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-/-).
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
“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-/-
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
For more information:
Disclosure: Dr. O’Reilly reports no relevant financial disclosures.
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
Disclosure: Dr. Shane reports no relevant financial disclosures.