Affiliations: Department of Pediatrics, Duke University Medical
Center, Durham, NC, USA | Department of Medicine, Kilimanjaro Christian Medical
Centre, Moshi, Tanzania | Department of Pediatrics, Kilimanjaro Christian
Medical College, Tumaini University, Moshi, Tanzania
Note: [] Correspondence: Coleen K. Cunningham, MD, Box 3499, Duke
University Medical Center, Durham, NC 27710, USA. Tel.: +1 919 684 6335; Fax:
+1 919 668 4859; E-mail: [email protected]
Abstract: In resource-limited settings lacking laboratory testing, clinical
staging criteria may not identify all human immunodeficiency virus
(HIV)-infected children who could benefit from antiretroviral therapy (ART). A
retrospective analysis was conducted to identify clinical markers in children
that could predict rapid progression and need for earlier ART. Pediatric
HIV-infected patients receiving care at an outpatient clinic at the Kilimanjaro
Christian Medical Centre (KCMC) in Moshi, Tanzania from November 2004–March
2006 were enrolled. Medical records were retrospectively reviewed for
sociodemographic data, growth parameters, and medical information. Bivariable
analysis was performed to identify predictors of clinical progression. Of 162
patients enrolled, 69 initially presented with mild clinical HIV disease and
this analysis focuses on progression within this group. Twenty-one of those 69
progressed clinically to WHO Stage 3/4 during the 18 months of follow-up; 19
progressed within 2–9 months and two additional children were found to have
progressed by the 9–18 months visit. Median (range) age at presentation among
69 patients with mild disease was 6.1 years (0.1–13.7 years), and 32 (46%)
were female. Fourteen (20% of 69) patients were on ART at their first visit
or started ART within the next 2 months (early ART), and an additional 20
(29% of 69) patients started ART in the following 2–18 months. Of initial
visit clinical and laboratory criteria, lymphadenopathy (P=0.046), chronic upper respiratory infections (P=0.010),
lower height-for-age z-score (P=0.007), lower
weight-for-age z-score (P< 0.001), and CD4% (P=0.016)
were associated with clinical progression. Fewer patients receiving early ART
progressed, as compared to patients receiving late ART (P=0.004). Almost one third
of children with clinically mild HIV disease
progressed to Stage 3/4 disease within 2–18 months. In settings lacking CD4
cell counts, current guidelines would not have identified the majority of these
children for treatment. Improved clinical criteria and low-tech modalities such
as point-of-care CD4 testing may help improve identification of children for
ART initiation.
Keywords: Pediatrics, HIV, highly active antiretroviral therapy
