Background
Studies of hospitalization among young children with HIV in resource-limited settings, in the context of early infant diagnosis and antiretroviral therapy (ART), are limited.
Methods
We used routinely collected data to describe hospitalization patterns among children diagnosed with HIV (born 2018-2022), in the Western Cape, South Africa. We used logistic regression to examine factors associated with hospitalization pre-ART start, and mixed-effects Poisson models to assess overall hospitalization rates (excluding birth admissions) and hospitalizations post-ART start.
Results
We included 2,219 children: 30% were diagnosed with HIV at birth (≤7 days), an additional 41% before age 1 year, and 29% at age ≥1 year. Median follow-up from birth was 38 months (IQR 24-50). Overall, 67% of children were hospitalized, of whom 50% had >1 hospitalization. Compared to those diagnosed with HIV at birth, overall hospitalization rates (excluding birth admissions) increased by 67% (95%CI:39-101%), 74% (95%CI:45-109%) and 29% (95%CI:9-51%) among those diagnosed at age 1 week to 3 months, >3 to 9 months, and >9 months, respectively. Excluding birth admissions, 35% of children were hospitalized pre-ART start (n=781/2219) and 27% of children who started ART were hospitalized at the time of ART start.
Compared to children who started ART before 1 month of age (but not at birth or during a birth admission), those who started at age 1-3, >3 to 6, and >6 to 12 months had increased pre-ART admission odds of 6.5 (95%CI:3.6-11.5), 10.7 (95%CI:6.0-19.0) and 14.7 (95%CI:8.2-26.1), respectively. Among children who received ART (96% protease inhibitor-based regimens), 38% had admissions post-ART start (n=747/1990). At 4 and 12 months after ART start, 49% and 47% of children with available results had unsuppressed viral load (VL≥1,000 copies/ml), respectively. Hospitalization rates post-ART start were twice as high among children who had unsuppressed VL at 4 or 12 months after ART start.
Conclusions
High hospitalization rates occur among young children with HIV. Earlier HIV diagnosis and ART initiation is associated with lower overall hospitalization rate, particularly pre-ART hospitalizations, whereas unsuppressed viral load is associated with higher post-ART hospitalization rates. Our study provides real-world evidence of the benefits of HIV testing at birth, a practice that has not yet been adopted globally, and highlights that morbidity among young children with HIV is only partially mitigated by early ART initiation.
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