title: Despite Access to Antiretrovirals for Prevention and Treatment, High Rates of Mortality Persist Among HIV-infected Infants and Young Children.
abstract: Outcomes of HIV-infected children before widespread use of antiretroviral therapy (ART) for treatment and prevention of mother-to-child transmission (PMTCT) have been well characterized but less is known about children who acquire HIV infection in the context of good ART access.
  
  
  
  We enrolled newly diagnosed HIV-infected children ≤24 months of age at 3 hospitals and 2 clinics in Johannesburg, South Africa. We report ART initiation and mortality rates during 6 months from enrollment and factors associated with mortality.
  
  
  
  Of 272 children enrolled, median age 6.1 months, 69.5% were diagnosed during hospitalization. By 6 months postenrollment, 53 (19.5%) died and 73 (26.8%) were lost-to-follow-up. Using Kaplan-Meier analysis, the probability of death by 6 months after enrollment was 23.5%. The median age of death was 9.1 months [95% confidence interval (CI): 8.6-12.0]. Overall, 226 (83%) children initiated ART which was associated with a 71% reduction in risk of death [hazard ratio (HR) = 0.29 (95% CI: 0.15-0.58)]. In multivariable analysis of infant factors, weight-for-age Z score < -2 standard deviation (SD) [HR = 2.43 (95% CI: 1.03-5.73)], CD4 <20% [HR = 3.29 (95% CI: 1.60-6.76)] and identification during hospitalization [HR = 2.89 (95% CI: 1.16-7.25)] were independently associated with mortality. In multivariable analysis of maternal factors, CD4 ≤350/no maternal ART was associated with increased mortality risk [HR = 2.57 (95% CI: 1.19-5.59)] versus CD4 >350/no maternal ART; exposure to maternal/infant antiretrovirals for PMTCT was associated with reduced mortality risk [HR = 0.53 (95% CI: 0.28-0.99)] versus no PMTCT.
  
  
  
  ART initiation is highly protective against death in young children. However, despite improved access to ART, young children remain at risk for early death; innovative approaches to rapidly diagnose and initiate treatment as early in life as possible are needed.
authors.affiliation: From the *ICAP, Mailman School of Public Health, †Department of Epidemiology, Mailman School of Public Health, and ‡Department of Pediatrics, College of Physicians & Surgeons, Columbia University, New York, New York; §Empilweni Services and Research Unit, Department of Pediatrics and Child Health, Rahima Moosa Mother and Child Hospital, and ¶Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; and ‖Sergeivsky Center, College of Physicians & Surgeons, Columbia University, New York, New York.
authors.forename: Elaine J
authors.initials: EJ
authors.lastname: Abrams
authors.forename: Selamawit
authors.initials: S
authors.lastname: Woldesenbet
authors.forename: Juliana
authors.initials: J
authors.lastname: Soares Silva
authors.forename: Ashraf
authors.initials: A
authors.lastname: Coovadia
authors.forename: Viviane
authors.initials: V
authors.lastname: Black
authors.forename: Karl-Günter
authors.initials: KG
authors.lastname: Technau
authors.forename: Louise
authors.initials: L
authors.lastname: Kuhn
mesh_terms: D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000401:mortality*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D012307:Risk Factors; D013019:South Africa / Q000453:epidemiology; D016019:Survival Analysis
chemical_list: D044966:Anti-Retroviral Agents