HIV-exposed children account for more than half of 24-month mortality in Botswana

摘要

Background The contribution of HIV-exposure to childhood mortality in a setting with widespread antiretroviral treatment (ART) availability has not been determined. Methods From January 2012 to March 2013, mothers were enrolled within 48?h of delivery at 5 government postpartum wards in Botswana. Participants were followed by phone 1–3 monthly for 24?months. Risk factors for 24-month survival were assessed by Cox proportional hazards modeling. Results Three thousand mothers (1499 HIV-infected) and their 3033 children (1515 HIV-exposed) were enrolled. During pregnancy 58?% received three-drug ART, 23?% received zidovudine alone, 11?% received no antiretrovirals (8?% unknown); 2.1?% of children were HIV-infected by 24?months. Vital status at 24?months was known for 3018 (99.5?%) children; 106 (3.5?%) died including 12 (38?%) HIV-infected, 70 (4.7?%) HIV-exposed uninfected, and 24 (1.6?%) HIV-unexposed. Risk factors for mortality were child HIV-infection (aHR 22.6, 95 % CI 10.7, 47.5?%), child HIV-exposure (aHR 2.7, 95?% CI 1.7, 4.5) and maternal death (aHR 8.9, 95 % CI 2.1, 37.1). Replacement feeding predicted mortality when modeled separately from HIV-exposure (aHR 2.3, 95?% CI 1.5, 3.6), but colinearity with HIV-exposure status precluded investigation of its independent effect. Applied at the population level (26?% maternal HIV prevalence), an estimated 52?% of child mortality occurs among HIV-exposed or HIV-infected children. Conclusions In a programmatic setting with high maternal HIV prevalence and widespread maternal and child ART availability, HIV-exposed and HIV-infected children still account for most deaths at 24?months. Lack of breastfeeding was a likely contributor to excess mortality among HIV-exposed children.