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Diarrhea caused significant morbidity in children born to mothers with HIV in Kenya
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2011 ASTMH
PHILADELPHIA — Data suggest that children with diarrhea who have mothers with HIV are at increased risk for having repeated diarrheal episodes, persistent diarrhea, deterioration in health within 60 days and death. These risks are present regardless the child’s HIV status, according to findings presented during the American Society of Tropical Medicine and Hygiene 60th Annual Meeting.
While data on diarrhea among children with HIV are limited, Ciara E. O'Reilly, PhD,and colleagues used data from the Global Enterics Multicenter Study (GEMS) study to assess outcome and etiology of moderate-to-severe diarrhea in Kenyan children aged younger than 5 years.
O’Reilly, from the Waterborne Diseases Prevention Branch in the Division of Foodborne, Bacterial and Mycotic Diseases, CDC worked with the Kenya Medical Research Institute/CDC-Kenya GEMS and Global AIDS Program on the analysis which looked at moderate-to-severe diarrhea among1) children who were infected with (HIV+); 2) children who were not infected with HIV, but who were potentially exposed to HIV through their HIV-positive mother (HIV-/+); and 3) children and their mothers who were not infected with (HIV-/-).
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The investigators abstracted HIV test results for enrolled children and their biological mothers. HIV infection was determined by PCR for children aged younger than 18 months, and by rapid antibody test for children aged older than 18 months and their mothers. Stool specimens were collected at enrollment.
Between Jan 25, 2010, and Feb 6, 2011, 541 (37%) of the 1,473 enrolled children with moderate-to-severe diarrhea had an HIV test at or before enrollment into GEMS. Sixteen children (3%) were HIV+; 118 children (20%) were HIV-/+; and 407 children (70%) were HIV-/.
For HIV-positive mothers of children in the HIV+ group, the median CD4 count was 331 cells/mcL and the median CD4 count was for the HIV-/+ children was 451 cells/mcL. Two (22%) of the HIV+ children and 12 (27%) of the HIV-/+ children were on antiretroviral therapy. Five (56%) of the HIV+ children; 27 (60%) of the HIV-/+ children; and 115 (76%) of the HIV-/- children were currently breastfeeding.
“On enrollment and two months later, HIV+ children were significantly more stunted (height-for-age z-score less than -2) compared to HIV-/- children. Four (25%) HIV+, nine (8%) HIV-/+, and 41 (10%) HIV-/- children were hospitalized for diarrhea. HIV-/+ children were significantly more likely to be enrolled multiple times with moderate-to-severe diarrhea,” according to the findings.
Enterotoxigenic Escherichia coli (25%), Cryptosporidiam (19%), enteropathogenic E. coli (13%), and astrovirus (6%), were more commonly found in stools from HIV+ children compared with HIV-/+ and HIV-/- children.
Death within 60 days of enrollment was more common among HIV+ (6%) and HIV-/+ children (4%) than among HIV-/- (2%) children, according to the study findings.
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Disclosure: Dr. O’Reilly reports no relevant financial disclosures.
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This collaborative 13-month study involving researchers from the CDC, KEMRI, and GEMS suggests that maternal HIV status may be associated with increased morbidity and mortality, independent of their infant’s HIV infection status. While the numbers of HIV-infected infant-maternal pairs comprised less than 5% of the total sample, and HIV-uninfected infant-maternal pairs comprised almost 75% of the total sample, the conclusions of the study are deserving of consideration.
In addition to the 75% stunted HIV-infected children, 30% of the exposed uninfected and infected, respectively, were also stunted suggesting that characteristics of the rural western Kenyan environment unrelated to HIV status that accounted for this growth delay. Interestingly, 10% more of the exposed uninfected children were underweight compared with the percentage of HIV-infected and uninfected children who were underweight, supporting a factor unrelated to infant infection status accounting for this observation.
Despite this highest percentage of underweight status, the HIV-exposed uninfected children had the lowest rate of diarrhea-related hospitalizations. This difference could relate to either a lesser severity of diarrheal illness in these children compared with infected and uninfected mothers and children, or could also pertain to access to resources. The more frequent isolation of bacterial and viral pathogens from the stools of infected children supports the likelihood that these children had an increased susceptibility to these organisms, although denominator data on the number of specimens submitted is not provided. If the children of HIV-infected mothers were more likely to seek care, and therefore to have a stool specimen tested, it is possible that the higher rates of recovery may have been due to more frequent testing, as well as an increased susceptibility to these organisms.
Noting that less than 5% of the 206 infant cohort were HIV-infected is reassuring, but is also a reminder that mother to child transmission is ongoing in this community and possibly related to rates of ARV uptake of approximately 25% in both groups of HIV infected mothers.
Limitations of this evaluation include the fact that one-third of the originally defined sample of 309 children were not assessed due to the inability to document HIV status. There may have been one or more characteristics of those subjects who were not included that could have biased the results. Additionally, the definition of diarrhea utilized in the study is not provided in the abstract.
Despite these caveats, this study provides preliminary information about the impact of diarrheal disease among HIV-infected and uninfected mothers and their children in western Kenya and supports the direction of resources toward the prevention of diarrheal disease. Expansion into a larger population may provide data to support the intriguing findings highlighted to date.
—Andi L. Shane, MD MPH, MSc
Infectious Diseases in Children Editorial Board
Disclosure: Dr. Shane reports no relevant financial disclosures.
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