Survival in children with perinatal HIV infection and very low CD4 lymphocyte counts

Objectives: To evaluate clinical conditions associated with mortality in HI V-infected children with CD4(+) counts <100 cells/<mu>l. Methods: The Pediatric Spectrum of HIV Disease Project is a longitudinal me dical record review study with eight study sites in the United States, whic h have been enrolling children since 1989. Survival time from baseline very low CD4 count (<100 cells/<mu>l) to death was estimated using the Kaplan-M eier method. Cox proportional hazards models were used to evaluate the effe ct of clinical variables on mortality. Results: Of 522 children (greater than or equal to1 year of age) with seria l CD4(+) T-lymphocyte measurements, the median age at the first very low CD 4 count was 4.8 years. The estimated median survival following the first ve ry low CD4 count was 36 months. The following factors present at the first very low CD4 count were independently associated with a higher risk of deat h: younger age, weight-for-age >2 standard deviations below the mean, and p reviously diagnosed AIDS. The subsequent development of cytomegalovirus (CM V)-associated disease, Mycobacterium avium intracellulare (MAI) infection, wasting syndrome, or esophageal candidiasis was also independently associat ed with a higher risk of death. Conclusion: Survival in HIV-infected children with very low CD4 counts befo re introduction of highly active antiretroviral therapy was highly variable . Poor nutritional status and the development of CMV disease or MAI infecti on were associated with the shortest survival times.