 17.85      
Clinical examination
Pulmonary signs 103 54.21 8 28.6 2.96 [1.16 to 7.74] 0.011
Trush 85 44.73 20 71.4 0.32 [0.12 to 0.82] 0
Poor general impression 82 43.15 6 21.43 2.78 [1.01 to 8.06] 0.028
Paleness 60 31.54 4 14.28 2.77 [0.86 to 9.88] 0.09
Polyadenopathy 61 32.10 4 14.28 2.84 [0.88 to 12.12] 0.08
Dermatosis 36 18.94 6 21.43 0.86 [0.30 to 2.56] 0.755
Admission diagnosis
Bacterial pneumonia 54 28.42 9 32.14 0.84 [0.33 to 2.15] 0.685
Malaria 29 15.26 6 21.43 0.66 [0.23 to 2.00] 0.279
Severe acute malnutrition 47 24.73 4 14.28 1.97 [0.61 to 7.09] 0.326
Anemia 31 16.32 3 10.71 1.69 [0.45 to 7.50] 0.304
Tuberculosis 3 1.58 - - - - -
Shingles 4 2.11 - - - - -
*Deterioration of the General state; **Acute and severe malnutrition

Table 2: Clinical characteristics of children with HIV.

Average period of monitoring

More than 2/3 (78.58%) of the children of group B were monitored for less than one year. The Average period of monitoring was 20.96 months for group A and 3.85 months for group B.

Disease episodes during follow-up

In total, 764 disease episodes occurred during the follow-up; 633 in group A (mean 3.2 episodes/child) and 131 in group B (mean 4.7 episodes/child). Anemia (p=0.036) and pneumonia (other than tuberculosis) (P=0.011) were more frequent in group A. The main diseases encountered in both groups are listed in Table 3.

Morbid events types Group A (n=633) Group B (n=131) OR [CI] P
Amount Percentage Amount Percentage
Anemia 166 26.22 23 17.55 1.67 [1.07 to 2.79] 0.036
Oropharyngeal candidiasis 50 7.89 10 7.63 1.02 [0.49 to 2.25] 0.918
Bacterial pneumonia 64 10.11 21 9.16 2.96 [1.16 to 7.74] 0.011
Prurigo 45 7.10 5 3.81 1.93 [0.72 to 5.64] 0.165
Malnutrition 36 5.68 3 2.29 2.57 [0.75 to 10.64] 0.164
Malaria 25 3.94 5 3.81 1.04 [0.37 to 3.15] 0.860
Parotitis 15 2.36 3 2.29 1.04 [0.28 to 4.57] 0.626
Tuberculosis 15 2.21 1 0.76 3.16 [0.43 to 64.62] 0.209
Meningoencephalitis 9 1.42 - - - - -

Table 3: Major morbid events listed during follow-up.

Hospitalizations

Hospitalizations were more common in the children of group A (124/190) than the children in group B (10/28; p=0.0027). Severe acute malnutrition constituted the leading cause of hospitalization in both groups (29.03% vs 40%).

Table 4 shows all the inpatient diagnoses.

Inpatient diagnoses Group A Group B
Amount (n=124) Percentage Amount (n=10) Percentage
Severe acute malnutrition 36 29.03 04 40.00
Pneumonia 31 25 - -
Severe malaria 21 16, 93 01 10.00
Gastroenteritis 26 20.96 01 10.00
Severe anemia 15 12.09 02 20.00
Pneumocystis 5 4.03 01 10.00
Pulmonary tuberculosis 2 1.61 - -
Bacterial meningitis 2 1.61 01 10.00
Cerebral toxoplasmosis 2 1.48 - -

Table 4: Selected inpatient diagnosis.

Mortality

The mortality rate was higher in group B (75%) than in group A (15.79%) (OR=16, 95% CI [5.79-45.90], P=0). Fatal outcomes were more frequent in those under 24 months, especially in group B (43.33% of deaths in group A versus 90.47% in group B) (OR=0.08, 95% CI [0.01-0.47.], P=0.0017). Furthermore, in young children of group B, fatal events also occurred earlier with two thirds taking place less than six months from the date of registration (66.60% versus 90.50%) (OR=0, 21, 95% CI [0.03-1.25], P=0.047). The main causes of death in both groups were malnutrition (26.67% vs. 28.57%), followed by anemia (16.66% vs. 14.28%) and the diarrhea (13.33% vs. 19.05%) as displayed in Table 5.

Causes of death Group A Group B
Amount (n=30) Percentage Amount (n=21) Percentage
Malnutrition 08 26.67 06 28.57
Anemia 05 16.66 03 14.28
Diarrhea 04 13.33 04 19.05
Bacterial pneumonia 01 3.33 03 14.28
Pleural pneumopathy 02 6.66 02 09.52
Tuberculosis 02 6.66 01 04.76
Septicemia 03 10.00 01 04.76
Pneumothorax 01 3.33 - -
Meningo– encephalitis 01 3.33 01 04.76
Cerebral toxoplasmosis 01 3.33 - -
Brain abscess 01 3.33 - -
Acute renal failure 01 3.33 - -

Table 5: Causes of Death.

The major causes of death are summarized in Table 5.

Discussion

Despite the progress made in the fight against HIV/AIDS, diagnosis and HIV-infected children, treatment are still tardy in countries with limited resources. The average age of children in our study at admission was high; 5 years 7 months (66.11 months) in group A and 4 years 1 month (49 months) in group B. Kwara et al. [6] in Ghana and Ugochukwu [7] in Nigeria reported similar mean age (4.5 years and 4.78 years). The majority of children in group A (84.74%) and more than one third of children in group B (29.28%) were symptomatic.

The most frequent reasons for check-up in group A were fever and coughing. Clinical examination revealed primarily pulmonary symptoms, weakened general condition for group A, and oral candidiasis for Group B. Babatunde et al. [8] in Nigeria and Lodha et al. [9] in India had also described these signs in variable proportions. More than half of the children in group B had severe immunodeficiency (54.74%). Diack et al. in Senegal [10] and Kariyo et al. [11] in Burundi respectively reported in their series 57.14% and 84% of severe deficiency. Strategies such as AIDS Testing Advices Initiated by Health Care Service Providers must be implemented in all health facilities in the country. This will allow early and rapid mass HIV testing, and an instant treatment of HIV-infected children.

Results demonstrate that next to HIV, concerned children also need to fight other severe affections such as pneumonia, malnutrition, malaria, anemia and tuberculosis. Pulmonary manifestations are common in pediatric HIV infection. In fact, in group B, 46.42% of the children had a history of pulmonary disease and 54.21% of the children in group A, presented signs of pulmonary affections on physical examination at the time of admission. Bacterial pneumonia (non-tuberculosis) was a frequent diagnosis in both groups: 28.42% of children in group A and 32.14% in group B had pneumonia at first admission to the HIV-care-program and, 10.11% (group A) and, 9.16% (group B) during follow-up. Almost a quarter of the children in group B (24.19%) were hospitalized for a pulmonary affection. HIV infection is a major risk factor for invasive pneumonia [12]. The Identification of bacteria in pneumonia remains difficult. For Gray et al. [12] the relevant organisms are Pneumocystis jiroveci and gram-negative bacilli.

In our study, anemia was frequently observed during follow-up in group A (26.22%). Seventeen children were hospitalized for severe anemia (hemoglobin <5 g/dl). Anemia is commonly reported in HIV/AIDS-positive children [13-15]. Its origin is multifactorial: both, poor nutritional status of the HIV infected children and also the more or less combined in-take of ARVs (AZT) and cotrimoxazole may play a role [14].

Malnutrition in HIV-infected children is a public health priority and a challenge for African countries with limited resources. There is an undeniable link between HIV infection and malnutrition. Indeed, nutritional requirements increase during HIV infection and the presence of malnutrition promotes permanent morbid condition in infected children. Severe acute malnutrition was found in 24.73% of the children in group A and 14.28% of the children in group B on admission; it has persevered during follow-up, since 5.68% of children in group A and 2.29% in group B was still undernourished during follow-up visits. Severe Acute Malnutrition was the leading cause of hospitalization in both groups (29.03% and 40%). The work of Kimani Murage in South Africa [16] and Choudhary in India, on the nutritional assessment of a HIV-infected children population revealed prevalences of 18% of severe acute malnutrition, 12.9% among children under 5 years and 39.4% in those over 5 years [17]. The early HIV/AIDS testing and malnutrition treatment improves the quality of life of children living with HIV. Care activities and nutritional support are essential in the management of pediatric HIV infection. Sunguya et al. reported [18], the routine administration of Therapeutic Food Ready for Employment in children on ART significantly reduces the occurrence of malnutrition.

Co-infections of tuberculosis and HIV/AIDS are a reality in pediatric care. They represent a challenge due to their unusual clinical manifestations, difficult diagnosis and particularly high morbidity and mortality rates. In our study, 37 children (19.47%), all from group A, showed a history of tuberculosis and 19 children were treated for pulmonary and extra-pulmonary tuberculosis, either at admission (1.58%) or during follow-up. Immune Reconstitution Inflammatory Syndrome or IRIS was encountered in 16 children. Diack et al. [10] and Bugaje et al. [19] found themselves with higher rates of TB: with 16% and 45.7% of HIV-cases. It would be important to instaure a free and global treatment program of the co-infection TB/HIV in health facilities because even if there are free anti-TB and anti-retroviral drugs, clinical para-investigations are limited and still not available free of charge.

In Côte-d'Ivoire, malaria is highly endemic. While its severe form (P. falciparum) was responsible for 16.93% of hospitalization among children in group A versus 10% in group B, during follow-up, the incidence of malaria was similar in both groups (malaria responsible for 3.94% of morbid events in group A and 3.81% in group B). It is possible that the concomitant intake of the Cotrimoxazole is protective. That drug has been reported to have a beneficial role in preventing malaria in people living with HIV [20].

Severe acute malnutrition was the primary cause of death in both groups (26.67% and 28.57%). Adonis-Koffy et al. [23] found 36.70% deaths in their study whose causes were mainly due to the combination of the protein-energy malnutrition and of a secondary dehydration to a diarrhea in 27.40% of the cases.

Mortality over the five years of follow-up was less pronounced in group A (15.79%) than in group B (75%) (P<0.001). Although some of the children in group B were eligible for ARV treatment according to national guidelines (stage B (25%) and C (14.28%)), circumstances prevented their antiretroviral therapy implementation. This may have been due to the lack of active and conscientious parent involvement, the presence of a vital distress or of the transaminases increasing. This explains the fact that some patients in group B at the WHO clinical state B did not receive ARV treatment despite their eligibility. Actually, a study by Camille et al. [21] in Togo showed a high and early mortality during the first 6 months of antiretroviral therapy.

The mortality rate was highest in the group of children aged less than 24 months (P=0.0017) in group B. Children under two years of age are indeed the population most at risk. Desmonde [22] reported that mortality rates were three times higher in children under 12 months than those older, before the introduction of ART.

Although instauring the prevention of mother to child transmission (PMTCT) of HIV seemed like a major hope in Côte d’Ivoire, its implementation still faces major difficulties. In 2011, according to the health statistics yearbook [5], only 404,443 mothers have been tested for HIV during their pregnancy with a positivity rate of 3.5% (14413 / 404443). The vast majority of children for a long time did not benefit from free PCR at 6 weeks of age, as this was only introduced in Côte d’Ivoire in 2011, thus after our study period. Their status therefore remained unknown.

Children under two years in particular, and all children under 5 years in general should benefit from early diagnosis and ARV treatment whatever the CD4 rate, according to the WHO 2013 recommendations.

The time to occurred death was shorter in group B (P<0.05). Only early antiretroviral therapy would inevitably reduce the mortality related to the HIV infection in children [24,25].

Conclusion

The pathology associated with pediatric HIV infection is very rich, including pulmonary affections, malnutrition, malaria, anemia, and tuberculosis. Their importance depends on whether the child is on antiretroviral treatment or not. Lack of early ARV therapy is a major reason for the encountered high mortality in HIV-positive children under 24 months of age.

Much remains to be done in countries with limited resources to improve pediatric HIV treatments and care, especially among the very young that simultaneously have to fight many childhood diseases. The implementation of WHO recommendations by national governments must become a priority in order to improve the survival of children living with HIV.

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