Children's HIV Deaths in Africa Largely Preventable

SEATTLE -- More than half of the children who died from HIV-related illnesses in Africa were not diagnosed with HIV prior to their death, and nearly all of these deaths were preventable, data from the Child Health and Mortality Prevention Surveillance (CHAMPS) study indicated.

Of more than 2,100 pediatric deaths captured in recent years across four African nations with a high burden of HIV, an expert panel found that 5% had HIV and that 102 of those 108 deaths could have been prevented, reported Inacio Mandomando, PhD, director of the CHAMPS-Mozambique clinic in Maputo.

Only 49% of the kids with HIV had been diagnosed before their deaths and only 40% had been prescribed antiretroviral therapy, according to findings presented here at the annual Conference on Retroviruses and Opportunistic Infections.

"We have demonstrated that HIV remains a major cause of child death in some high burden countries, and almost all deaths could have been prevented," he said at a press conference.

HIV-related deaths in children are likely under-reported due to the practice of recording a single cause of death, Mandomando explained.

"Clinicians in outpatient departments and under-5 clinics should be reminded of the importance of retesting mother-infant pairs when seeing recurrent infections or failure-to-thrive," he said. "Children who die with HIV almost all have multiple conditions contributing to death. These conditions can provide us with insight into how we can reduce HIV-associated mortality in children."

In the study, the researchers found that 97% of the HIV-associated child deaths had other infectious processes in the causal chain, said Mandomando. "These were most commonly lower respiratory infections, sepsis, and malaria. The pathogens most seen with these infections were CMV [cytomegalovirus] and Klebsiella."

The CHAMPS study is designed to investigate mortality in children under age 5 years across nine countries in sub-Saharan Africa and South Asia. Investigators examine the complex causes of death in depth using "novel techniques," said Mandomando. The results are then disseminated to key stakeholders in the nations and globally, with the goal of turning the findings into action through implementation science.

"CHAMPS starts with death notifications from the community or a facility in our catchment area," Mandomando said. "After enrolling the child, we collect samples using minimally invasive tissue sampling [MIPS] and other techniques and we collect data from medical records. We also do a verbal autopsy with the parents. After all analyses have been completed, an expert panel reviews the record for each child and assigns immediate underlying and comorbid causes of death."

Excluding stillbirths, the researchers looked at 2,135 deaths from 2017 to 2021 among neonates and children ages 1 to 4 years from South Africa (n=715), Mozambique (n=543), Kenya (n=482), and Sierra Leone (n=395) where MIPS was performed.

HIV was detected in 28 children in South Africa (3.9%), 33 in Mozambique (6.1%), 34 in Kenya (7.1%), and 13 children in Sierra Leone (2.8%). For each country, the proportion given HIV prevention and treatment services before death was assessed.

"We found two-thirds of children in South Africa had been diagnosed while alive, but only one-half of those were on antiretroviral therapy," Mandomando said. "In contrast, Kenya had one-third diagnosed, and all were on antiretroviral therapy. Mozambique had the highest treatment coverage at 60%, while Sierra Leone had the lowest treatment coverage at 9%."

Below 1% of the neonates examined in the study died of an HIV-related circumstance, Mandomando said. "The proportion of deaths attributable to HIV increased with age across all countries, with only South Africa showing a decrease in child deaths caused by HIV."

In Mozambique, for example, 15% of children less than a year old died due to HIV-related causes, but that number increased to 18.7% of deaths in the group ages 1 to 4 years. In South Africa, the deaths in the neonates attributable to HIV was 12.4%, which fell to 7.6% in the group of kids ages 1 to 4 years.

Kenya and Mozambique have the highest burden of HIV-related deaths in kids 1 to 4 years, with almost one in five child deaths being HIV-associated, he said.

Elaine Abrams, MD, of Columbia University's Mailman School of Public Health in New York City, told MedPage Today that the key point in the study is that so many of the children were not known to have had HIV, and if their status had been known and they were put on medication, their lives potentially could have been saved.

"There are international interventions that have been implemented around the globe, and overall, they have made headway in testing children and getting children on effective treatment, but the proportion of children on effective treatment is much lower than adults in the same community," said Abrams, who was not involved with the study.

She said that while the number of children being born with HIV infection even in Africa is quite low compared with all the children born there, doctors who identify an adult with HIV should test family members to see if there is infection in the household. In that way, physicians can identify young children who may not have been previously known to have HIV.

"In the United States, pregnant woman are routinely tested for HIV, and depending on the state, there are different laws regarding repeat testing during testing to try to identify those women who may have acquired HIV during pregnancy, and around testing the babies if the mom's status is not known," Abrams continued. "In the United States, less than 50 children a year are born with HIV."

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