Outcome of HIV-exposed uninfected children undergoing surgery
Jonathan S Karpelowsky
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Alastair JW Millar
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Nelleke van der Graaf
Guido van Bogerijen
Heather J Zar
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Department of Pediatric Surgery, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town
,
South Africa
Background: HIV-exposed uninfected (HIVe) children are a rapidly growing population that may be at an increased risk of illness compared to HIV-unexposed children (HIVn). The aim of this study was to investigate the morbidity and mortality of HIVe compared to both HIVn and HIV-infected (HIVi) children after a general surgical procedure. Methods: A prospective study of children less than 60 months of age undergoing general surgery at a paediatric referral hospital from July 2004 to July 2008 inclusive. Children underwent age-definitive HIV testing and were followed up post operatively for the development of complications, length of stay and mortality. Results: Three hundred and eighty children were enrolled; 4 died and 11 were lost to follow up prior to HIV testing, thus 365 children were included. Of these, 38(10.4%) were HIVe, 245(67.1%) were HIVn and 82(22.5%) were HIVi children. The overall mortality was low, with 2(5.2%) deaths in the HIVe group, 0 in the HIVn group and 6(7.3%) in the HIVi group (p = 0.0003). HIVe had a longer stay than HIVn children (3 (2-7) vs. 2 (1-4) days p = 0.02). There was no significant difference in length of stay between the HIVe and HIVi groups. HIVe children had a higher rate of complications compared to HIVn children, (9 (23.7%) vs. 14(5.7%) (RR 3.8(2.1-7) p < 0.0001) but a similar rate of complications compared to HIVi children 34 (41.5%) (RR = 0.6 (0.3-1.1) p = 0.06). Conclusion: HIVe children have a higher risk of developing complications and mortality after surgery compared to HIVn children. However, the risk of complications is lower than that of HIVi children.
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Background
HIV-exposed uninfected (HIVe) children are a rapidly
growing population. Programs for the prevention of
mother to child transmission (PMTCT) have reduced
the transmission rate of perinatal HIV infection to
approximately 2% to 5% [1-3]. Such programs have
therefore effectively reduced the number of HIV
infected (HIVi)children but identified an increasing
population of HIVe children [4].
HIVe children have been overlooked as a group of
children who may be at an increased risk of illness
compared to HIV-unexposed (HIVn) children. Recently,
increased morbidity and mortality in HIVe children
compared to HIVn children has been reported [4-10].
Many factors may account for this including innate
deficiencies in immunity [11-13], feeding practices [14],
poor protection from maternal antibodies or
environmental exposures [6].
As PMTCT programs expand, an increasing number
of HIVe children can be expected to require a routine
or emergency surgical procedure [15,16]. Currently no
data exist on the risk of morbidity and mortality
postsurgery in such children. The aim of this study was to
investigate the mortality and post-operative
complications in HIVe children compared to both HIVn and
HIVi children after a general surgical procedure.
Methods
A prospective cohort study was performed, from July
2004 to July 2008 at a single tertiary general paediatric
surgical centre in Cape Town, Western Cape, South
Africa. The general paediatric surgical service acts as a
regional and national referral centre with approximately
2400 operations performed annually. The study was
approved by the ethics committee of the Faculty of
Health sciences, University of Cape Town.
The study site is a high HIV prevalence area, with an
estimated HIV prevalence amongst pregnant women of
approximately 16% [17]. There is a well-developed
PMTCT program with HIV transmission rates of
approximately 2-4%. The Western Cape has
approximately 70000 births per annum [1], of which
approximately 11000 babies per year are expected to be HIVe.
Inclusion criteria were children less than 60 months of
age, undergoing a general surgical procedure. The
recruitment was conducted in two phases. 1) Phase 1
(pilot data), enrolled only HIV-exposed children, from
July 2004 to December 2006. This was done to gather
pilot data, to inform the larger phase 2 study. 2) Phase 2
enrolled all children irrespective of HIV exposure from
January 2007 until July 2008 inclusive. Analysis was
conducted on both phase 1 and phase 2 data.
Age definitive HIV testing with pre and post-test
counselling was done in children whose HIV status was
unknown. HIV infection was defined as 2 positive HIV
ELISA (DetermineAbbott, Abbott Park, Ill. USA) tests
in children > 18 months; a positive ELISA test, and if
positive a confirmatory PCR test in children less than 18
months. HIV exposure was defined as a positive ELISA
but negative PCR in children < 18 months or in children
> 18 months knowledge of an infected mother but a
negative ELISA in the child.
Informed consent from a parent or legal guardian was
obtained. Details of the (...truncated)