ORIGINAL ARTICLE

Short-term mortality and implementation of antiretroviral treatment for critically ill HIV-infected children in a developing country

C Cowburn¹, M Hatherill², B Eley¹, J Nuttall¹, G Hussey¹, L Reynolds², Z Waggie², L Vivian³ and A Argent²

¹ Infectious Diseases Clinic, Red Cross Children’s Hospital and University of Cape Town, Cape Town, South Africa
² Paediatric Intensive Care Unit, Red Cross Children’s Hospital and University of Cape Town, Cape Town, South Africa
³ Primary Health Care Directorate, Red Cross Children’s Hospital and University of Cape Town, Cape Town, South Africa

Correspondence to:
Correspondence to:
Dr C Cowburn
School of Child and Adolescent Health, University of Cape Town, Clinical Investigation Unit S4, Red Cross Children’s Hospital, Klipfontein Road, Cape Town, 7700, South Africa; ccowburn{at}gmail.com

Objective: To describe the short-term outcome of critically ill HIV-infected children with access to highly active antiretroviral therapy (HAART) in a developing region.

Methods: Prospective observational study conducted in a paediatric teaching hospital in Cape Town, South Africa. All children admitted to the paediatric intensive care unit (PICU) with suspected HIV infection were screened. Data are n (%) with 95% confidence intervals.

Results: Sixty eight of 96 HIV antibody-positive children, median age 3 months, were confirmed HIV-infected. Predicted PICU mortality was 0.42. Fifty one children (75%; 95% CI 65 to 85%) survived to PICU discharge, but hospital survival was only 51% (95% CI 40 to 63%). Limitation of intervention (LOI) decisions were a factor in the majority of PICU and ward deaths. Twenty one PICU survivors (31%; 95% CI 20 to 42%) commenced HAART, and two children were already on treatment. Nineteen children (28%) were considered to be established on HAART after 1 month. Thirteen HIV-infected children (19%; 95% CI 10 to 28%), representing 25% (95% CI 14 to 37%) of all PICU survivors, and 68% (95% CI 48 to 89%) of those PICU survivors who were established on HAART remain well on treatment after median 350 days.

Conclusion: The majority of HIV-infected children survived to discharge from PICU, but only half survived to hospital discharge. LOI decisions, usually made in PICU, directly influenced short-term survival and the opportunity to commence HAART. Although few critically ill HIV-infected children survived to become established on HAART, the long-term outcome of children on HAART is encouraging and warrants further investigation.

Abbreviations: CDC, Centers for Disease Control and Prevention; CPR, cardiopulmonary resuscitation; EFV, efavirenz; HAART, highly active antiretroviral therapy; IDC, infectious diseases clinic; LOI, limitation of intervention; LRTI, lower respiratory tract infection; NNRTI, non-nucleoside reverse transcriptase inhibitor; NRTI, nucleoside reverse transcriptase inhibitor; PICU, paediatric intensive care unit; PMTCT, prevention of mother-to-child transmission; SMT, standardised mortality ratio

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