title: An Analysis of the Last Clinical Encounter before Outpatient Mortality among Children with HIV Infection and Exposure in Lilongwe, Malawi.
abstract: BACKGROUND
  Human immunodeficiency virus (HIV) contributes to nearly 20% of all deaths in children under five years of age in Malawi. Expanded coverage of antiretroviral therapy has allowed children to access treatment on an outpatient basis. Little is known about characteristics of the final outpatient encounter prior to mortality in the outpatient setting.
  
  
  METHODS
  This retrospective cohort study assessed clinical factors associated with mortality among HIV-exposed infants and HIV-infected children less than 18 years of age at the Baylor College of Medicine Abbott Fund Children's Center of Excellence in Lilongwe, Malawi. We compared clinical indicators documented from the final outpatient encounter for patients who died in the outpatient setting versus those who were alive after their penultimate clinical encounter.
  
  
  RESULTS
  Of the 8,546 patients who were attended to over a 10-year period at the Baylor Center of Excellence, 851 had died (10%). Of children who died, 392 (46%) were directly admitted to the hospital after their last clinical encounter and died as inpatients. Of the remaining 459 who died as outpatients after their last visit, 53.5% had a World Health Organization (WHO) stage IV condition at their last visit, and 25% had a WHO stage III condition. Multivariate regression analysis demonstrated that poor nutritional status, female gender, shorter time as a patient, more clinical encounters in the prior month, if last visit was an unscheduled sick visit, and if the patient had lost weight since their prior visit independently predicted increased mortality in the outpatient setting after the final clinical encounter.
  
  
  CONCLUSIONS
  Clinical indicators may assist in identifying children with HIV who have increased risk of mortality in the outpatient setting. Recognizing these indicators may aid in identifying HIV-infected children who require a higher level of care or closer follow-up.
authors.affiliation: Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.|Baylor College of Medicine, Houston, Texas, United States of America.
authors.forename: Chris A
authors.initials: CA
authors.lastname: Rees
authors.affiliation: Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.|School of Medicine, University of Colorado, Denver, Colorado, United States of America.|University of North Carolina Project-Malawi, Lilongwe, Malawi.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Flick
authors.affiliation: Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.
authors.forename: David
authors.initials: D
authors.lastname: Sullivan
authors.affiliation: Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.
authors.forename: Menard
authors.initials: M
authors.lastname: Bvumbwe
authors.affiliation: Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.
authors.forename: Joseph
authors.initials: J
authors.lastname: Mhango
authors.affiliation: School of Medicine, University of Colorado, Denver, Colorado, United States of America.
authors.forename: Mina C
authors.initials: MC
authors.lastname: Hosseinipour
authors.affiliation: Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.|Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Houston, Texas, United States of America.
authors.forename: Peter N
authors.initials: PN
authors.lastname: Kazembe
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality*; D006801:Humans; D007223:Infant; D008295:Malawi; D008297:Male; D010045:Outpatients / Q000706:statistics & numerical data*; D011379:Prognosis; D012189:Retrospective Studies
chemical_list: D019380:Anti-HIV Agents