Pediatric Human Immunodeficiency Virus Infections Admissions and Outcome at Wesley Guild Hospital, Ilesa, Nigeria

Abstract

Background:

The burden, profile, and outcomes of pediatric human immunodeficiency virus (HIV) have not been exhaustively studied in developing countries. The present study hopes to fill some of this knowledge gap.

Aim:

The study aimed to document the burden and profile of pediatric HIV admission at Wesley Guild Hospital, Ilesa, Nigeria, with emphasis on highlighting peculiarities in our setting.

Methods:

A retrospective study of the case records of all HIV-infected children admitted and managed on the pediatric infectious ward over 15 years. Data obtained from the information were analyzed using SPSS version 20, and inferences were made.

Results:

The total HIV-infected children population studied consisted of 18 (47.4%) boys and 20 (52.6%) girls with a mean age of 4.06 ± 3.90 years. Transmission of HIV was vertical in all, while diagnosis of HIV infection was made during the index admission in 35 (92.1%). Tuberculosis, community-acquired pneumonia, severe malaria, Pneumocystis pneumonia, sepsis, and cryptococcal infections accounted for more than 80% of admissions. Severe malaria was more common in the above 5 years of age group. Candida and scabies were the most common coinfections and infestations, respectively. More than 50% of admissions were complicated with anemia and hypoxemia. The nine recorded deaths represent 23.7% of the population studied, with Pneumocystis pneumonia and cryptococcal infections accounting for more than half of the deaths. Hypoxemia and acquired immunodeficiency syndrome were significantly associated with death (P < 0.001).

Conclusion:

Childhood HIV infections are a significant contributor to pediatric infectious morbidity, with high HIV case mortality rates. Strategies to reverse this narrative are urgently needed for deployment.

INTRODUCTION

The burden and profile of human immunodeficiency virus (HIV) infections in children from developing countries is scant. However, pediatric HIV infection continues to thrive and remain a scourge because of poorly coordinated and funded control programs.[,2,3] The HIV medicine discipline has not remained static over the decades. National recommendations for highly active antiretroviral therapy have changed several times from the triple nucleotide/nucleoside reverse transcriptase inhibitor and nonnucleoside reverse transcriptase inhibitor-based drugs to the currently recommended regimen with the inclusion of HIV integrase inhibitors, like dolutegravir.[4,5]

Paradoxically, despite the dynamic changes recorded in the HIV medicine discipline, reports evaluating the clinical profile and outcomes of HIV-infected individuals have progressively reduced and become a drought over the last two decades.[,7,8] Furthermore, the available reports are not fully representative of the current experience in contemporary practice. All the issues documented above stimulated our interest to conduct this research and provide up-to-date information on the clinical profile and outcome of HIV-infected children.

Hopefully, the findings from this study will shed more light in some areas of knowledge gaps. Hopefully, findings from this study will illuminate a poorly researched aspect of the association between malaria and childhood HIV infection.

METHODS

This study is a retrospective review of pediatric HIV admissions, clinical characteristics, and outcomes of all HIV-infected children admitted on the pediatric wards of Wesley Guild Hospital, Ilesa, between January 1, 2011, and June 1, 2025. Ethical approval was obtained from the Ethics Review Committee of the Obafemi Awolowo University Teaching Hospitals Complex, of which Wesley Guild Hospital is one of the institutions making up the complex. The ethical clearance certificate issued had the protocol number: ERC/2025/05/20. All rules governing ethical research were observed and complied with in the conduct of this study. Consent was also obtained from the health record unit to review the case notes.

All the case notes of HIV-infected children admitted to the pediatric wards in the stated time period were obtained and necessary information extracted. Diagnosis of HIV in all the subjects was first established and based on appropriate serologically positive retrovirus test reports for all children aged above 18 months and positive DNA polymerase chain reaction (PCR) test in children and infants <18 months.[9] The age and time of HIV diagnosis were noted and classified based on its temporal relationship to the admission, namely before admission or during the index admission. The details of the retrovirus status of the mother were also obtained from the case records.

Some of the details obtained from the case records include the age and sex of the patient at admission, duration of admission, and outcome. The indication for admission was sought and established on a logical sequence of history, examination, and investigations. All complications as well as their management and the indication for admission were sought and recorded in a pro forma. Additional details extracted from the case notes include history of when highly active antiretroviral therapy and co-trimoxazole preventive therapy were initiated, as well as details of adherence to medications. The staging of the HIV infection was based on the World Health Organization (WHO) clinical staging.[9,10] Outcomes of the children were noted and classified as discharged well and alive, discharge against medical advice, referral, and/or death, as the case may be.

All the data obtained from the extracted information were inputted into Statistical Product and Service Solutions version 20. SPSS Inc. (2010). SPSS Base 20.0. Chicago, IL, USA.[11] Continuous variables were analyzed to give means and range for the age of the children, and categorical data were analyzed to test for proportions and significance using the Chi-square test, and P < 0.05 was considered statistically significant.

RESULTS

General characteristics

A total of 38 pediatric HIV disease admissions were recorded on the pediatric infectious ward between the years 2010 and 2025. This number constitutes 0.8% of the total 4560 infectious disease admissions at the pediatric infectious disease ward and 58.5% of the total 65 HIV-infected children enrolled for care at the Wesley Guild Hospital, Ilesa, Nigeria.

Age and sex distribution

The ages of the children studied ranged between 2 days and 13 years with a mean age of 4.06 ± 3.90 years. The majority of the children were under 5 years, while minority were aged above 10 years. Of the 38 admissions, 18 (47.4%) were male, while 20 (52.6%) were female, thus giving a male-to-female ratio of 1:1.1. The age and sex distribution of the children studied are shown in Table 1.

Table 1.

Age and sex distribution of the children studied

Age group (years)	Male	Female	Total
<1	5	8	13
1–5	4	7	11
6–10	7	3	10
11–15	2	2	4
Total	18	20	38

Mode of acquisition, testing for diagnosis and time at which HIV was diagnosed

The mode of acquisition of HIV was vertical in all 38 children. Of the 38 children studied, the diagnosis of HIV was made by DNA PCR testing in the 17 children younger than 18 months and by rapid enzyme-linked immunosorbent assay test in the 21 children older than 18 months. Diagnosis of HIV was during the index admission in 35 (92.1%) and before admission in the remaining 3 (7.9%).

Indications for admissions and coinfections in the children studied

The common indications for admission in the 38 children were tuberculosis, community acquired and Pneumocystis jerovecci pneumonia (PCP) and malaria. Some children had more than one indication for admission. Full details of the indication for admission are shown in Table 2.

Table 2.

Indications for admission among the studied children

Indications for admission	n (%)
Pneumonia	7 (18.5)
Tuberculosis	6 (15.8)
Severe malaria	4 (10.5)
Pneumocystis jirovecii pneumonia	4 (10.5)
Cryptococcal sepsis	4 (10.5)
Septicemia	3 (7.9)
Acute gastroenteritis with dehydration	2 (5.3)
Persistent diarrhea with dehydration	2 (5.3)
Cryptococcal infection	2 (5.3)
Asthma exacerbation	1 (2.6)
Febrile convulsion secondary to sepsis	1 (2.6)
Cellulitis	1 (2.6)
Diphtheria	1 (2.6)

The five cases of severe malaria recorded in this series were constituted by two cases each of cerebral malaria and severe anemia, and prostration in children aged 6, 1, 3, 11, and 11 years, respectively. All cases of PCP were diagnosed in infants <3 months, and all cases were associated with hypoxemia. The cases of cryptococcal infections were recorded in two infants aged 3 and 7 months.

Of the 38 children studied, 18 (47.3%) coinfections were recorded. The coinfections recorded in the 18 children include cases of candidiasis, scabies, nonsevere malaria, and acute and chronic secretory otitis media in 11 (28.9%), 3 (7.9%), 2 (5.3%), 1 (2.6%), and 1 (2.6%) each, respectively. Some children had more than one coinfection. Among the 11 children with candidiasis, 5 had oral thrush, and 4 had perineal candidiasis, while 3 had features suggestive of esophageal candidiasis. Scabies was the only identified infestation presenting with excoriations and papules in the finger webs, axilla, buttocks area, and pruritus, which was worse at night. The classical form of scabies was the predominant presentation. All of the cases of scabies responded to topical benzyl benzoate monotherapy.

Complications associated with the main indications for admission

Anemia was the most common complication associated with the disease indication for admission. Eight children presented with severe anemia requiring transfusion with packed cell volume ranging from 14% to 19%. Six and three children had moderate and mild anemia with packed cell volumes ranging between 26%–28% and 21%–25%, respectively. Hypoxemia was the next most common complication, and it was found in eight children with respiratory disease conditions like Koch, community-acquired pneumonia, and PCP. Pulse oximetry peripheral saturation readings ranged from 70% to 89% among those diagnosed with hypoxemia. All patients with hypoxemia were managed with supplemental oxygen administered as modified CPAP with the targeted minimum saturation set between 90% and 95%. Dehydration was recorded in the two cases of children with gastroenteritis. Immune reconstitution inflammatory syndrome was recorded in two children on treatment for tuberculosis.

World Health Organization clinical staging of the human immunodeficiency virus-infected children

Of the total population, 3 (7.9%) had evidence of Stage II disease, while 26 (68.4%) had evidence of Stage III disease, and the remaining 9 (23.7%) had evidence of acquired immunodeficiency syndrome (AIDS). None of the children admitted belonged to the WHO Stage I class. The three children with Stage II disease presented with exacerbation of asthma and acute gastroenteritis with moderate dehydration and faucial diphtheria. The nine children with Stage IV disease were constituted by four cases of PCP, two cases of disseminated tuberculosis, and two cases of cryptococcal infection, with one infant presenting with cryptococcemia and the other presenting with cryptococcal meningitis. The remaining child with AIDS had an unidentified intracranial mass. The subjects with Stage III disease were majorly constituted with disease conditions such as pulmonary tuberculosis, community-acquired pneumonia, and severe malaria.

Weight of the children

The weight of the children ranged from 1.50 to 34.0 kg with a mean of 12.13 ± 8.82 kg. Most of the children studied had normal weight for age. Based on weight for age, failure to thrive was recorded in 7 (18.4%), underweight malnutrition in 12 (31.6%), severe acute malnutrition in 3 (7.9%), and marasmus in 2 (5.3%). Two (5.3%) neonates had low birth weights with birth weights <2.5 kg.

Comorbidities in the studied children

Of the 38 children in the studied population, 4 (10.5%) had comorbidity, while 34 (89.5%) did not. The four comorbid conditions recorded were atrial septal defect, chronic kidney disease, asthma, and sickle cell anemia, respectively. The comorbidities of chronic kidney disease, sickle cell anemia, and asthma were diagnosed before diagnosis of HIV. The three patients were followed up in different health facilities, without suspecting HIV infection before diagnosis in this study.

Duration of hospitalization

The range of hospital admissions was from 1 to 42 days, with a mean of 9.29 ± 8.70. Very short stay admissions were recorded in 5 (14.7%) patients, who stayed for 1 day or less because they were discharged after observation and eventually got better or died when brought in extreme condition. On the other hand, 4 days was the mode in terms of hospital admission recorded in 6.

Outcome

Twenty-eight (73.7%) 38 studied children had a good outcome and were discharged well for follow-up. Two (5.3%) children were discharged against medical advice, at the insistence of the parents. A total of 9 (23.7%) deaths were recorded among the 38 admitted children infected with HIV. The nine deaths account for 6.4% of the total 140 mortalities on the pediatric infectious ward in the 15-year study period. The diseases accounting for deaths include three cases of PCP, two cases of cryptococcal infections, one case each of Koch’s disease, disseminated tuberculosis, faucial diphtheria with airway obstruction, and chronic kidney disease with tuberculous pneumonia coinfection.

Concerning the cryptococcal deaths, only parenteral fluconazole was accessible for treatment. Amphotericin B and flucytosine could not be obtained for cryptococcal infection treatment.

Association between age group category and outcome

Children in the age group of 11 years and above recorded the highest proportion of deaths, with 1 (25.0%) death recorded in the age category, while 6 (23.5%) deaths were recorded in the remaining 34 children aged below 10 years. The differences between the two groups were not significant with χ² = 0.62, P = 0.89. These details can be found in Table 3

Table 3.

Association between age group category, anemia, hypoxemia, human immunodeficiency virus clinical staging, and outcome

	Death	Survived	χ 2	P
Age categories
>1 month	4	9	0.62	0.89
1–5 years	2	9
6–10 years	2	8
>11 years	1	3
Total	9	29
Anemia
Yes	3	15	0.62	0.43
No	6	14
Total	9	29
Hypoxemia
Yes	8	1	27.74	<0.01
No	1	28
Total	9	29
WHO HIV staging
Stage I, II, and III	2	26	16.11	<0.01
Stage IV	7	3
Total	9	29

HIV=Human immunodeficiency virus, WHO=World Health Organization

Association between World Health Organization clinical staging and outcome

Of the 28 children with the WHO clinical Stage II and III, 26 (92.9%) survived, while 2 (7.1%) died; on the other hand, 3 (30.0%) of the 10 children with AIDS survived, and the remaining 7 (70.0%) died. The differences in the two groups are significant (χ² = 16.11, P < 0.01). Full details can be found in Table 3.

Association between hypoxemia and outcome

Concerning the 29 children who survived, 1 (3.4%) had hypoxemia, and 28 (96.6%) had normal pulse oximetry saturation, while on the other hand, 8 (88.9%) of the 9 patients who died had hypoxemia. Full details of the association between hypoxemia and outcome are shown in Table 3.

Association between anemia and outcome

Three (16.7%) deaths occurred among the 18 anemic group, while 6 (20.0%) deaths were recorded among the 20 that were not anemic. Full details of the association can be found in Table 3, and the differences are not significant.

Highly active antiretroviral therapy and co-trimoxazole preventive therapy initiation

Of the 38 children studied, 31 (81.6%) had yet to initiate highly active antiretroviral therapy, while the remaining 7 (18.4%) had done so. Of the seven who had initiated, six were on an abacavir/lamivudine and dolutegravir combination regimen, while the remaining one was on lopinavir-/ritonavir-based combination.

Concerning co-trimoxazole preventive therapy, 31 (81.6%) out of the total 38 population had yet to initiate preventive therapy, while the remaining 7 (18.4%) had done so.

DISCUSSION

The present study may erroneously portray that HIV infection is not a notable cause of morbidity and mortality. Our prevalence estimate was below 1%. However, it is significant that more than half of the children admitted had not been previously diagnosed as HIV-infected or previously enrolled for care. Furthermore, the fact that most of our subjects were diagnosed at advanced stages is a pointer that many HIV-infected children are still undetected in our communities.

The vertical mode of transmission of HIV was unacceptably high in our series, with all our population acquiring HIV by mother-to-child transmission. The 100% vertical transmission rate in this study is the highest estimate compared to other studies.[,7,8] Thus, a lot has to be done in preventing mother to child transmission of HIV. Vertical transmission is the main modality of sustaining the pediatric HIV population. Therefore, there is a need for more concerted efforts by the concerned government and other appropriate health agencies and stakeholders to critically appraise their prevention of mother-to-child transmission of HIV programs to control this disease in the pediatric age group.

The present study also suggests a failure in the early infant screening and diagnosis of HIV programs in our health setting. The scope of the present research was not extended to cover why most of our HIV-infected series were being discovered for the first time during the index admission. Further research needs to look into this gap and provide recommendations on how to mitigate this challenge. Certainly, there were missed opportunities in the diagnosis of this admission, as some of these children had earlier contact with a health facility, most especially those with comorbid diseases, before the present admission. Research has shown that missed opportunities for earlier HIV diagnosis tend to impact negatively on HIV disease progression.[12]

Considering this high rate of undetected HIV infections, it may be advisable for our health facilities to embrace the provider-initiated testing and counseling services for all children visiting the various hospital units such as the clinics or wards. Late diagnosis of HIV sets the stage for fast progression of HIV disease and may have been responsible for the preponderance of advanced-stage HIV infection recorded in our series. Previous reports also suggest a preponderance of children with advanced stages in their series.[,7,8,14,15]

Our findings of tuberculosis, pneumonia, and diarrhea as the prevalent diseases among our series are consistent with previous reports.[,7,8,14,15,16] However, our findings of notable cases of severe malaria in our admissions are novel to the best of our knowledge. A previous report from Mozambique suggests that affectation of the central nervous system with meningitis and malaria is common in children infected with HIV.[17] This present study, however, highlights significant findings of a preponderance of severe malaria above the age of 5 years, which is outside the usual under-5-year age setting for severe malaria. Susceptibility to malaria in HIV infected children can be explained by the general depilatory effect of HIV on macrophages of which the monocyte cells is linked to. Monocytes are a type of white cells that can differentiate to macrophages and they have been documented to be a part of the immune system controlling parasite burden and protecting against host malaria infection.[18] All the children with severe malaria presented in advanced Stage III.

In addition, all the children diagnosed with severe malaria were not on co-trimoxazole prophylaxis because they were newly HIV-diagnosed patients. Previous reports have highlighted the protective effect of co-trimoxazole prophylaxis against malaria and Pneumocystis pneumonia.[19,20]

Pneumocystis pneumonia and cryptococcal infections were the two notable common infections recorded in early infancy in the present study. They were responsible for significant mortality in our series. Both infections are highly lethal and challenging to diagnose and manage in resource-constrained settings, due to the invasive location of the infections and lack of diagnostics.[21,22] However, in addition to good clinical acumen, a chest radiograph and availability of a rapid cryptococcal antigen test are useful and reliable aids in making the diagnosis of Pneumocystis pneumonia and invasive cryptococcal infection, respectively, in resource-constrained settings.[23] The chest radiograph may also reveal reticulonodular, nodular, or interstitial infiltrates with pulmonary affectation in cryptococcal infection.[24] Thus, there is a need for access to cheap and sensitive diagnostics that can aid prompt diagnosis in our setting and similar settings.

The deaths attributable to both Pneumocystis pneumonia and cryptococcal infections are significant as they account for more than 50% of the deaths recorded in our series. It is important to pay more attention to both diseases not only by making the diagnostics easily available but also by ensuring easy access to the appropriate antifungal medications by those who need them. Previous studies conducted in Africa have shown that diagnostics, medications, and trained personnel to diagnose and manage these infections are generally lacking in African countries.[,26,27] There is, therefore, a need to train personnel and provide necessary medications to reverse the ugly outcomes associated with these infections.[27]

The most common coinfection in our series was candidiasis. The Candida infections identified in the present study included thrush and skin Candida affecting the perineum and buttocks. These Candida infections are commonly associated with HIV infection.[28,29] There were also a couple of presumed esophageal Candida infections. Diagnoses of esophageal and tracheal candidiasis can be challenging, but response to empirical treatment with an antifungal like fluconazole in individuals with dysphagia on swallowing with evidence of gastrointestinal tract infection can provide an inkling to the diagnosis and can be curative.

Scabies was the most common infestation recorded in our series. Our findings are consistent with those of Oyedeji et al.’s study of skin infections and infestations in HIV-infected children at Osogbo, Nigeria.[30] Diagnosis can also be challenging; however, the good response to benzyl benzoate provided assurance that our diagnosis was likely correct. None of our series presented as Norwegian scabies.

Our mortality rates from our HIV-infected case series admissions compare favorably with other settings in Nigeria.[,7,8] Hypoxemia was significantly responsible for the demise of most patients, and this is not surprising, as most patients infected with HIV presented with respiratory illnesses like tuberculosis, pneumonia, or PCP and present late with either Stage III or IV HIV disease.

A giant stride in reversing the ugly trends and high estimates associated with HIV infection will be to pay emphasis in preventing mother-to-child transmission of HIV. Furthermore, early detection of HIV by screening pregnant mothers for HIV and engaging the very early and early infant diagnosis programs as recommended by WHO, coupled with the rapid initiation of highly active antiretroviral therapy among those HIV-infected, should bring notable changes to the HIV scourge in our setting and other similar settings.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.