© 2009 BMJ Publishing Group & Royal College of Paediatrics and Child Health
Successful paediatric HIV treatment in rural primary care in Africa
Africa Centre for Health & Population Studies, University of KwaZulu-Natal, South Africa
Correspondence to: Ruth M Bland, Africa Centre for Health & Population Studies, University of KwaZulu-Natal, South Africa, PO Box 198, Mtubatuba, KwaZulu-Natal, 3935, South Africa; rbland{at}africacentre.ac.za
Accepted 18 September 2009
Objective: Clinical outcomes of HIV-infected children on antiretroviral treatment (ART) in a decentralized, nurse/counsellor-led programme.
Design: Clinical cohort.
Setting: KwaZulu-Natal, South Africa.
Patients: HIV-infected children aged 
15 years on ART, June 2004-2008
Main outcome measures: Survival according to baseline characteristics including age, WHO clinical stage, haemoglobin, and CD4% was assessed in Kaplan-Meier analyses; hazard ratios for mortality estimated using Cox proportional hazards regression. Changes in laboratory parameters and weight-for-age z-scores (WAZ) after 6-12 months on treatment.
Results: 477 HIV-infected children initiated ART: at a median age of 74 months (range 4-180); median CD4 count (CD4%) 433 cells/mm3 (17%); and median HIV viral load log 4.2 copies/ml; 105 (22%) were on treatment for tuberculosis; and 317 (76.6%) were WHO Stage 3/4. There were significant increases after ART initiation in CD4% (17% vs. 22%; p<0.001), haemoglobin (9.9 vs. 11.7 g/L; p0.001), and albumin (30 vs. 36 g/L; p0.001). 32 (6.7%) children died over 732 child-years of follow-up (43.7 deaths per 1000 child-years; 95% CI, 32.7 - 58.2), 17 (53.1%) within 90 days of treatment initiation; median age of death 84 (IQR 10-181) months. Children with baseline haemoglobin 8g/L were more likely to die (adjusted HR 4.5; 95% CI 1.6 - 12.3), as were those aged <18 months compared to >60 months (adjusted HR 3.2; 95% CI 1.2 - 9.1).
Conclusions: Good clinical outcomes in HIV-infected children on ART are possible in a rural, decentralized service. Few young children are on ART, highlighting the urgent need to identify HIV-exposed infants.
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