Baseline characteristics associated with mortality among children living with HIV initiating ART at a rural district HIV clinic of Mozambique

This study describes the incidence and factors associated with mortality in children living with HIV and initiating ART at rural settings. We analyzed routinely collected data from electronic medical records of children, aged under 15 years or younger, living with HIV (CLHIV) who were routinely managed at Carmelo Hospital of Chokwe, from 2002 to 2019, located in the Chokwe district, Gaza province, Mozambique. Kaplan-Meier survival curves and Cox regression analyzes were used to model the time to death and predictors of mortality respectively. Overall, 1341 HIV-infected children on ART contributed to a total number of 6705 child-years of observation. The overall death rate was 2.8 per 100 child-years. Cox regression predicted a higher risk of death among children aged 2 years or below (adjusted hazard ratio [aHR] 3.34, 95% confidence interval [CI] 1.46–3.74; p < 0.001), in inpatient CLHIV (aHR 1.88, 95% CI 1.19–2.97, p = 0.007), patients with WHO clinical stage III and IV disease (aHR 2.05, 95% CI 1.19–3.55, p = 0.010; aHR 4.30, 95% CI % 2.27–8.17, p < 0.001), having CD4 counts under 100 cells/µL (aHR 3.67, 95% CI 2.51–5.35, p < 0.001), receiving anti-TB treatment within 90 days of ART initiation (aHR 1.84, 95% CI 1.16–2.93, p = 0.010). Kaplan-Meier analysis showed higher cumulative incidence of mortality after 4 years of follow-up, above 70% in inpatient CLHIV, 54% of those that received ATT within 90 days of ART initiation, and 35% with CD4 < 100 cells/µL (log Rank test p < 0.0001). Reducing morbidity and mortality in this vulnerable group of patients requires a concerted effort to educate care workers on the guidelines for the management of advanced pediatric HIV Disease. Emphasis should be placed on early identification of CLHIV with lower CD4 cell counts, and screening for asymptomatic opportunistic infections.