- Email: [email protected]
AIDS: A Five-Year Experience in a Tertiary Hospital
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Pattern of Pediatric HIV/AIDS: A Five-Year Experience in a Tertiary Hospital Ben Onankpa, MBBS, FWACP; Lydia Airede, MBBS, FWACS; Ibitoye Paul, MBBS; and Idowu Dorcas, MLS
Objectives: to determine the mode of transmission, clinical presentation and the outcome in children with HIV/AIDS at the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria. Methodology: a five-year retrospective study of children with HIV/AIDS from January 2001 to December 2005. Screening was based on World Health Organization criteria. Confirmation of HIV seropositivity was from a positive ELISA and then a western blot assay. Results: 10,107 children were admitted over the said fiveyear period; 1,359 died, giving a mortality rate of 13.5%. Eight-hundred-forty (8.3%) of the admitted children had HIV/AIDS; 305 (36.3%) died. Mother-to-child transmission accounted for the highest mode of transmission, 794(94.5%). There were 44 (5.3%) cases of unidentified route of infection and two (0.2 %) cases of sexual abuse in males aged 11 and 13 years. Fever (81.3%), diarrhea (75.0%), vomiting (41.4%), difficulty in breathing (39.8%) and refusal of feeds (39.8%) were the commonly encountered clinical features. Septicemia (49.5%) and acute respiratory tract infections (40.9%) were the major admitting diagnoses and major causes of deaths. Deaths from HIV infection accounted for 22.4% of the total deaths for the study period. Conclusions: Mother-to-child transmission of HIV is still high in the area of study, and pediatric HIV/AIDS remains a significant cause of childhood morbidity and mortality. Present efforts to strengthen and sustain prevention of mother to child transmission are highly encouraged. Advocacy for protection of children against sexual abuse should be strengthened. Key words: children/adolescents n HIV/AIDS n clinical evaluation n Nigeria © 2008. From the Department of Paediatrics, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Sokoto State, Nigeria. Send correspondence and reprint requests for J Natl Med Assoc. 2008;100:821–825 to: Dr. Ben Onankpa, Department of Paediatrics, Usmanu Danfodiyo University Teaching Hospital, PMB 2370, Sokoto, Sokoto State, Nigeria; e-mail: [email protected]
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Introduction
T
he prevalence of HIV infection in Nigeria rose consistently until 2003, when it showed a slight decrease (i.e., from 1.8% in 1991 to 5.8% in 2002. The seroprevalence for 2003 was 5.0%, while that of 2005 was 4.4%. Nigeria has the third largest number of people living with HIV worldwide, with about 3 million Nigerians infected.1-4 Prevalence of HIV infection among pregnant women visiting an antenatal clinic is about 4.4% with mother-to-child transmission of 10%.5 An estimated 100,000 HIV-infected infants are born each year.3-5 More than 1.2 million children have been orphaned in Nigeria since the beginning of the epidemic, the highest for any country globally.3,5 HIV infection in Nigeria, therefore, remains a significant cause of childhood morbidity and mortality either in combination with other illnesses or alone. This is more so as the progression occurs more rapidly in infected newborns than in adults.2 Hospital admissions among children with HIV infection vary from 1.5–29% of hospitalized children in Africa.6-8 Morbidities frequently seen among the children include acute respiratory tract infections, diarrhea diseases, malnutrition, anemia, malaria and meningitis.6,8,9 Mortalities among HIV-infected children in sub-Saharan Africa, including Nigeria, are significantly high. The frequent causes include the triad of diarrhea diseases, acute respiratory tract infections/pneumonias and malnutrition.6,9,10 There is, therefore, the need for further and regular information on HIV/AIDS from the sub-Saharan African in order to curb this monster. The objective of this paper is therefore to determine the pattern of admission of children that presented with HIV/AIDS, their clinical presentations and outcomes in Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria.
Patients and Methods
This retrospective study was carried out at UDUTH over a five-year period, from January 1, 2001 to December 31, 2005. Sokoto State is located in the northwestern part of Nigeria with a population of 3.4 million people. VOL. 100, NO. 7, JULY 2008 821
Pattern of Pediatric HIV/AIDS; a Five-Year Experience
The hospital has a 500-bed space and an annual delivery rate of approximately 2,200 babies. In addition to its tertiary functions, the hospital offers secondary services and clientele extends to the neighboring states of Zamfara, Kebbi, Katsina and Niger. Patients do come from the neighboring country of Niger republic. The study populations included infants/children aged 5 weeks to 13 years with HIV/AIDS admitted to the pediatric wards (exclusive of the neonatal ward) of UDUTH over a five-year period. The following information was obtained from their hospital case notes; sociodemographic data, clinical history/features, diagnosis and outcome. All the study subjects were positive for HIV, and the screening was done based on World Health Organization (WHO) clinical criteria.11 Using the manufacturer’s specifications for procedures, all subjects were screened for HIV infection using the ELISA method with Vironostika reagent kit (Organon Teknika, Boxtel). The confirmation test was by western blot for those who were reactive for the screening test. A reactive ELISA with a confirmatory western blot assay was taken as seropositivity for HIV in the study subjects. Assay for viral antigens is not available in the study center; therefore, children <18 months of age (possible presence of maternal antigens to HIV)11,12 were diagnosed based on a combi-
nation of positive HIV antibody test and WHO clinical criteria.11 The findings were presented as simple percentages and frequencies. Chi-squared test, where appropriate, was used for the statistical analysis.
Results
A total number of 10,107 children were admitted into the pediatric wards within the study period of five years. There were 6,121 (60.6%) males and 3,986 (39.4%) females, giving a male:female ratio of 1.5:1. Of the admitted children, 1,359 died (mortality rate of 13.5%); and 840 of the admitted children had HIV infection, accounting for 8.3% of the total admissions. Of the children with HIV/AIDS, there were 438 (52.1%) males and 402 (47.9%) females for a male:female ratio of 1.1:1 (Table 1). Whereas females constituted only 39.4% of all admitted patients, they constituted a significant percentage (49.7%) of HIV cases (c2=22.54, p= 0-0000021). The children admitted with HIV infection were all aged 5 weeks to <13 years with mean [standard deviation (SD)] 15.6 months (25.74). The mothers of 37 (4.4%) subjects were already known to be seropositive for HIV. All the subjects were positive for HIV-1 infection. There were no observed cases of mixed infection or that of HIV-2 infection alone.
Table 1. Age and gender distribution of 840 infants/children with HIV/AIDS Age <1 year ≥1 to <3 years ≥3 to <5 years ≥5 years
Male (%) 74 (46.0) 301 (54.5) 54 (51.4) 9 (40.9)
Gender Female (%) Total 87 (54.0) 161 251 (45.5) 552 51 (48.6) 105 13 (59.1) 22
Total
438
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840
Table 2. Route of transmission of HIV in 840 infants/children Route Mother to child Unidentified route Homosexuality Total
Frequency 794 44 2 840
Percentage 94.5 5.3 0.2 100
Table 3. Clinical features of HIV/AIDS—presenting complaints and signs (n=840) Presenting Complaints Fever Diarrhea Vomiting Difficulty in breathing Refusal of feeds Weight loss Jaundice
Frequency (%) Clinical Signs 680 (81.3) Anemia 630 (75.0) Fever 348 (41.4) Crepitations in lung fields 326 (38.8) Oral thrush 323 (38.5) Hepatomegaly 223 (26.6) Skin lesions 59 (7.0) Others
822 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Frequency (%) 630 (75.0) 611 (72.7) 584 (69.5) 564 (67.2) 473 (56.3) 223 (26.6) 122 (14.5)
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Pattern of Pediatric HIV/AIDS; a Five-Year Experience
Mother-to-child transmission accounted for the highest presumed mode of transmission (i.e., the 794 (94.5%) mothers that were seropositive for HIV infection). There were 44 (5.3%) cases of unidentified route of infection and two (0.2%) cases of homosexuality in males aged 11–13 years (Table 2). Percentage weights for age were used to assess the nutritional status of the children on admission; those with <60% of their percentage weight for age were 353 (42.02%), 60–80%: 169 (20.12%), 80–100%: 274 (32.62%) and >100%: 44 (5.24%) (p>0.05). Three-hundred-eighty-one (45.40%) of the subjects had weights <80% expected for age. Seven-hundred-ninety-four mothers (94.5%) of the 840 subjects were positive, and 46 (5.5%) were negative for the HIV infection. There were 15 discordant couples with all the mothers positive, while the all fathers were negative. The parents were all within childbearing age: the mothers were aged 15–43 years and the fathers 27– 55 years. Three-hundred-seventy-eight (45.0%) of the study subjects were delivered to primigravidas. Second birth orders were 268 (31.91%), while third birth orders and above were 194 (23.09%). The observed clinical features in the study subjects
were presenting complaints of fever (81.3%), diarrhea (75.0%), vomiting (41.4%), difficulty in breathing (39.8%) and refusal of feeds (39.8%) (Table 3). The clinical signs were anemia (75.0%), fever (65.6%), crepitations in lung fields (69.5%), oral thrush (67.2%) and hepatomegaly (56.3%) (Table 3). Other clinical features include convulsions, skin lesions and failure to thrive. Respiratory tract infections (59.4%) and septicemia (31.6%) were the major admitting diagnoses (Table 4). Blood cultures were positive for Streptococcus pneumoniae and Hemophilus influenzae type b in 19 (2.3%) and 14 (1.7%) of study subjects, respectively; others were sterile. Bronchial larvage/sputum induction was not performed. Abdominal ultrasonography revealed biliary atresia in a five-week-old infant who presented with refusal of feeds and severe jaundice but died within 72 hours of admission. Three-hundred-five (36.3%) of the study subjects died as a result of severe lower respiratory tract infections, and septicemia accounted for >90% of the total deaths in children admitted with HIV infection—49.5% and 40.9% respectively. Though there was no significant statistical difference (p>0.05), among deaths in the different age groups, more deaths (73.5%) were recorded in children
Table 4. Identified pathological conditions observed in infants/children with HIV/AIDS (n=840) Diagnosis Pneumonias Septicemia Failure to thrive Urinary tract infections Malaria Biliary atresia Total
Frequency (%) Deaths (%) 499 (59.4) 150 (49.5) 265 (31.6) 125 (40.9) 59 (7.0) 20 (6.4) 9 (1.1) 7 (0.8) 7 (2.2) 1 (0.1) 1 (0.3) 840 (100) 305 (100)
Table 5. Age at presentation of 840 infants/children with HIV/AIDS and their outcome Age Alive (%) Dead (%) SAMA (%) Total <1 year 92 (57.1) 59 (36.7) 10 (6.2) 161 ≥1 to <3 years 332 (60.1) 203 (36.8) 17 (3.1) 552 ≥3 to <5 years 69 (55.7) 36 (34.3) 105 ≥5 years 13 (59.1) 7 (31.8) 2 (9.1) 22 Total
506
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SAMA: Signed against medical advice
Table 6. Percentage weight for age on admission and outcome in infants/children admitted with HIV/ AIDS (n=840) Percentage <60% 60–80% 80–100% >100% Total
Weight for Age (n) 353 169 274 44 840
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Mortality n (%) 269 (32.0) 23 (2.8) 13 (1.5) 0 (0.0) 305 (36.3)
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Pattern of Pediatric HIV/AIDS; a Five-Year Experience
aged <3 years (Table 5). Case fatality among the children using their percentage weights for age showed a linear relationship. In other words, the lower the percentage weights for age, the higher the mortality (Table 6). Children whose percentage weights for age were <60% had higher mortality, accounting for >80% of the deaths. Twenty-nine children were taken away by their parents after they had signed against medical advice; hence, their outcome was difficult to determine.
Discussion
Pediatric HIV/AIDS accounted for one-fifth of deaths among children (22.4%) at the UDUTH within the study period of five years. HIV/AIDS, therefore, still remains a significant cause of morbidity and mortality among children in Sokoto despite the recent and the relatively low seropositive report.1,5 The admission rate was 8.3% for pediatric HIV/AIDS. This is higher than a recent report from Abuja, Nigeria,13 but in keeping with reports of 8–29% from other parts of Africa.7,8 Reasons for the increase in admission rate may include increasing index of suspicion by pediatricians, availability of pediatric antiretroviral drugs and medical care.5 There is also an increased mother-to-child transmission that resulted from increasing prevalence of HIV infection in Nigeria.1,3,5 Vertical transmission is the commonest reported route of transmission of HIV in children worldwide.1,3,7 In our study, this route accounted for >90% of HIV infection in preschool-age children with HIV. There is the need, therefore, to strengthen the genuine call by concerned stakeholders for an efficient and sustainable program for the prevention of mother-to-child transmission. The majority of the mothers did not know their HIV serostatus prior to the admission of their children with HIV infection. At screening, >90% of the mothers were positive and <6% negative for the infection. However, 37 mothers were already aware of their HIV seropositive status. There were 15 discordant couples, with all the mothers positive and the fathers negative. We are aware of the negative consequences of HIV discordance in a family. This had led to breakdown of most marriages with the children left without continued care and support.12 The men may abandon their wives and/or children, a major threat to the care of the very young children and the old members of the families. All the parents were within childbearing age and are also in the economically productive age group. This is worrisome, particularly as it has a direct negative effect on economy of the families, communities and the nation at large. There is, therefore, the need for existing measures, including voluntary counseling and testing, for adults and also provision of the needed care and support to be strengthened. The birth order in our study was as observed in a previous study.13 with first and second children more affected. 824 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
HIV infection from either unscreened blood or blood from donors during the window period, though not observed in this study, has occurred in many individuals, especially in developing countries.2,4,6 It is therefore pertinent that blood and blood products be properly screened before transfusion and transfused only when it becomes very necessary. Previous reports from Africa had put respiratory tract infections at 85% cause of morbidity and mortality among children with HIV/AIDS.6,10,11,14 This was reflected in our study with pneumonias, accounting for about 60% and 50% of admissions and deaths, respectively. It was difficult to identify the causative agent(s) of pneumonia in all our study subjects, but, the 33 positive blood cultures and raised white blood cell counts with neutrophilia in the other patients strongly suggest bacterial infections. There was no diagnosis of pulmonary tuberculosis made in any of the studied children. This we have attributed to the usual difficulty encountered in the diagnosis of pulmonary tuberculosis in children in centers with low resource. More deaths occurred in children aged <3 years in our study. This is similar to previous works done within the country.6,13,15 This age group also had poor nutritional status with low percentage weights for age, further predisposing them to infections.10,13,15,16 Therefore, efforts aimed at reducing infections (a leading cause of morbidity and mortality) in them, including improved socioeconomic status, nutritional status and routine immunization, should be encouraged. Pediatric HIV/AIDS remains a major contributor to childhood morbidity and mortality. We therefore ask for improvement and sustenance of the government’s and other stakeholder’s laudable efforts/measures such as a program for the prevention of mother-to-child transmission. There is also the need to strengthen the advocacy for the protection of children against sexual abuse and for reduction in adult HIV infection rates. The present free antiretroviral drugs provided by the Nigerian government and other stakeholders for children with HIV/ AIDS should be sustained.
References
1. Nigeria Epidemiological fact sheets on HIV/AIDS and sexually transmitted infections. (2002): update fact sheet 01/01/02 UNAIDS, UNICEF, World Health Organization. 2. Wiktor SZ, Ekpini E, Nduati RW. Prevention of mother-to-child transmission of HIV-1 in Africa. AIDS. 1997;11(suppl B):S79-S87. 3. Global summary of the HIV and AIDS Epidemic update.UNAIDS/WHO epidemic update; December 2005. 4. Joint United Nations Programme on AIDS/HIV (UNAIDS). AIDS epidemic update/report. Dec 2000.www unaids.org/epidemic update/report dec 00/index dec. html. Accessed 08/01/01. 5. 2003 National HIV sero prevalence sentinels Survey, Technical report by The Federal Ministry of Health, Nigeria, 2004. 6. Angyo TM, Okpeh ES, Onah J. Paediatric AIDS in Jos, Nigeria. West Afri J Med. 1998;17(4):268-272. 7. Hashim MS, Salih MA, El Ha AA, et al. AIDS and HIV infection in Sudanese children: a clinical and epidemiological study, AIDS patient care. Sex
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Pattern of Pediatric HIV/AIDS; a Five-Year Experience Transm Dis. 1997;11:331-337. 8. Yeung S, Wilkinson D, Escott S, et al. Paediatirc HIV infection in a rural South African district hospital. Trop Pediatr. 2000;46(2):107-110. 9. Emordi U, Okafor GO. Clinical manifestations of HIV infection in children at Enugu, Nigeria. J Trop Pediatr. 1998;44:73-76. 10. Taha ET, Graham SM, Kumwenda NI, et al. Morbidity among Human Immunodeficiency Virus - l - infected and uninfected African children. Pediatrics. 2000;106(6): e 77-79. 11. World Health Organization. Acquired Immunodeficiency Syndrome (AIDS) WHO/CDC case definition for AIDS. Weekly Epidemiol Rec. 1986;61:69-73. 12. Oniyangi O, Awani B, Iregbu KC. The pattern of paediatric HIV/AIDS as seen at the National Hospital Abuja, Nigeria. Nig J Clinical Pract.
2006;9:147-152. 13. Greenberg AE, Dabis F, Marum LH, et al. HIV infection in Africa. In: Pazzo PA, Wilfert CM III, eds. Paediatric AIDS. The challenge of HIV in infants, children and adolescent. Lippiincott: Williams and Wilkins; 2000:23-24. 14. Salami AK, Olubayo PO. Hospital Prevalence of PTB and co-infection with HIV infection in Ilorin. A review of nine years. West AfriJ Med. 2002;21:24-27. 15. Akpede GO Arube JP, Rabasa AI, et al. Presentation and outcome of HIV-l infection in hospitalized infants and other children in North-Eastern Nigeria. East Afr Med J. 1997;74:21-27. 16. Angyo IA, Amali-Adikwu, Okpeh ES. Protein-Energy Malnutrition and Human Immunodeficiency Virus infection in Children in Jos. Nig J Paedtr. 1998;25:64-67. n
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Pattern of Pediatric HIV/AIDS: A Five-Year Experience in a Tertiary Hospital Ben Onankpa, MBBS, FWACP; Lydia Airede, MBBS, FWACS; Ibitoye Paul, MBBS; and Idowu Dorcas, MLS
Objectives: to determine the mode of transmission, clinical presentation and the outcome in children with HIV/AIDS at the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria. Methodology: a five-year retrospective study of children with HIV/AIDS from January 2001 to December 2005. Screening was based on World Health Organization criteria. Confirmation of HIV seropositivity was from a positive ELISA and then a western blot assay. Results: 10,107 children were admitted over the said fiveyear period; 1,359 died, giving a mortality rate of 13.5%. Eight-hundred-forty (8.3%) of the admitted children had HIV/AIDS; 305 (36.3%) died. Mother-to-child transmission accounted for the highest mode of transmission, 794(94.5%). There were 44 (5.3%) cases of unidentified route of infection and two (0.2 %) cases of sexual abuse in males aged 11 and 13 years. Fever (81.3%), diarrhea (75.0%), vomiting (41.4%), difficulty in breathing (39.8%) and refusal of feeds (39.8%) were the commonly encountered clinical features. Septicemia (49.5%) and acute respiratory tract infections (40.9%) were the major admitting diagnoses and major causes of deaths. Deaths from HIV infection accounted for 22.4% of the total deaths for the study period. Conclusions: Mother-to-child transmission of HIV is still high in the area of study, and pediatric HIV/AIDS remains a significant cause of childhood morbidity and mortality. Present efforts to strengthen and sustain prevention of mother to child transmission are highly encouraged. Advocacy for protection of children against sexual abuse should be strengthened. Key words: children/adolescents n HIV/AIDS n clinical evaluation n Nigeria © 2008. From the Department of Paediatrics, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Sokoto State, Nigeria. Send correspondence and reprint requests for J Natl Med Assoc. 2008;100:821–825 to: Dr. Ben Onankpa, Department of Paediatrics, Usmanu Danfodiyo University Teaching Hospital, PMB 2370, Sokoto, Sokoto State, Nigeria; e-mail: [email protected]
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Introduction
T
he prevalence of HIV infection in Nigeria rose consistently until 2003, when it showed a slight decrease (i.e., from 1.8% in 1991 to 5.8% in 2002. The seroprevalence for 2003 was 5.0%, while that of 2005 was 4.4%. Nigeria has the third largest number of people living with HIV worldwide, with about 3 million Nigerians infected.1-4 Prevalence of HIV infection among pregnant women visiting an antenatal clinic is about 4.4% with mother-to-child transmission of 10%.5 An estimated 100,000 HIV-infected infants are born each year.3-5 More than 1.2 million children have been orphaned in Nigeria since the beginning of the epidemic, the highest for any country globally.3,5 HIV infection in Nigeria, therefore, remains a significant cause of childhood morbidity and mortality either in combination with other illnesses or alone. This is more so as the progression occurs more rapidly in infected newborns than in adults.2 Hospital admissions among children with HIV infection vary from 1.5–29% of hospitalized children in Africa.6-8 Morbidities frequently seen among the children include acute respiratory tract infections, diarrhea diseases, malnutrition, anemia, malaria and meningitis.6,8,9 Mortalities among HIV-infected children in sub-Saharan Africa, including Nigeria, are significantly high. The frequent causes include the triad of diarrhea diseases, acute respiratory tract infections/pneumonias and malnutrition.6,9,10 There is, therefore, the need for further and regular information on HIV/AIDS from the sub-Saharan African in order to curb this monster. The objective of this paper is therefore to determine the pattern of admission of children that presented with HIV/AIDS, their clinical presentations and outcomes in Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria.
Patients and Methods
This retrospective study was carried out at UDUTH over a five-year period, from January 1, 2001 to December 31, 2005. Sokoto State is located in the northwestern part of Nigeria with a population of 3.4 million people. VOL. 100, NO. 7, JULY 2008 821
Pattern of Pediatric HIV/AIDS; a Five-Year Experience
The hospital has a 500-bed space and an annual delivery rate of approximately 2,200 babies. In addition to its tertiary functions, the hospital offers secondary services and clientele extends to the neighboring states of Zamfara, Kebbi, Katsina and Niger. Patients do come from the neighboring country of Niger republic. The study populations included infants/children aged 5 weeks to 13 years with HIV/AIDS admitted to the pediatric wards (exclusive of the neonatal ward) of UDUTH over a five-year period. The following information was obtained from their hospital case notes; sociodemographic data, clinical history/features, diagnosis and outcome. All the study subjects were positive for HIV, and the screening was done based on World Health Organization (WHO) clinical criteria.11 Using the manufacturer’s specifications for procedures, all subjects were screened for HIV infection using the ELISA method with Vironostika reagent kit (Organon Teknika, Boxtel). The confirmation test was by western blot for those who were reactive for the screening test. A reactive ELISA with a confirmatory western blot assay was taken as seropositivity for HIV in the study subjects. Assay for viral antigens is not available in the study center; therefore, children <18 months of age (possible presence of maternal antigens to HIV)11,12 were diagnosed based on a combi-
nation of positive HIV antibody test and WHO clinical criteria.11 The findings were presented as simple percentages and frequencies. Chi-squared test, where appropriate, was used for the statistical analysis.
Results
A total number of 10,107 children were admitted into the pediatric wards within the study period of five years. There were 6,121 (60.6%) males and 3,986 (39.4%) females, giving a male:female ratio of 1.5:1. Of the admitted children, 1,359 died (mortality rate of 13.5%); and 840 of the admitted children had HIV infection, accounting for 8.3% of the total admissions. Of the children with HIV/AIDS, there were 438 (52.1%) males and 402 (47.9%) females for a male:female ratio of 1.1:1 (Table 1). Whereas females constituted only 39.4% of all admitted patients, they constituted a significant percentage (49.7%) of HIV cases (c2=22.54, p= 0-0000021). The children admitted with HIV infection were all aged 5 weeks to <13 years with mean [standard deviation (SD)] 15.6 months (25.74). The mothers of 37 (4.4%) subjects were already known to be seropositive for HIV. All the subjects were positive for HIV-1 infection. There were no observed cases of mixed infection or that of HIV-2 infection alone.
Table 1. Age and gender distribution of 840 infants/children with HIV/AIDS Age <1 year ≥1 to <3 years ≥3 to <5 years ≥5 years
Male (%) 74 (46.0) 301 (54.5) 54 (51.4) 9 (40.9)
Gender Female (%) Total 87 (54.0) 161 251 (45.5) 552 51 (48.6) 105 13 (59.1) 22
Total
438
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Table 2. Route of transmission of HIV in 840 infants/children Route Mother to child Unidentified route Homosexuality Total
Frequency 794 44 2 840
Percentage 94.5 5.3 0.2 100
Table 3. Clinical features of HIV/AIDS—presenting complaints and signs (n=840) Presenting Complaints Fever Diarrhea Vomiting Difficulty in breathing Refusal of feeds Weight loss Jaundice
Frequency (%) Clinical Signs 680 (81.3) Anemia 630 (75.0) Fever 348 (41.4) Crepitations in lung fields 326 (38.8) Oral thrush 323 (38.5) Hepatomegaly 223 (26.6) Skin lesions 59 (7.0) Others
822 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Frequency (%) 630 (75.0) 611 (72.7) 584 (69.5) 564 (67.2) 473 (56.3) 223 (26.6) 122 (14.5)
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Mother-to-child transmission accounted for the highest presumed mode of transmission (i.e., the 794 (94.5%) mothers that were seropositive for HIV infection). There were 44 (5.3%) cases of unidentified route of infection and two (0.2%) cases of homosexuality in males aged 11–13 years (Table 2). Percentage weights for age were used to assess the nutritional status of the children on admission; those with <60% of their percentage weight for age were 353 (42.02%), 60–80%: 169 (20.12%), 80–100%: 274 (32.62%) and >100%: 44 (5.24%) (p>0.05). Three-hundred-eighty-one (45.40%) of the subjects had weights <80% expected for age. Seven-hundred-ninety-four mothers (94.5%) of the 840 subjects were positive, and 46 (5.5%) were negative for the HIV infection. There were 15 discordant couples with all the mothers positive, while the all fathers were negative. The parents were all within childbearing age: the mothers were aged 15–43 years and the fathers 27– 55 years. Three-hundred-seventy-eight (45.0%) of the study subjects were delivered to primigravidas. Second birth orders were 268 (31.91%), while third birth orders and above were 194 (23.09%). The observed clinical features in the study subjects
were presenting complaints of fever (81.3%), diarrhea (75.0%), vomiting (41.4%), difficulty in breathing (39.8%) and refusal of feeds (39.8%) (Table 3). The clinical signs were anemia (75.0%), fever (65.6%), crepitations in lung fields (69.5%), oral thrush (67.2%) and hepatomegaly (56.3%) (Table 3). Other clinical features include convulsions, skin lesions and failure to thrive. Respiratory tract infections (59.4%) and septicemia (31.6%) were the major admitting diagnoses (Table 4). Blood cultures were positive for Streptococcus pneumoniae and Hemophilus influenzae type b in 19 (2.3%) and 14 (1.7%) of study subjects, respectively; others were sterile. Bronchial larvage/sputum induction was not performed. Abdominal ultrasonography revealed biliary atresia in a five-week-old infant who presented with refusal of feeds and severe jaundice but died within 72 hours of admission. Three-hundred-five (36.3%) of the study subjects died as a result of severe lower respiratory tract infections, and septicemia accounted for >90% of the total deaths in children admitted with HIV infection—49.5% and 40.9% respectively. Though there was no significant statistical difference (p>0.05), among deaths in the different age groups, more deaths (73.5%) were recorded in children
Table 4. Identified pathological conditions observed in infants/children with HIV/AIDS (n=840) Diagnosis Pneumonias Septicemia Failure to thrive Urinary tract infections Malaria Biliary atresia Total
Frequency (%) Deaths (%) 499 (59.4) 150 (49.5) 265 (31.6) 125 (40.9) 59 (7.0) 20 (6.4) 9 (1.1) 7 (0.8) 7 (2.2) 1 (0.1) 1 (0.3) 840 (100) 305 (100)
Table 5. Age at presentation of 840 infants/children with HIV/AIDS and their outcome Age Alive (%) Dead (%) SAMA (%) Total <1 year 92 (57.1) 59 (36.7) 10 (6.2) 161 ≥1 to <3 years 332 (60.1) 203 (36.8) 17 (3.1) 552 ≥3 to <5 years 69 (55.7) 36 (34.3) 105 ≥5 years 13 (59.1) 7 (31.8) 2 (9.1) 22 Total
506
305
29
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SAMA: Signed against medical advice
Table 6. Percentage weight for age on admission and outcome in infants/children admitted with HIV/ AIDS (n=840) Percentage <60% 60–80% 80–100% >100% Total
Weight for Age (n) 353 169 274 44 840
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Mortality n (%) 269 (32.0) 23 (2.8) 13 (1.5) 0 (0.0) 305 (36.3)
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Pattern of Pediatric HIV/AIDS; a Five-Year Experience
aged <3 years (Table 5). Case fatality among the children using their percentage weights for age showed a linear relationship. In other words, the lower the percentage weights for age, the higher the mortality (Table 6). Children whose percentage weights for age were <60% had higher mortality, accounting for >80% of the deaths. Twenty-nine children were taken away by their parents after they had signed against medical advice; hence, their outcome was difficult to determine.
Discussion
Pediatric HIV/AIDS accounted for one-fifth of deaths among children (22.4%) at the UDUTH within the study period of five years. HIV/AIDS, therefore, still remains a significant cause of morbidity and mortality among children in Sokoto despite the recent and the relatively low seropositive report.1,5 The admission rate was 8.3% for pediatric HIV/AIDS. This is higher than a recent report from Abuja, Nigeria,13 but in keeping with reports of 8–29% from other parts of Africa.7,8 Reasons for the increase in admission rate may include increasing index of suspicion by pediatricians, availability of pediatric antiretroviral drugs and medical care.5 There is also an increased mother-to-child transmission that resulted from increasing prevalence of HIV infection in Nigeria.1,3,5 Vertical transmission is the commonest reported route of transmission of HIV in children worldwide.1,3,7 In our study, this route accounted for >90% of HIV infection in preschool-age children with HIV. There is the need, therefore, to strengthen the genuine call by concerned stakeholders for an efficient and sustainable program for the prevention of mother-to-child transmission. The majority of the mothers did not know their HIV serostatus prior to the admission of their children with HIV infection. At screening, >90% of the mothers were positive and <6% negative for the infection. However, 37 mothers were already aware of their HIV seropositive status. There were 15 discordant couples, with all the mothers positive and the fathers negative. We are aware of the negative consequences of HIV discordance in a family. This had led to breakdown of most marriages with the children left without continued care and support.12 The men may abandon their wives and/or children, a major threat to the care of the very young children and the old members of the families. All the parents were within childbearing age and are also in the economically productive age group. This is worrisome, particularly as it has a direct negative effect on economy of the families, communities and the nation at large. There is, therefore, the need for existing measures, including voluntary counseling and testing, for adults and also provision of the needed care and support to be strengthened. The birth order in our study was as observed in a previous study.13 with first and second children more affected. 824 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
HIV infection from either unscreened blood or blood from donors during the window period, though not observed in this study, has occurred in many individuals, especially in developing countries.2,4,6 It is therefore pertinent that blood and blood products be properly screened before transfusion and transfused only when it becomes very necessary. Previous reports from Africa had put respiratory tract infections at 85% cause of morbidity and mortality among children with HIV/AIDS.6,10,11,14 This was reflected in our study with pneumonias, accounting for about 60% and 50% of admissions and deaths, respectively. It was difficult to identify the causative agent(s) of pneumonia in all our study subjects, but, the 33 positive blood cultures and raised white blood cell counts with neutrophilia in the other patients strongly suggest bacterial infections. There was no diagnosis of pulmonary tuberculosis made in any of the studied children. This we have attributed to the usual difficulty encountered in the diagnosis of pulmonary tuberculosis in children in centers with low resource. More deaths occurred in children aged <3 years in our study. This is similar to previous works done within the country.6,13,15 This age group also had poor nutritional status with low percentage weights for age, further predisposing them to infections.10,13,15,16 Therefore, efforts aimed at reducing infections (a leading cause of morbidity and mortality) in them, including improved socioeconomic status, nutritional status and routine immunization, should be encouraged. Pediatric HIV/AIDS remains a major contributor to childhood morbidity and mortality. We therefore ask for improvement and sustenance of the government’s and other stakeholder’s laudable efforts/measures such as a program for the prevention of mother-to-child transmission. There is also the need to strengthen the advocacy for the protection of children against sexual abuse and for reduction in adult HIV infection rates. The present free antiretroviral drugs provided by the Nigerian government and other stakeholders for children with HIV/ AIDS should be sustained.
References
1. Nigeria Epidemiological fact sheets on HIV/AIDS and sexually transmitted infections. (2002): update fact sheet 01/01/02 UNAIDS, UNICEF, World Health Organization. 2. Wiktor SZ, Ekpini E, Nduati RW. Prevention of mother-to-child transmission of HIV-1 in Africa. AIDS. 1997;11(suppl B):S79-S87. 3. Global summary of the HIV and AIDS Epidemic update.UNAIDS/WHO epidemic update; December 2005. 4. Joint United Nations Programme on AIDS/HIV (UNAIDS). AIDS epidemic update/report. Dec 2000.www unaids.org/epidemic update/report dec 00/index dec. html. Accessed 08/01/01. 5. 2003 National HIV sero prevalence sentinels Survey, Technical report by The Federal Ministry of Health, Nigeria, 2004. 6. Angyo TM, Okpeh ES, Onah J. Paediatric AIDS in Jos, Nigeria. West Afri J Med. 1998;17(4):268-272. 7. Hashim MS, Salih MA, El Ha AA, et al. AIDS and HIV infection in Sudanese children: a clinical and epidemiological study, AIDS patient care. Sex
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Pattern of Pediatric HIV/AIDS; a Five-Year Experience Transm Dis. 1997;11:331-337. 8. Yeung S, Wilkinson D, Escott S, et al. Paediatirc HIV infection in a rural South African district hospital. Trop Pediatr. 2000;46(2):107-110. 9. Emordi U, Okafor GO. Clinical manifestations of HIV infection in children at Enugu, Nigeria. J Trop Pediatr. 1998;44:73-76. 10. Taha ET, Graham SM, Kumwenda NI, et al. Morbidity among Human Immunodeficiency Virus - l - infected and uninfected African children. Pediatrics. 2000;106(6): e 77-79. 11. World Health Organization. Acquired Immunodeficiency Syndrome (AIDS) WHO/CDC case definition for AIDS. Weekly Epidemiol Rec. 1986;61:69-73. 12. Oniyangi O, Awani B, Iregbu KC. The pattern of paediatric HIV/AIDS as seen at the National Hospital Abuja, Nigeria. Nig J Clinical Pract.
2006;9:147-152. 13. Greenberg AE, Dabis F, Marum LH, et al. HIV infection in Africa. In: Pazzo PA, Wilfert CM III, eds. Paediatric AIDS. The challenge of HIV in infants, children and adolescent. Lippiincott: Williams and Wilkins; 2000:23-24. 14. Salami AK, Olubayo PO. Hospital Prevalence of PTB and co-infection with HIV infection in Ilorin. A review of nine years. West AfriJ Med. 2002;21:24-27. 15. Akpede GO Arube JP, Rabasa AI, et al. Presentation and outcome of HIV-l infection in hospitalized infants and other children in North-Eastern Nigeria. East Afr Med J. 1997;74:21-27. 16. Angyo IA, Amali-Adikwu, Okpeh ES. Protein-Energy Malnutrition and Human Immunodeficiency Virus infection in Children in Jos. Nig J Paedtr. 1998;25:64-67. n
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