Predictors of mortality among HIV exposed infants at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia

Based on the Joint United Nations Program on HIV/AIDS (UNAIDS) report in 2018, 36.9 million people living with Human Immunodeficiency Virus (HIV). Of which, more than 50% were women and 90% of HIV positive pregnant women live in sub-Saharan Africa [1]. According to the global plan towards the elimination of new HIV infections among children mother to child HIV transmission has been reduced by 60% and the number of ADIS related child death was 49,000 as a referee of 2015 report [2]. It shows child mortality continued to be a persistent global problem. In 2015, an estimated 1.2 million babies were born from HIV-positive mothers [3, 4]. Those children born from HIV positive mothers are at higher risk of death [5]. Infant health is one of the indicators of countries developmental progress.

Consequently, at the international and national level, different strategies have been implemented to reduce mortality of children born from HIV positive mother. Notably, the World Health Organization (WHO) four prongs Prevention of Mother-to-Child Transmission (PMTCT) of HIV approach considered a key entry point of care for HIV positive pregnant, laboring and lactating women and their children is to be an infant mortality preventive strategy. These include primary prevention of HIV infection, prevention of unintended pregnancy among HIV positive women, prevention of HIV transmission from infected women to their children and treatment, care and support of HIV infected women, their newborn and families [6, 7]. Moreover, the Ethiopian ministry of health initiated ‘option B+’ PMTCT approach since 2013 [6]. This approach recommends initiating Antiretroviral Therapy (ART) for all pregnant, laboring and lactating women, improving ART coverage, test to HIV and start HAART for all HIV positive children, early diagnosis for HIV exposed infant and improving health service utilization [6, 8].

Despite these much of interventions, the mortality of children who born from HIV positive mother is the public health problem for African and other less developed countries [9]. The incidence of child mortality reported 5/1000 person-year in India [10] and 150 per 1000 person-years in Zimbabwe [11]. It is also reported in Uganda (3.9%) [12], Cameron (23.9%) [13], Malawi (6.3–9.3%) [14], Rwanda (4.8%) [15], and Kenya 39% [16].

The High mortality of infants born from HIV positive mother has been attributed to different predictors. Some of the predictors identified in the previous studies from different countries include advanced maternal disease [17], HIV infection of the child [11, 14, 18], low birth weight [14], maternal survival status [19], early and abrupt breastfeeding cessation and mixed feeding [13, 15, 20], and prematurity [13].

In Ethiopia, there is no study done to estimate the mortality of HIV exposed infants before. Therefore, we assessed mortality and its predictors among HIV exposed infants at the University of Gondar comprehensive specialized hospital, Northwest Ethiopia.

This study showed that the overall infants’ mortality rate was 8.88 (95% CI: 6.36–12.36) per 100 child-year. This result is higher from the study conducted in Pune India (2.4/100-person-year) [10], Malawi (3.4/100 per person-year) [14], and Zambia (3.5/100 person-years) infants [20]. The exact reason for this difference in mortality is unknown, but it is probably multifactorial. This variation might be due to different follow-up period implemented. The study in India took 12 months’ follow-up period and 70 days a study in Zambia. The difference in the study population is another source; in Malawi only infants up to 48 weeks of age were included. Other possible explanation might be a high burden of infection [21], childhood illness [22], low coverage of prophylaxis [23, 24], high prevalence of under-nutrition [25, 26], low coverage of immunization [27], mixed feeding practice, pre-lacteal feeding [28], low infrastructure [29], health care facilities related infection [30], poor-bottle feeding hygiene recorded in Ethiopia, particularly in the current study region ( [31]. The expansion of ART initiation during delivery remains a national health priority. Hence, asymptomatic infections are remaining undiagnosed and not managed that increased probability of death.

In the Cox multivariable regression analysis parent death was a 3-fold risk for their child death among HIV exposed infants compared with those infants’ with parent alive. The evidence was supported by other studies from Zimbabwe [17] and a systemic review of HIV exposed uninfected African infant [9]. In Ethiopia, Orphan problems are universal. These children are subjected to abuse, neglect exploitation, and carelessness to bring to health institution early and/or to provide medication as ordered [32]. This is because those infants who lost their mother, father or both would lack quality of care and support, which might expose the child to the nutritional insecurity that leads to growth and development failure and undernutrition. Undernourished children could be vulnerable to infectious disease [33] and it increases the death of infants.

This study showed that infants who were on non-exclusive breastfeeding had at higher risk of death compared with infants on exclusive breastfeeding. This finding supported by studies from Cameron [13], a systemic review of HIV exposed infant studies [31], Zambia [20] and Uganda [12]. Mixed feeding, short duration of breastfeeding, and cessation of breastfeeding predisposes infants to dietary pathogens, diarrhea, and declined immunity [11]. As a result, infant mortality can be occurred more likely.

Infants with low birth weight were at high risk for death compared with infants who have normal birth weight. Finding in Malawi [14] also showed that low birth weight increases child mortality. In Ethiopia, the burden of low birth weight is one of the main problems, 17.3% newborn are below normal birth weight [34]. It exposed the infant to hypoglycemia, hypothermia, mental retardation, and growth failure that exposed to infection and related complication, which further contribute to child mortality.

In this study presence of the suggestive sign and symptom of HIV, infection was one of the predictors of infant mortality. The result was supported by a systemic review on HIV-exposed uninfected African child [9] and a study in Botswana [35]. This may be due to HIV exposed infants are expected to impaired immunity system than HIV unexposed infants. This sign and symptoms are the indications of underdiagnosed and non-managed systemic infections. As infection rate increase the risk of death is high.

Growth failure was one of the predictors of infant mortality which increases the death rate of infants by 2.9 times compared with infants who had normal growth. This evidence was supported by a systemic review conducted on HIV exposed uninfected infant [25]. This may be due to the reason that those infant with growth failure can expose to infection, immunological failure, and increased hospitalization that could increase mortality of infants.

Mortality of HIV exposed infants was high in Ethiopia. Prevention of the occurrence of HIV infection symptom, growth failure, and low birth weight is essential and further treat early whenever they occurred. Still, behavioral change interventions on mother who practice non-exclusive breastfeeding are indicated. Especial care for orphan infants is required due to their nature of vulnerability to varieties of health problem. It would be good to fill all the data properly on the chart, registration book and follow-up forms, like immunization status, income, and hospitalization rate of the child.