Utility of clinical parameters to identify HIV infection in infants below ten weeks of age in South Africa: a prospective cohort study

HIV-infected and HIV-uninfected exposed infants < 10 weeks of age were identified through Vertical Transmission Prevention programs. Clinical and laboratory data were systematically recorded, groups were compared using Kruskal-Wallis, analysis of variance (ANOVA), and Fisher's exact tests. Receiver Operating Characteristic (ROC) curves were compiled using combinations of clinical findings.417 HIV-infected and 125 HIV-exposed, uninfected infants, median age 46 days (IQR 38-55), were included. The median CD4 percentage in HIV-infected infants was 34 (IQR 28-41)%. HIV-infected infants had lower weight-for-age, more lymphadenopathy, oral thrush, and hepatomegaly than exposed uninfected infants (Adjusted Odds Ratio 0.51, 8.8, 5.6 and 23.5 respectively; p < 0.001 for all). Sensitivity of individual signs was low (< 20%) but specificity high (98-100%). If any one of oral thrush, hepatomegaly, splenomegaly, lymphadenopathy, diaper dermatitis, weight < 50th centile are present, sensitivity for HIV infection amongst HIV-exposed infants was 86%. These algorithms performed similarly when used to predict severe immune suppression.A combination of physical findings is helpful in identifying infants most likely to be HIV-infected. This may inform management algorithms and provide guidance for focused laboratory testing in some settings, and should be further validated in these settings and elsewhere.Identifying HIV infection in early infancy is an important challenge to effective paediatric HIV care and treatment. HIV-infected infants have a high mortality, particularly in heavily disease-burdened settings [1-6]. The Children with HIV Early Antiretroviral Therapy (CHER) trial [4] recently showed that early antiretroviral therapy (ART), commenced at a median of 7 weeks of age was associated with a 75% reduction in mortality versus the prevailing standard of care at the time (the WHO 2006 guidelines) [7]. Importantly, most deaths occurred in the first few months of life and none of