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Objective. To assess patterns of morbidity and associated factors in late infancy and early childhood among human immunodeficiency virus (HIV)-infected and -uninfected African children. Design. Prospective study. Setting. The Queen Elizabeth Central Hospital, Blantyre, Malawi. Participants. Children with known HIV status from an earlier perinatal intervention trial were enrolled during the first year of life and followed to ∼36 months of age. Outcome Measures. Morbidity and mortality information was collected every 3 months by a questionnaire. A physical examination was conducted every 6 months. Blood to determine CD4+ values was also collected. Age-adjusted and Kaplan-Meier analyses were performed to compare rates of morbidity and mortality among infected and uninfected children. Results. Overall, 808 children (190 HIV-infected, 499 HIV-uninfected but born to infected mothers, and 119 born to HIV-uninfected mothers) were included in this study. Of these, 109 died during a median follow-up of 18 months. Rates of childhood immunizations were high among all children (eg, lowest was measles vaccination [87%] among HIV-infected children). Age-adjusted morbidity rates were significantly higher among HIV-infected than among HIV-uninfected children. HIV-infected children were more immunosuppressed than were uninfected children. By 3 years of age, 89% of the infected children died, 10% were in HIV disease category B or C, and only ∼1% were without HIV symptoms. Among HIV-infected children, median survival after the first occurrence of acquired immunodeficiency syndrome-related conditions, such as splenomegaly, oral thrush, and developmental delay, was Conclusions. The frequency of diseases was high, and progression from asymptomatic or symptomatic HIV disease to death was rapid. Management strategies that effectively reduce morbidity for HIV-infected children are needed.

Background: Longitudinal studies face power reduction due to loss to follow up (LTFU). Bias may also arise because of differences between those who stay in the study and those who are LTFU We studied factors associated with LTFU in a cohort of HIV sero-negative and sera-positive mothers in urban Malawi. Objective: To bridge the existing gaps by examining the factors associated with attrition. Design: Longitudinal study. Setting: Queen Elizabeth Central Hospital (QECH) and the Kamuzu Central Hospital in Blantyre, Malawi. Subjects: One thousand three hundred and fifty three women who attended the prenatal clinic, between October 1989 and October 1990 were recruited as part of a study to determine rates and risk factors of sero-prevalence and sera-conversion of HIV -1 among this cohort. Results: In this cohort study, 1353 women were enrolled at delivery and 1188 (88%) returned for the first follow-up visit at three months post-partum. Of those who returned, 177 (15%) were subsequently lost during the remaining months of follow-up. The main predictors of L TFU were younger maternal age, lower educational level of the father, HIV infection of the mother, lower birth weight of the index child and mother not being married. Conclusions: Researchers planning studies in developing countries should consider the impact of lower education and poorer infant health on study retention in developing countries.

HIV-1 prevalence is approximately 23% among men working at a sugar estate in Malawi. Given the scale of the HIV epidemic in this country, it is important to determine possible cofactors of infection. The authors investigated associations between HIV-1 prevalence and herpes simplex virus 2 (HSV-2), hepatitis C virus (HCV), and hepatitis B virus (HBV) infections (indicated by anti-HSV-2, anti-HCV and HBsAg positivity, respectively) in a nested case-control study of 279 HIV-positive and 280 HIV-negative male workers. The prevalence of HSV-2 infection was 88.1% among HIV-positive persons and 64.3% among HIV-negative control subjects (p

Background Mortality from cryptococcal meningitis remains very high in Africa. In the Advancing Cryptococcal Meningitis Treatment for Africa (ACTA) trial, 2 weeks of fluconazole (FLU) plus flucytosine (5FC) was as effective and less costly than 2 weeks of amphotericin-based regimens. However, many African settings treat with FLU monotherapy, and the cost-effectiveness of adding 5FC to FLU is uncertain. Methods The effectiveness and costs of FLU+5FC were taken from ACTA, which included a costing analysis at the Zambian site. The effectiveness of FLU was derived from cohorts of consecutively enrolled patients, managed in respects other than drug therapy, as were participants in ACTA. FLU costs were derived from costs of FLU+5FC in ACTA, by subtracting 5FC drug and monitoring costs. The cost-effectiveness of FLU+5FC vs FLU alone was measured as the incremental cost-effectiveness ratio (ICER). A probabilistic sensitivity analysis assessed uncertainties and a bivariate deterministic sensitivity analysis examined the impact of varying mortality and 5FC drug costs on the ICER. Results The mean costs per patient were US $847 (95% confidence interval [CI] $776–927) for FLU+5FC, and US $628 (95% CI $557–709) for FLU. The 10-week mortality rate was 35.1% (95% CI 28.9–41.7%) with FLU+5FC and 53.8% (95% CI 43.1–64.1%) with FLU. At the current 5FC price of US $1.30 per 500 mg tablet, the ICER of 5FC+FLU versus FLU alone was US $65 (95% CI $28–208) per life-year saved. Reducing the 5FC cost to between US $0.80 and US $0.40 per 500 mg resulted in an ICER between US $44 and US $28 per life-year saved. Conclusions The addition of 5FC to FLU is cost-effective for cryptococcal meningitis treatment in Africa and, if made available widely, could substantially reduce mortality rates among human immunodeficiency virus–infected persons in Africa., The combination of flucytosine plus fluconazole (FLU) is cost-effective, compared with the commonly used regimen of FLU monotherapy, for cryptococcal meningitis treatment in Africa, with an incremental cost-effectiveness ratio of US $65 per life-year saved at the current price.