The prevalence rate of paediatric HIV infection of 10.0% in this study is lower than earlier reports from Africa [20, 21] and Nigeria[5, 6, 22]. However, the studies from Nigeria were among high risk groups suspected to have immunosuppression and all studies were done before HIV DNA PCR testing facilities were available and used serological tests which might give a false positive results in patients aged <18 months. Other studies that reported lower prevalence rates [6, 8, 7] were mostly retrospective and among hospitalized children thus some cases might have been missed. Conversely, the study site being a referral site might have accounted for the high prevalence rate observed. One limitation of the study however, is in the subset of HIV exposed infants <6 weeks old and those still breast feeding. This group will need a repeat HIV DNA PCR at 3 months and 6 weeks after stopping breastfeeding due to the less than optimal sensitivity of the HIV DNA PCR in infants <6 weeks and continued exposure from breastfeeding, some of these patients might actually turn out to be HIV infected. This however was not captured in this study being cross-sectional in design. A longitudinal study would better describe this.
The Provider Initiated HIV Testing and Counselling guideline[1, 15] is useful in identifying HIV infection in patient presenting to health facilities and do not have the classical symptoms and signs of the infection, thereby limiting missed opportunities for early detection and care. In this study, of such children without the classical features of HIV Infection, 17 (3.1%) children were found to be seropositive for HIV infection, and 10 (1.8%) were confirmed positive for retroviral infection. This finding gives credence to the need to offer routine screening to all children presenting in health facilities as provided in the WHO guideline[1, 15]. In addition HIV infected children may present with conditions which are also seen in HIV uninfected children in the general population as highlighted in this study.
The controversy as to whether gender is a risk factor for MTCT of HIV [23, 24] continues. In this study, as observed by Adejuyigbe et al and Oniyangi et al, there was a slight female preponderance, which contrast with other reports from Africa[11, 14, 22, 20]. MTCT accounting for 93.3% of infection in this study indicates the need to intensify efforts to get MTCT service to the large numbers of Nigerian women needing it. Transmission via blood transfusion and possible sexual route observed in this study means that as in other parts of Nigeria[5, 6, 8, 11, 22] calls for the need to improve blood transfusion services and need for paediatricians to always consider sexual mode of transmission when attending to HIV infected adolescents.
The clinical presentation of children with HIV infection in Ibadan is similar to that from other parts of Africa and Nigeria[8, 11, 22, 25]. These symptoms and signs are also seen in HIV negative children but the Odds Ratio show the higher likelihood of HIV infected children presenting with these features and some were predictive of HIV infection on multivariate regression analysis. Their presence, singly or in combination, should heighten the index of suspicion for HIV infection in children. The rarity of neurological features in HIV infected children observed here has been reported earlier and might be due to the relatively long time required for neurological features to develop.
Malnutrition, particularly marasmus, and pneumonia are prevalent clinical syndromes in HIV infected African children[5, 22, 20]. Malnutrition was present in 76% of children in this study. It has been recognized as an underlying contributing factor to childhood morbidity and mortality and contributes to about 56% of under-five mortalities in the developing countries. The severe malnutrition observed in HIV infected children is definitely a major factor that needs attention. The high TB-HIV co-infection rate in this study re-echo's the unholy alliance between these two conditions and the burden they pose on the health of children in our environment. Efforts to expand HIV prevention, treatment and care services must thus be matched by similar services for TB prevention and treatment.
Based on the revised WHO Paediatric Clinical Staging of HIV/AIDS, about 75% of the patients in this study presented in advanced clinical stages 3 and 4, and similar observations had been reported from other parts of Nigeria . Also 57.8% were severely immunosuppressed which also compares with 55.7% with severe immunosuppression observed by Ugochukwu et al. In addition, 50% had viral loads >100,000 copies/ml. The implication of these is that most children presented at the advanced stages of the disease associated with poor prognosis and need for antiretroviral therapy. There is thus a need to evolve methods of early identification and proper management of HIV infected children to prevent clinical and immunological deterioration, which further reiterates the need for implementing the PITC guidelines.
HIV contributes significantly to orphan rate, with rates as high as 25.75% and 10.8% in sub-Saharan Africa and Nigeria respectively[1, 3]. A similarly high orphan rate among HIV positive children in this study calls for an urgent need for support services for both HIV affected and infected children bearing in mind the poor social services in these parts of the world. In addition efforts need to be intensified to reduce HIV infection and AIDS related deaths in adults by scaling up HIV prevention interventions and improved access to antiretroviral therapy as this will reduce paediatric HIV from MTCT and the number of AIDS orphans.
Mortality rate was 11.6% among admitted children in the study population, with a slightly higher rate of 14.3% among HIV positive children. Higher mortality figures of 26.1-46.3% have been reported from other parts of Nigeria[5, 6, 8], while in a prospective 5 year study of HIV infected Rwandan children, the estimated risk of death at 2 and 5 years of age was 45% and 62%, respectively and the risk of dying was 21 times higher than in uninfected children. The high mortality figures observed in these studies were in the pre-antiretroviral era and so the lower mortality rate observed in this study could have been due to the antiretroviral treatment programme in place at the study centre which facilitated the management of these patients and thus gave a better outcome.