Identifying missed opportunities for early intervention among HIV-infected paediatric admissions at Chris Hani Baragwanath hospital, Soweto, South Africa

Background and design. HIV is a major contributor to childhood morbidity and mortality in South Africa. We describe HIV prevalence, disease profile, outcome and missed opportunities for early intervention in a cohort of HIV-infected children admitted to Chris Hani Baragwanath Hospital’s general paediatric wards between 1 October 2007 and 31 December 2007. Results. Of 1 510 admissions, 446 (29.5%) were HIV infected. Many children (238, 54.1%) were newly diagnosed in hospital and most had advanced HIV disease (405, 92%). The principal admission diagnoses were pneumonia (165, 37.5%), gastro-enteritis (97, 22%), sepsis (86, 19.5%) and tuberculosis (92, 21%). Of children identified as HIV infected before admission, 128/202 (63.4%) were not accessing antiretroviral treatment (ART), although 121/128 (94.5%) met ART eligibility criteria. Of 364 ART-na ve eligible children, only 15 (4.1%) were commenced on ART as inpatients. Problems with PMTCT implementation in infants under 6 months (N=166) included lack of maternal antenatal HIV testing (51, 30.7%); poor uptake of maternal/infant nevirapine prophylaxis (60, 36.2%); limited use of co-trimoxazole (CTX) prophylaxis (44/147, 29.9%); and delayed infant HIV polymerase chain reaction testing (98/147, 87.5%). Of infants known to be HIV infected prior to hospitalisation, 37/51 (73%) had not initiated ART. The in-hospital case fatality rate (CFR) among HIV-infected children was triple that of the combined HIV-uninfected, exposed and unknown group (12% v. 3.6%). Infants <12 months of age accounted for 73.6% of all HIV-related deaths (CFR 17.1%). Conclusions. HIV remains highly prevalent and contributes to significant in-hospital mortality. Missed opportunities for PMTCT, HIV diagnosis and ART initiation are frequent. Interventions to optimise paediatric HIV outcomes should target maternal HIV diagnosis, early infant diagnosis, uptake of CTX prophylaxis and prompt initiation of ART, especially among infants. Hospitalised ART-eligible children should be prioritised for inpatient initiation of ART.