Abstract
.HIV-exposed, uninfected (HEU) children are a growing population at particularly high risk of infection-related death in whom preventing diarrhea may significantly reduce under-5 morbidity and mortality in sub-Saharan Africa. A historic cohort (1999–2002) of Kenyan HEU infants followed from birth to 12 months was used. Maternal and infant morbidity were ascertained at monthly clinic visits and unscheduled sick visits. The Andersen–Gill Cox model was used to assess maternal, environmental, and infant correlates of diarrhea, moderate-to-severe diarrhea (MSD; diarrhea with dehydration, dysentery, or related hospital admission), and prolonged/persistent diarrhea (> 7 days) in infants. HIV-exposed, uninfected infants (n = 373) experienced a mean 2.09 (95% CI: 1.93, 2.25) episodes of diarrhea, 0.47 (95% CI: 0.40, 0.55) episodes of MSD, and 0.34 (95% CI: 0.29, 0.42) episodes of prolonged/persistent diarrhea in their first year. Postpartum maternal diarrhea was associated with increased risk of infant diarrhea (Hazard ratio [HR]: 2.09; 95% CI: 1.43, 3.06) and MSD (HR: 2.89; 95% CI: 1.10, 7.59). Maternal antibiotic use was a risk factor for prolonged/persistent diarrhea (HR: 1.63; 95% CI: 1.04, 2.55). Infants living in households with a pit latrine were 1.44 (95% CI: 1.19, 1.74) and 1.49 (95% CI: 1.04, 2.14) times more likely to experience diarrhea and MSD, respectively, relative to those with a flush toilet. Current exclusive breastfeeding was protective against MSD (HR: 0.30; 95% CI: 0.15, 0.58) relative to infants receiving no breast milk. Reductions in maternal diarrhea may result in substantial reductions in diarrhea morbidity among HEU children, in addition to standard diarrhea prevention interventions.
Highlights
Diarrhea remains a significant cause of morbidity and mortality among children living in sub-Saharan Africa (SSA), contributing to nearly 10% of under-5 deaths in the region.[1,2] Increasing evidence suggests diarrhea, moderateto-severe diarrhea (MSD) and prolonged/persistent diarrhea, is associated with considerable long-term morbidity, including growth compromise, increased frequency of other infections, and poor cognitive development.[3,4,5,6]In 2018, there were more than two million young women (15–24 years) in SSA living with HIV.[7]
The remaining 373 HEU infants were included in this analysis, including 355 who remained uninfected in the first year and 18 who subsequently acquired HIV at a median age of 181 days, whose visits after the last negative HIV test were censored
Risk factors varied by type of diarrhea with any diarrhea primarily associated with likelihood of infectious exposure, whereas risk factors for MSD included likelihood of an infectious exposure and factors potentially associated with a child’s ability to fight the infection
Summary
In 2018, there were more than two million young women (15–24 years) in SSA living with HIV.[7] Widespread implementation of programs to prevent mother-to-child transmission (PMTCT) of HIV has successfully reduced the risk of HIV transmission to children, resulting in a growing population of children exposed to HIV but uninfected (HEU).[8] Being born to or living with an HIV-infected mother may present unique risk factors for diarrhea, such as frequent bouts of maternal diarrhea and/or increased maternal household antibiotic use. With 1.2 million HEU infants born each year, a reduction in diarrhea among this uniquely vulnerable population would contribute to the global decline in diarrhea burden.[9] We determined incidence and risk factors for diarrhea, MSD, and prolonged/persistent diarrhea in a cohort of HEU infants
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