Background: HIV disease has altered the incidence, presentation and outcome of common pediatric childhood illnesses. Although several studies have described the etiology of HIV-associated pneumonia, none have evaluated radiological features or the response to standard WHO treatment in these children.
Aim: We performed a prospective nested sub-study within a larger international trial (A.P.P.I.S) to compare the radiological features and outcome of WHO-defined severe pneumonia among HIV-infected, exposed uninfected children who were randomized to receive parental penicillin or oral amoxicillin in Durban, South Africa.
Methods: Of the four hundred and twenty five children between 2 and 59 months of age with WHO defined severe pneumonia were enrolled into the sub-study; 366 had anonymous HIV testing performed with informed consent and HIV pre-test counseling. These patients were classified as HIV-infected, exposed or uninfected according to HIV Elisa and DNA PCR testing. Outcome was assessed by failure to improve at 48 hours post enrollment or deterioration in clinical features at any point up to 14 days. Chest radiographs were performed on admission and evaluated by independent radiologists according to a combination of WHO defined radiological criteria for pneumonia and internationally standardized radiological criteria. Findings on outcome and radiological features were then stratified for HIV status.
Results: 82 (22.4%) children were HIV-infected, 40 (10.9%) were HIV-exposed and 244 (66.7%) were HIV-uninfected. The day 14 outcome in children below 12 months of age was significantly worse in the HIV-1infected than HIV-uninfected group (OR 2.8, 95% CI 1.35-3.5;p = 0.002). while HIV-1 infected and uninfected children 12 months and above had equivalent outcomes. Both parental penicillin and oral amoxicillin had equivalent response rates in all HIV groups. According to the WHO radiological classification, HIV-uninfected children had significantly higher proportion of “other consolidates/infiltrates” than “end point for consolidation” (p = 0.002) while HIV infected children had similar proportions of these endpoints on admission. Among children who failed WHO standard antimicrobial treatment “other consolidates/infiltrates” were significantly higher than “endpoint for consolidation” in the HIV infected group (OR 5.45 (95% CI 1.58- 21.38) p< 0.002) while the reverse was true for HIV-exposed uninfected children (OR 4.13 (95% CI 0.88- 20.57) p< 0.036).
Interpretation: The WHO standard treatment guideline for severe pneumonia is inadequate for HIV -1 infected infants. The increased prevalence of “other consolidates/infiltrates” among HIV-1 infected children who failed standard treatment would support the prevalence of other non bacterial microbes including Pneumocystis Jirovecii pneumonia and the addition co-trimoxazole to WHO standard treatment may be warranted.
- HIV exposed uninfected children
- HIV infected
- severe pneumonia