Alternatives to CD4 lymphocyte count and HIV viral load as lower-cost predictors of mortality in children born to HIV-infected mothers in a resource-limited setting

In global regions with high prevalence and poor prophylactic measures, children are vulnerable to acquiring HIV. In these settings, the use of disease progression assays such as HIV-1 viral load and CD4 lymphocyte count may be expensive and/or unavailable. Because of these barriers and the peak in roll-out of antiretrovirals, lower-cost alternative assays for assessing HIV prognosis are needed to guide the use of ARV therapy. Few studies have attempted to validate less-costly markers in HIV-infected children. The objective of this study was to investigate the utility of plasma albumin, ferritin, total lymphocyte count (TLC) and white blood cell count (WBC) to predict mortality in children born to HIV-infected mothers in a resource-limited setting. Subjects were part of a randomized, controlled trial to examine effects of maternal multivitamin supplementation on maternal/child health outcomes in Dar Es Salaam, Tanzania. Child plasma albumin, ferritin, TLC and WBC were measured at 6 weeks and 6 months of age. Using Cox proportional hazards models, these parameters were related to child mortality over a 24-month follow-up. Models were also stratified by child HIV status. Preliminary results indicated that albumin, ferritin, TLC and WBC measurements at 6 weeks and 6 months were available for 610 subjects. Over 24 months of follow-up, 117 (19%) of 610 children died. Out of 610 children, 466 had albumin< 3.5g/dL. Children with albumin< 3.5g/dL had an 85% increased mortality rate over the 24 month follow-up period [Hazard Ratio (HR)=1.85 , 95% CI: 1.07-3.19, p=0.03]. Analyses were adjusted for CD4 cell count, time-varying HIV status, weight-for-age, plasma values of selenium, ferritin, vitamin A, vitamin E, and maternal vitamin regimen. Among HIV-uninfected children, low albumin levels were related to a xx increased mortality rate (HR=xxx, 95%CI..). Among those who became HIV-infected over follow-up, there was an indication of an increased mortality rate among children with low albumin levels (HR=xxx, 95%CI..). Results on the associations of ferritin, TLC and WBC and child mortality are forthcoming. If our continued analyses support these conclusion then even in resource-limited regions where CD4 and viral load assays may be unavailable, alternative markers such as albumin may potentially be used to as a prognostic marker in pediatric HIV care.