Routine inpatient provider-initiated HIV testing in Malawi, compared with client-initiated community-based testing, identifies younger children at higher risk of early mortality.
OBJECTIVE
To determine how routine inpatient provider-initiated HIV testing differs from traditional community-based client-initiated testing with respect to clinical characteristics of children identified and outcomes of outpatient HIV care.


METHODS
Prospective observational cohort.


METHODS
Routine clinical data were collected from children identified as HIV-infected by either testing modality in Lilongwe, Malawi, in 2008. After 1 year of outpatient HIV care at the Baylor College of Medicine Clinical Center of Excellence, outcomes were assessed.


RESULTS
Of 742 newly identified HIV-infected children enrolling into outpatient HIV care, 20.9% were identified by routine inpatient HIV testing. Compared with community-identified children, hospital-identified patients were younger (median 25.0 vs 53.5 months), with more severe disease (22.2% vs 7.8% WHO stage IV). Of 466 children with known outcomes, 15.0% died within the first year of HIV care; median time to death was 15.0 weeks for community-identified children vs 6.0 weeks for hospital-identified children. The strongest predictors of early mortality were severe malnutrition (hazard ratio, 4.3; 95% confidence interval, 2.2-8.3), moderate malnutrition (hazard ratio, 3.2; confidence interval, 1.6-6.6), age < 12 months (hazard ratio, 3.2; 95% confidence interval, 1.4-7.2), age 12 to 24 months (hazard ratio, 2.5; 95% confidence interval, 1.1-5.7), and WHO stage IV (hazard ratio, 2.2; 95% confidence interval, 1.1-4.6). After controlling for other variables, hospital identification did not independently predict mortality.


CONCLUSIONS
Routine inpatient HIV testing identifies a subset of younger HIV-infected children with more severe, rapidly progressing disease that traditional community-based testing modalities are currently missing.
Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX 77030, USA. gp147834@bcm.edu
Geoffrey A
GA
Preidis
Eric D
ED
McCollum
William
W
Kamiyango
Alejandro
A
Garbino
Mina C
MC
Hosseinipour
Peter N
PN
Kazembe
Gordon E
GE
Schutze
Mark W
MW
Kline
D015492:AIDS Serodiagnosis; D000553:Ambulatory Care; D002648:Child; D002675:Child, Preschool; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000401:mortality*; D006776:Hospitals, Pediatric; D006801:Humans; D007297:Inpatients; D008295:Malawi; D008297:Male; D044342:Malnutrition / Q000150:complications / Q000401:mortality; D008403:Mass Screening / Q000379:methods*; D011446:Prospective Studies; D012307:Risk Factors