title: Risk factors associated with increased mortality among HIV infected children initiating antiretroviral therapy (ART) in South Africa.
abstract: OBJECTIVE
  To identify demographic and clinical risk factors associated with mortality after initiation of antiretroviral therapy (ART) in a cohort of human immunodeficiency (HIV) infected children in KwaZulu-Natal, South Africa.
  
  
  METHODS
  We performed a retrospective cohort study of 537 children initiating antiretroviral therapy at McCord Hospital in KwaZulu-Natal, South Africa. Data were extracted from electronic medical records and risk factors associated with mortality were assessed using Cox regression analysis.
  
  
  RESULTS
  Overall there were 47 deaths from the cohort of 537 children initiating ART with over 991 child-years of follow-up (median 22 months on ART), yielding a mortality rate of 4.7 deaths per 100 child years on ART. Univariate analysis indicated that mortality was significantly associated with lower weight-for-age Z-score (p<0.0001), chronic diarrhea (p = 0.0002), lower hemoglobin (p = 0.002), age <3 years (p = 0.003), and CD4% <10% (p = 0.005). The final multivariable Cox proportional hazards mortality model found age less than 3 years (p = 0.004), CD4 <10% (p = 0.01), chronic diarrhea (p = 0.03), weight-for-age Z-score (<0.0001) and female gender as a covariate varying with time (p = 0.03) all significantly associated with mortality.
  
  
  CONCLUSIONS
  In addition to recognized risk factors such as young age and advanced immunosuppression, we found female gender to be significantly associated with mortality in this pediatric ART cohort. Future studies are needed to determine whether intrinsic biologic differences or socio-cultural factors place female children with HIV at increased risk of death following initiation of ART.
authors.affiliation: The Ragon Institute of Massachusetts General Hospital, Charlestown, Massachusetts, United States of America.
authors.forename: Brian C
authors.initials: BC
authors.lastname: Zanoni
authors.forename: Thuli
authors.initials: T
authors.lastname: Phungula
authors.forename: Holly M
authors.initials: HM
authors.lastname: Zanoni
authors.forename: Holly
authors.initials: H
authors.lastname: France
authors.forename: Margaret E
authors.initials: ME
authors.lastname: Feeney
mesh_terms: D000293:Adolescent; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000401:mortality*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D057286:Electronic Health Records; D005260:Female; D005500:Follow-Up Studies; D006678:HIV / Q000187:drug effects / Q000472:pathogenicity*; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality* / Q000821:virology; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D013019:South Africa; D059039:Standard of Care; D015996:Survival Rate; D016896:Treatment Outcome
chemical_list: D019380:Anti-HIV Agents