Risk factors for mortality in Malawian children with human immunodeficiency virus and tuberculosis co-infection

Abstract

SETTING A large urban pediatric human immunodeficiency virus (HIV) clinic in Lilongwe, Malawi. OBJECTIVE To identify demographic and clinical risk factors for mortality in children co-infected with HIV and tuberculosis (TB). DESIGN A retrospective cohort study of HIV-infected children (aged <18 years) enrolled between October 2004 and October 2010 with at least one current or historical TB diagnosis. Descriptive statistics and logistic regression analyses were performed to determine factors associated with mortality. RESULTS A total of 1561 patients met the inclusion criteria, representing 32% of patients ever enrolled. Median age at TB diagnosis was 3.8 years (interquartile range 1.5–7.4); 60.9% had severe immune suppression and 47.6% of those with available data had some degree of acute malnutrition at TB diagnosis. Of the 1113 patients with known outcomes, 225 (20.2%) died. Children with TB-HIV co-infection not initiated on anti-retroviral therapy (ART) at any time were 8.8 times more likely to die compared to those initiated on ART 0–2 months after initiation of anti-tuberculosis treatment (adjusted OR 8.83, 95%CI 4.42–17.63). Severe immuno-suppression and World Health Organization Stage IV were also associated with mortality. CONCLUSIONS Pediatric TB-HIV co-infection is common and mortality is high in this cohort of Malawian children. Prompt initiation of ART should be emphasized in this high-risk patient population.

Mortality among pulmonary tuberculosis and HIV-1 co-infected Nigerian children being treated for pulmonary tuberculosis and on antiretroviral therapy: a retrospective cohort study

“…The mortality rate of 1.4 per 100 child-years and the proportion of deaths (16/260, 6.2%) observed among our study patients was lower compared to the proportion of deaths among HIV-TB co-infected children treated for TB and on ART in a Malawian study 5 (92% had PTB) where 11.05% (123/1113) died, but slightly higher than that of a South African study 7 (74.5% had PTB) where mortality was 4.8%. Another study from the West Indies 20 in children with HIV-TB co-infection (87% had PTB) receiving ATT and on ART, showed a higher mortality figure of 20% compared to the 6.2% in our study.…”

“…Early initiation of ART, within 2-8 weeks of starting ATT in the majority (61.5%) of our patients, may have contributed to the lower mortality in our study. We observed that fewer deaths (5/16, 31.2%) were recorded among children in the study period 2008-2013 when ART was initiated within 2-8 weeks of starting ATT, which was comparable to the Malawian study 5 where fewer deaths (44/225, 19.5%) occurred in children with TB-HIV coinfection initiating ART within 0-2 months of starting ATT. There were fewer children with severe malnutrition (27.1%) in our study and this also could have contributed to the lower mortality.…”

“…In agreement with our study, it is well established that mortality is generally lower in HIV-infected children on ART compared to those not on ART, with or without TB coinfection. 5,21,22 Our lower mortality figure may be attributed to our HIV programme's policy of prompt screening for TB of all children diagnosed with HIV, and followed by the immediate commencement of ATT prior to early initiation of ART. Our sensitivity analysis examined the worst-case scenario where all LTFU patients were considered to have died.…”

“…4 In the African sub-region various risk factors for mortality have been identified in children with TB-HIV co-infection, before or during ART; some of these children had received antituberculosis treatment (ATT) prior to ART initiation while others had not. [4][5][6][7][8][9] However, mortality data including the risk factors for mortality in HIV infected children with pulmonary TB (PTB), being treated for PTB and on ART, are lacking in Nigeria. Such data could be useful in the overall strategy of reducing the morbidity and mortality associated with TB-HIV co-infection in children, not only in Nigeria but also in the African sub-region.…”

Diagnosis and Treatment of Tuberculosis Among Children at an HIV Care Program in Dar es Salaam, Tanzania

“…Consequently, tuberculosis (TB) is a leading cause of morbidity and mortality in HIV-infected patients, including children [2]. Once infected, children are substantially more likely than adults to progress to TB disease [3].…”