Managing HIV in the PICU — The experience at the red cross War Memorial Children’s Hospital in Cape Town

Abstract

The HIV pandemic has affected children throughout the developing world. This article describes the experience of the Paediatric Intensive Care Unit at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa. Over the last 20 years we have improved our management of HIV infected children requiring intensive care admission. In the absence of anti-retroviral therapy, long term outcomes from PICU admission of HIV infected children have not improved significantly, and it is debatable whether PICU admission is justified. Once anti-retroviral therapy is available to children, there may be significant improvements in outcome and possible affected children should be admitted to the PICU if resources are available.

Factors present on admission associated with increased mortality in children admitted to a paediatric intensive care unit (PICU)

“…With the advent of ARV therapy, mortality in HIV-infected children has decreased significantly in both high-and middle-income countries. [5] Ultimately the aim should be to reduce the need for intensive care in these children and instead focus on improved systems to prevent mother-to-child transmission and the early initiation of ARVs where necessary. [16] Increasing PRISM, PELOD and PIM3 scores were all associated with increasing mortality rates, as expected (p<0.05).…”

“…Access to social grants is associated with decreased illness and improved growth monitoring and therefore plays an important role in mitigating these factors. [4] HIV has placed increased demands on health services in South Africa (SA), [5] with many infected children presenting in early infancy with life-threatening illnesses. The introduction of antiretroviral (ARV) therapy has improved the outcome of HIV-infected children, leading to a review of paediatric ICU (PICU) admission criteria with greater accommodation of these children.…”

“…The introduction of antiretroviral (ARV) therapy has improved the outcome of HIV-infected children, leading to a review of paediatric ICU (PICU) admission criteria with greater accommodation of these children. [5] Globally severe malnutrition affects 13 million children under the age of 5 years, with case fatality rates between 20% and 30%. [6] The second highest burden is seen in sub-Saharan Africa.…”

Short-term treatment outcomes of children starting antiretroviral therapy in the intensive care unit, general medical wards and outpatient HIV clinics at Red Cross War Memorial Children’s Hospital, Cape Town, South Africa: A retrospective cohort study

“…Mortality in these children was high, with rates of 27% and 44% recorded at RCWMCH and Tygerberg Hospital, respectively. [15] Since the introduction of ART, mortality in children has decreased substantially. Our study reports a 13.2% probability of mortality in children admitted to the ICU and subsequently commenced on ART, which although significantly higher than those in the GMW and OHC cohorts, is approximately half the pre-ART ICU mortality.…”

The Assessment, Evaluation, and Management of the Critically Ill Child in Resource-Limited International Settings

“…In addition, as pointed out by Argent, treating illness without long-term therapy may not be the best use of ICU resources in this setting. 7 Thus, unlike resource-rich areas where every effort is made to give every child the best chance for recovery in spite of the costs of treatment, the pediatric intensivist in a resource-limited setting must have clear inclusion and exclusion criteria to discern which child would be benefitted by critical care (►Table 1).…”