Background : Late diagnosis of HIV infection is an important cause of death in children. Objectives: To determine the prevalence of late diagnosed HIV infection in children, describe the socio-demographic characteristics and to analyze outcome of these children. Methods: From January 2015 to October 2016, we carried out a prospective analytical study in the pediatric departments of University Teaching Hospital of the Brazzaville. Late diagnosed HIV children were selected for this work. Data analysis was performed in univariate and multivariate with Epi Info 7.2.1. Results: Of the 6058 hospitalized children, 103 (1.7%) were selected, 57.3% were boys; the median age was 21.9 months (IQR, 17.8 - 76.7 months). Children of low socio-economic status accounted for 68.0%, those motherless: 43.7%. None of the children were tested for HIV before hospitalization. Mothers had a low education level in 60.2% of cases and were unaware of prevention of mother-to-child transmission (PMTCT): 60.3%. Children mostly showed signs of stages 4 (49.5%), and 3 (31.1%) of HIV infection, immunodeficiency was severe for 68.0% of children. Children discharged from the hospital accounted for 62.1% of which 15.53% against medical advice. The case fatality rate was 37.9%. The risk factors for death in univariate analysis were: age < 12 months (OR = 8.66), maternal death (OR = 17.93), severe malnutrition (OR = 66.07), clinical stages 4 (OR = 66.07) and severe immunodeficiency (OR = 17.37). The main pathologies responsible for death were respiratory infections (38.5%) and diarrheal diseases (30.8%). Conclusion: Improvement of PMTCT program effectiveness, universal access to early detection and antiretroviral therapy for infants are needed to reduce the number of late diagnosed HIV-children and therefore HIV-related morbidity and mortality.
Human Immunodeficiency Virus (HIV) infection described for the first time in children in the 80 s [
The study was carried out in the pediatric departments of the University Teaching Hospital (UTH) of Brazzaville. Brazzaville is the capital of the Republic of Congo and the UTH, the national referral hospital. The population of Brazzaville was estimated at 1,373,382 at the last national census (2009), HIV prevalence is 3.1% in adults and 6000 children live with HIV [
We carried out a prospective analytical study between January 2015 and July 2016. All children aged from 1 month to 17 years hospitalized in the pediatric wards of the UTH of Brazzaville and presenting suggestive manifestations of the HIV infection according to the clinical definition of WHO cases [
We recorded all data on a standardized and structured form. The data included two types of variables: variables relating to children and those for parents/caregivers. For children, we recorded: age, gender, pathological history suggestive of HIV infection, nutritional status as assessed by WHO standards [
The sources of information were the caregiver of the child, the child himself when he was able to express, the attending physician and medical records.
HIV status: HIV infection was defined as a positive HIV rapid antibody diagnostic and PCR tests results for Children under 18 months and as two positive HIV rapid antibody diagnosis tests results for those aged 18 months and over.
The diagnosis of HIV infection was considered late when it was made after the onset of the signs of the disease in children aged 5 and under, and in those over 5 when the signs of the disease corresponded to clinical stage 3 or 4 or when advanced or severe immunodeficiency [
Nutritional status as assessed by WHO standards [
Socio-economic status (SES) was assessed using the National Congolese Center for Statistics and Economic Studies (CNSEE) classification [
The data was processed and analyzed with Epi info 7.2.1 software. Quantitative variables were expressed in median and interquartile range (IQR) and qualitative variables in percent. The numbers of each variable were also specified. The percentages were compared with the independence Chi-2 test or the Fischer test (when at least one of the theoretical numbers was less than 5) and the odds ratio (OR). In the multivariate logistic regression model, we included only variables significantly associated with death from the univariate analysis (p ≤ 0.20). The significance level was set at 5% and the 95% confidence interval (CI).
We obtained informed consent from parents/caregivers for interviews. The study was conducted in compliance with the Helsinki Declaration [
From January 2015 to July 2016, 6058 children were hospitalized to UTH, among them 103 (1.7%) HIV-infected children, all of whom meet the criteria for late
diagnosed HIV infection and were included in our study (the patient selection flow diagram is shown in
The socio-demographic, clinical and evolutionary characteristics of the population are detailed in
HIV knowledge assessed in all caregivers was considered good in 30 (29.1%) of them, acceptable in 50 (48.6%) and poor in 23 (22.3%). The existence of the PMTCT program was known by 23 (39.7%) of the 58 living mothers. Twenty mothers (34.5%)/58 reported having been tested for HIV during pregnancy; for 10 mothers the test result was negative in the first trimester, 3 mothers did not know the test result and for the 7 others the test result was positive. 5 out of 7 HIV-positive mothers had initiated antiretroviral therapy, which was subsequently discontinued for a variety of reasons (denial of the disease, fear of stigma and discrimination, fear that the spouse discovers her status and stock-outs of antiretroviral), and 2 others did not received antiretroviral therapy.
None of the children were tested for HIV before hospitalization, even those whose mothers were diagnosed with HIV during pregnancy.
Characteristics | n (%) | Cumulative frequency (%) |
---|---|---|
Age group (month) [1 - 11] [12 - 23] [24 - 60] [61 - 120] >120 | 38 (36.9) 15 (14.6) 20 (19.4) 16 (15.5) 14 (13.6) | 36.9 51.5 70.9 86.4 100.0 |
Gender Male Female | 59 (57.3) 44 (42.7) | 57.3 100.0 |
Vital status of parents Mother deceased Father deceased Both deceased parents | 45 (43.7) 34 (33.0) 25 (24.3) | |
School level of the mother Never schooled Primary Secondary University Unspecified | 29 (28.2) 33 (32.0) 21 (20.4) 8 (7.8) 12 (11.6) | 28.2 60.2 80.6 88.4 100.0 |
Socio-economic status High Middle Low | 7 (6.8) 26 (25.2) 70 (68.0) | 6.8 32.0 100.0 |
Nutritional status Normal Moderate malnutrition Severe malnutrition | 7 (6.8) 45 (43.7) 51 (49.5) | 2.9 32.0 100.0 |
Clinical stage (WHO) Stage 1 Stage 2 Stage 3 Stage 4 | - 20 (19.4) 32 (31.1) 51 (49.5) | 19.4 68.9 100.0 |
Immunodeficiency (WHO) None or not significant Mild Advanced Severe | - 2 (1.9) 31 (30.1) 70 (68.0) | 1.9 32.0 100.0 |
The main causes of hospitalization were bronchopulmonary infections, which accounted for 51.5% of cases (including pulmonary tuberculosis) and diarrheal diseases (39.8%) (
Among the 103 children identified, 48 (46.6%) were discharged with ART, sixteen children (15.53%) went out against medical advice. for 39 children (37.9%), the evolution was towards a death. The median duration of hospital stay was 9 days (IQR, 6 - 14 days).
The risk factors for death was identified only in univariate analysis, the multivariate analysis showed no risk factors independently associated with death (
The pathologies responsible for death were: bronchopulmonary infections n = 15 (38.5%), diarrheal diseases n = 12 (30.8%), pulmonary tuberculosis n = 4, malaria n = 3, meningitis and encephalitis 2 cases each and anemia 1 case.
Variables | Deceased N (%) | Univariate analysis | Mulivariate analysis | ||
---|---|---|---|---|---|
OR [CI] | p | Adjusted OR [CI] | p | ||
Age < 12 months | 26(68.4) | 8.66 [3.47 - 21.63] | 0.000001 | 0.36 [0.03 - 3.34] | 0.37 |
Maternal death | 32 (71.1) | 17.93 [6.46 - 49.71] | 0.0000 | 1.20 [0.05 - 24.47] | 0.90 |
Clinical stage 4 | 37 (72.6) | 66.07 [14.14 - 308.62] | 0.0000 | - | 0.95 |
Severe malnutrition | 37 (72.6) | 66.07 [14.14 - 308.62] | 0.0000 | - | 0.96 |
Severe immunodeficiency | 37(52.9) | 17.37 [3.85 - 78.27] | 0.000004 | 0.0 [0.00 - 1.0E12] | 0.90 |
OR = odds ratio; CI = confidence interval.
This work allowed us to determine the number of late diagnosed HIV-infected children in the UTH of Brazzaville and to analyze mortality. The prevalence of 1.7% noted in this work is lower than those reported by MOYEN (3%) and MBIKA (2.5%) respectively in 1993 and 1998 [
The often late and advanced diagnosis of HIV infection in children is a reality in many low and middle income countries [
HIV infection in this work was often early-onset, 36.9% of children less than 1 year old and the majority less than 2 years old at the time of diagnosis. The high incidence of early clinical form of HIV infection in children in Africa is a known fact [
The pathologies responsible for hospitalization and death were dominated by respiratory infections and diarrheal diseases, as already reported by other authors [
The mortality rate observed in this study is particularly high, other authors consulted reported similar mortality rates [
The Congo has adopted these recommendations, but is still slow to ensure that these recommendations are scaled up.
The risk factors for death identified in univariate analysis in this work are identical to those reported by other authors [
This work presents some limitations, the first concerns the site of the study, the fact that it was performed in a single hospital makes it difficult to extrapolate the results to the whole country, however, the UTH is the center where the majority of late diagnosed HIV-children are hospitalized. The second is related to the study population, it would have been interesting to compare children diagnosed late to those diagnosed early to better identify the causes behind the late diagnosis. Routine screening of all hospitalized children would have made it possible to have the actual prevalence. And the small size of our sample did not allow identify risk factors for death in multivariate analysis.
Despite its limitations, this study is the first on this subject since the implementation of PMTCT and setting up free healthcare for HIV in Congo and our findings draw the attention of health authorities and health professionals to the importance of late diagnosis of HIV infection in HIV-related morbidity and mortality in Brazzaville and probably in many cities in sub-Saharan Africa, to emphasize the value of early diagnosis and treatment of HIV infection in children for reducing mortality, and finally to describe the factors that contribute to late diagnosis.
Late diagnosed HIV infection remains common and causes heavy mortality in children in Brazzaville. Congo should build capacity in its PMTCT program, but also implement an effective strategy for routine early detection of HIV infection and treatment of infected children to reduce prevalence, improve diagnosis of infection HIV and therefore reduce HIV-related morbidity and mortality in children.
We thank all the staff of the Pediatric Department at UTH of Brazzaville for their enthusiastic collaboration and hard work on this project. We are indebted to children and caregivers who participated in the study.
The authors declare that they have no competing interests.
Oko, A.P.G., Olandzobo, A.G., Ekouya-Bowassa, G., Ndjobo, M.I.C., Ollandzobo, L., Pandzou-Guembo, N., Lombet, L., Poathy, J.P.Y., Missambou-Mandilou, S.V., Mbika-Cardorelle, A. and Moyen, G.M. (2017) Late Diagnosis of HIV Infection in Children: Prevalence and Outcome. Open Journal of Pediatrics, 7, 331-344.