ORIGINAL ARTICLE |
https://doi.org/10.5005/jp-journals-10081-1455 |
Prevalence and Clinical Presentation in Newly Diagnosed Human Immunodeficiency Virus-infected Children Aged 2 Months to 5 Years in Federal Medical Centre, Katsina, Nigeria: A Cross-sectional Study
1–3Department of Pediatrics, Federal Teaching Hospital Katsina, Katsina, Nigeria
4Department of Pediatrics, University of Global Health Equity, Kigali, Rwanda
Corresponding Author: Fatima F Nasir, Department of Pediatrics, Federal Teaching Hospital Katsina, Katsina, Nigeria, Phone: +2348035334221, e-mail: fatimanasirfaskari@gmail.com
Received: 02 October 2024; Accepted: 07 December 2024; Published on: 20 March 2025
ABSTRACT
Aim and background: The recent Nigerian human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) Indicator and Impact Survey (NAIIS) has revealed a decline in the national seroprevalence of pediatric HIV infection. This study aimed to determine the seroprevalence of pediatric HIV infection in a hospital-based study and to determine the clinical presentations among newly diagnosed children at Federal Medical Centre (FMC), Katsina.
Materials and methods: Consecutive new patients aged 2 months to 5 years who presented at the emergency pediatric unit of the hospital were screened for HIV infection. History and physical examination findings were documented for each child. Seropositive children <18 months had their status confirmed using HIV deoxyribonucleic acid polymerase chain reaction (HIV DNA PCR).
Results: Of the 508 children screened, four were seropositive for HIV, giving a seroprevalence of 0.8%. Common symptoms in the HIV-infected children were fever (100%), vomiting (75%), poor weight gain (75%), and cough (50%). Common signs in HIV-infected children were oral thrush (75%), skin lesions (75%), generalized lymphadenopathy (50%), and parotid fullness (25%). However, only oral thrush was predictive of HIV infection (p < 0.007).
Conclusion: This study reveals a substantial reduction in the seroprevalence of HIV infection among children presenting at the pediatric emergency unit of FMC Katsina. Of the symptoms and signs associated with the infection, only oral thrush was predictive.
Clinical significance: The study contributed to knowledge by documenting the seroprevalence of pediatric HIV in FMC Katsina and the clinical features predictive of HIV infection.
Keywords: Clinical presentation, Human immunodeficiency virus infection, Seroprevalence
How to cite this article: Nasir FF, Ibrahim M, Suleiman BM, et al. Prevalence and Clinical Presentation in Newly Diagnosed Human Immunodeficiency Virus-infected Children Aged 2 Months to 5 Years in Federal Medical Centre, Katsina, Nigeria: A Cross-sectional Study. Pediatr Inf Dis 2025;7(2):39–43.
Source of support: Nil
Conflict of interest: None
INTRODUCTION
The recent national survey on key human immunodeficiency virus (HIV)-related health indicators by the Nigerian HIV/acquired immunodeficiency syndrome (AIDS) Indicator and Impact Survey (NAIIS) revealed a decline in the national seroprevalence of pediatric HIV infection,1 but the morbidity and mortality of the infection have remained high in Nigeria. The clinical presentation of pediatric HIV infection also mimics common pediatric clinical conditions.2 With the decline in national seroprevalence of HIV infection, is there a change in the clinical presentation of the infection? It is therefore anticipated that this study will reveal the current seroprevalence of the infection in a hospital-based study to determine if the seroprevalence is on the decline as well and if there is any difference in the clinical presentation among newly diagnosed HIV-infected children in FMC Katsina and those that are seronegative for the infection.
OBJECTIVES
To determine the seroprevalence and clinical presentation in newly diagnosed HIV-infected children aged 2 months to 5 years seen at Federal Medical Centre (FMC), Katsina.
SPECIFIC OBJECTIVES
To determine, among children aged 2 months to 5 years in FMC Katsina:
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The seroprevalence of pediatric HIV infection.
-
The clinical presentations (symptoms and signs) of pediatric HIV infection.
Research Hypothesis
Null hypothesis: There is no difference in the clinical presentations among newly diagnosed seropositive children aged 2 months to 5 years and those that are seronegative for HIV seen at FMC, Katsina.
Alternate hypothesis: There is a significant difference in the clinical presentations among newly diagnosed seropositive children aged 2 months to 5 years and those that are seronegative for HIV seen at FMC, Katsina.
MATERIALS AND METHODS
Study Design
The study was a prospective, descriptive cross-sectional study.
Study Population
The study population included all children aged 2 months to 5 years seen and admitted at the Children Emergency Unit of Federal Medical Centre Katsina from July 2019 to March 2020.
Inclusion Criteria
The study included all children aged 2 months to 5 years who were admitted into the emergency unit, and whose parents/caregivers consented to the study.
Exclusion Criteria
Previously diagnosed HIV-infected patients were excluded.
Bias was minimized by making sure that all patients that presented to the emergency presentation unit (EPU) were recruited except those whose parents declined consent.
Sample Size Determination
The sample size was calculated using the formula for calculating sample size for qualitative variables3 as follows:
n = Z2pq/d2
n = Sample size
Z = Corresponding standard deviate at confidence level of 95% of type one error, which is equivalent to 1.96
p = Estimated incidence = 13.8%
d = Level of precision 3%
q = 1 – p
n = (1.96)2 × 0.138 × 0.862 / 0.03 × 0.03
n = 508
Data Collection Procedure
A pretested proforma was administered on all study participants to obtain their relevant clinical information. This included the biodata, full clinical history including nutritional and immunization status, anthropometric measurements, and family socioeconomic information. All subjects had general and systemic physical examinations at first contact, and the findings were entered in the study record form.
HIV screening was performed with the Determine HIV1/2 strip (Alere Medical Co., 357 Matsuhidai, Matsudo-shi, Chiba 270-214, Japan). Children who tested negative on determine were considered HIV-negative. For subjects who were beyond 18 months of age and tested positive on Determine, a second test using the UNI-GOLD rapid test kit (Trinity Biotech Plc., IDA Business Park, Bray, Co. Wicklow, Ireland) was performed as a confirmatory test.4,5 Subjects who tested positive on the second test using the UNI-GOLD rapid test kit were considered HIV infected. When the result of the second test was negative, however, a third test was performed as a tiebreaker, using HIV 1/2 STAT-PAK (Chembio Diagnostic Systems, Inc., 3661 Horseblock Road, Medford, NY 11763, USA).6 The child was confirmed positive/negative for HIV infection when the third test was positive/negative, respectively. For children <18 months, DNA-PCR using dried blood spots on filter paper was performed in a regional reference laboratory to confirm their HIV status.
Data Analysis
Statistical Package for Social Sciences (IBM SPSS®) software version 24.0 (IBM Corp., Armonk, NY, USA) was used for data analysis. The age was grouped into single-year categories: 2–12, 13–24, 25–36, 37–48, and 49–60 months. The socioeconomic status of the parent/guardian was grouped using the Oyedeji classification. The average of the father’s and mother’s occupation and educational qualifications was taken and then grouped into upper (1 and 2), middle (3), and lower (4 and 5) social classes. The continuous data was checked for normality. Age was summarized using median and interquartile range because it was skewed. Categorical variables, for example, gender, ethnicity, social class, and nutritional status, were summarized using frequencies and percentages. Categorical variables like clinical features were compared using either the Chi-squared test or Fisher’s exact test, as appropriate. Results were presented in tables. The prevalence of HIV infection was calculated using the formula: number of HIV cases/total number of screened subjects × 100. A p-value of <0.05 was considered statistically significant.
RESULTS
Within the period of this study, 508 children aged 2–60 months were recruited consecutively. The median age was 23 months, with an interquartile range (IQR) of 10–35 months. The male-to-female ratio was 1.3:1 (Table 1).
| Frequency (n = 508) | Percentage (%) | |
|---|---|---|
| Gender | ||
| Male | 289 | 56.9 |
| Female | 219 | 43.1 |
| Age-group (month) | ||
| 2–12 | 146 | 28.7 |
| 13–24 | 117 | 23.0 |
| 25–36 | 94 | 18.5 |
| 37–48 | 76 | 15.0 |
| 49–60 | 75 | 14.8 |
| Ethnicity | ||
| Hausa | 457 | 89.9 |
| Fulani | 19 | 3.7 |
| Yoruba | 12 | 2.4 |
| Igbo | 6 | 1.2 |
| *Others | 14 | 2.8 |
| Social class | ||
| Upper | 131 | 25.8 |
| Middle | 163 | 32.1 |
| Lower | 214 | 42.1 |
Social class is based on Oyedeji classification of social class; *Others: Igala, Idoma, Gobirawa, Etsako, Kanuri, Zabarmawa, Bare-bari, Shuwa, Kahugu, and Dera
Seroprevalence of Pediatric Human Immunodeficiency Virus Infection
Of the 508 subjects screened, four subjects tested positive, giving a seroprevalence of 0.8%. A confirmatory DNA PCR was conducted on two of the four seropositive subjects because they were <18 months old. The remaining two subjects were aged 18 months and above. All were male. The sociodemographic characteristics of HIV seropositive children are summarized in Table 2.
| Patient 1 | Patient 2 | Patient 3 | Patient 4 | |
|---|---|---|---|---|
| Age (months) | 14 | 11 | 43 | 31 |
| Gender | M | M | M | M |
| Maternal HIV status* | Positive | Positive | Positive | Negative |
| Social class | 3 | 5 | 3 | 1 |
| Ethnicity | Hausa | Hausa | Hausa | Igbo |
M, male; *Mothers confirmed HIV-positive upon child’s diagnosis
Clinical Features of Pediatric Human Immunodeficiency Virus Infection
The most common presenting symptom in patients confirmed positive for HIV infection was fever, which was present in all of them. The symptom that was statistically significantly different between HIV-positive and HIV-negative patients was failure to gain weight (p = 0.026). Other presenting symptoms are summarized in Table 3.
| Clinical features | HIV status | p-value | |||
|---|---|---|---|---|---|
| Positive n = 4 |
% | Negative n = 504 |
% | ||
| Fever Cough Breathlessness Diarrhea Vomiting Poor weight gain Recurrent otorrhea Body pains Convulsion Pallor Jaundice Cyanosis Parotid fullness Oral thrush Generalized lymphadenopathy Skin lesions Edema Hepatomegaly Splenomegaly |
4 2 2 2 3 3 1 0 0 1 0 0 1 3 2 3 0 1 0 |
100 50.0 50.0 50.0 75.0 75.0 25.0 0.0 0.0 25.0 0.0 0.0 25.0 75.0 50.0 75.0 0.0 25.0 0.0 |
442 170 85 141 124 98 0 38 153 115 28 4 5 5 34 25 24 115 19 |
87.7 33.7 16.9 28.0 24.6 19.4 0.0 7.5 30.4 22.8 5.6 0.8 1.0 1.0 6.8 5.0 4.8 23.0 3.8 |
1.000 0.608 0.138 0.316 0.050 0.026 0.080 1.000 0.321 1.000 1.000 1.000 0.047 0.000 0.027 0.001 1.000 1.000 1.000 |
Df, 1; Test, Fisher’s exact; Skin lesion, rashes, eczema, impetigo; Bold values denotes p-values that were <0.05 significant
Oral thrush, parotid fullness, generalized lymphadenopathy, and skin lesions occurred more commonly in HIV-positive subjects compared to HIV-negative subjects (p < 0.047) (Table 3). A binary logistic regression was performed (Table 4) to ascertain the likelihood of predicting HIV positivity in the presence of all the significant clinical features. The logistic regression model was significant with χ2 = 27.042, df = 1, p < 0.001. The model (binary logistic regression) explains 59.0% of the variance in HIV positivity and correctly classified 99.2% of cases. Clinical features associated with an increased likelihood of HIV positivity were oral thrush, poor weight gain, and skin lesions. While patients with oral thrush were 53 times more likely to have HIV infection (p < 0.007), those with poor weight gain and parotid fullness were 3 and 2 times more likely to be HIV seropositive, respectively.
| Symptoms/signs | HIV-positive N = 4 |
HIV-negative n = 504 |
Adjusted odds ratio (95% CI) | p-value |
|---|---|---|---|---|
| Poor weight gain | 3 | 98 | 3.357 (0.197–57.229) | 0.403 |
| Parotid fullness | 1 | 5 | 1.758 (0.016–188.810) | 0.813 |
| Oral thrush | 3 | 5 | 53.226 (2.922–970.886) | 0.007 |
| Generalized lymphadenopathy | 2 | 34 | 0.384 (0.014–10.255) | 0.568 |
| Skin lesion | 3 | 25 | 0.090 (0.005–1.589) | 0.100 |
Df, 1
The percentage of children with malnutrition was high in the study population (66.1%). It was higher in those with HIV infection compared to those without (75 vs 65.7%), p > 0.05. Table 5 describes the relationship between weight for stature and HIV infection.
| Nutritional status/weight for stature (z-score) | HIV-positive (%) | HIV-negative (%) | Total (%) | p-value |
|---|---|---|---|---|
| <–3 –3 to <–2 –2 to <–1 0 1 2 3 Total |
3 (75.0) 0 (0.0) 0 (0.0) 1 (25.0) 0 (0.0) 0 (0.0) 0 (0.0) 4 (100.0) |
151 (30.0) 131 (26.0) 49 (9.7) 143 (28.4) 14 (2.8) 11 (2.2) 5 (0.9) 504 (100.0) |
154 (30.3) 131 (26.2) 49 (9.6) 144 (28.3) 14 (2.7) 11 (2.2) 5 (0.9) 508 (100.0) |
0.610 |
Test, Fisher’s exact = 5.821; df, 1
DISCUSSION
The seroprevalence obtained in this study (0.8%) was lower than the 2.9% reported in a recent worldwide survey by United Nations International Children’s Emergency Fund (UNICEF) among children aged 0–9 years.7 The lower seroprevalence obtained in this study compared to the UNICEF findings could be because this is a local study conducted in a part of the country with the lowest seroprevalence of HIV infection, while the UNICEF study was global and included regions with high seroprevalence in children. The seroprevalence was higher than the 0.2% reported in children in the recent nationwide NAIIS survey.1 The higher seroprevalence found in this study may be explained by this being a hospital-based study involving sick children, whereas the earlier reported survey was community-based and involved both healthy and sick children. The seroprevalence obtained in this study was higher when compared with the number of HIV-infected children reported from North America and Europe. Antenatal care, access to HIV care and prevention, elimination of mother-to-child transmission (eMTCT), and hospital delivery were almost universal in Europe and North America, as opposed to the study location in Nigeria, where antenatal care attendance was poor and started late in pregnancy. Furthermore, a lot still needs to be done with regard to universal availability of eMTCT services and other HIV care and prevention services in the study environment.8 Compared with other Nigerian studies, however, the seroprevalence found in this study was much lower. The prevalence was reported from other Nigerian centers as 10% from Ibadan, 4.5% from Ekiti, 25.8% from Port Harcourt, 14.9% from Abeokuta, 13.8% from Kano, 11.9% from Abuja, and 10% in Kogi.5,9,13 The lower seroprevalence could be a reflection of the success of programs toward the control of HIV in the country, including prevention of HIV among general and target populations, eMTCT of HIV, improving HIV treatment, care, support and adherence services, and improved uptake of PMTCT.14,15
From this study, the age-group 36–48 months had the highest number of HIV-positive children (age-group HIV seroprevalence of 1.4%). This is not in keeping with what was reported from Blantyre, Malawi, where infants <6 months were more affected with HIV (31.9%) compared to older children.16 The differences could be due to delays in diagnosis and possibly missed implementation of PITC, as some of the HIV-positive patients in this study had presented at different health care facilities (at an earlier age) but were not screened for HIV. HIV symptoms and signs were apparent by 13 months of age in all the HIV-positive children, as reported by Spira et al. in Rwanda.17 That study, however, recruited HIV-positive mothers and followed up their babies from birth through five years, thereby diagnosing infected children early. Their finding was therefore not unexpected, as most HIV-infected children in developing countries present with a rapid course of disease.18
The findings in this study in terms of clinical features of HIV infection are not different from other studies that were conducted when the national seroprevalence of HIV infection was high. The most common presenting symptom in patients confirmed positive for HIV infection was fever. Other symptoms common in HIV infected subjects were poor weight gain and vomiting.
This study found that oral thrush, parotid fullness, generalized lymphadenopathy, and skin lesions occurred more commonly in HIV-positive subjects compared to HIV-negative subjects. As earlier noted, common clinical presenting features of pediatric HIV infection mimic those of other common childhood illnesses.2 The signs are generally nonspecific.
This study also found that among the clinical features commonly seen in HIV-infected children, oral thrush was significantly predictive of HIV infection. This is similar to what was reported by Ogunbosi et al.2 and Obiagwu et al.10 The presence of this sign should therefore raise an index of suspicion of HIV infection in children, especially with the declining burden of HIV infection in the country.
This study also reveals the poor nutritional status of the study population. In 2018, Katsina state was ranked 2nd highest in the prevalence chart of global acute malnutrition, with a prevalence of 9.2%, in a National Nutrition and Health Survey conducted by the National Bureau of Statistics, National Population Commission, and the Federal Ministry of Health.19 Katsina state also had the highest prevalence of stunting (58%), far higher than the national stunting prevalence of 32%.19 This high burden of malnutrition is due to a number of reasons, including a high level of poverty, maternal malnutrition, poor infant and young child feeding practices, nonavailability, and poor access to healthcare, water, and sanitation.20 In this study, the proportion of children with malnutrition was slightly higher among those with HIV infection compared to those without the infection (75 vs 65.7%). Marasmus (nonedematous SAM) was the most common type of malnutrition seen among both HIV-infected and noninfected children in this study. Previous studies have reported this.21,24
CONCLUSION
From this study, it is concluded that the prevalence of HIV infection among children aged 2 months to 5 years in Federal Medical Centre Katsina (now Federal Teaching Hospital Katsina) was low (0.8%). The predominant symptoms and signs documented in HIV-positive subjects were fever, poor weight gain, vomiting, oral thrush, parotid fullness, generalized lymphadenopathy, and skin lesions. However, only oral thrush is predictive of HIV infection.
Clinical Significance
The study contributed to knowledge by documenting the seroprevalence of pediatric HIV in FMC Katsina and the clinical features predictive of HIV infection.
Limitation of the Study
This is a hospital-based study; hence, it may not give the true seroprevalence of HIV infection among children in the general population in Katsina State.
INTERPRETATION
The seroprevalence of HIV infection is low in Katsina, and there is no difference in the clinical presentation of the infection (currently, when the seroprevalence is low) compared to when the seroprevalence was high in the country. An accompanying finding was the high prevalence of malnutrition among all children in Katsina State, which was noticeably higher than the national prevalence.
GENERALIZABILITY
The study was limited to children aged 2 months to 5 years; therefore, findings from this study may not be generalized to all children and adolescents.
ORCID
Fatima F Nasir https://orcid.org/0000-0001-6285-7729
Mu’uta Ibrahim https://orcid.org/0000-0003-3590-6040
Bello M Suleiman https://orcid.org/0000-0002-5481-6801
Olayinka R Ibrahim https://orcid.org/0000-0002-2621-6593
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