Severe morbidity and mortality in untreated HIV-infected children in a paediatric care programme in Abidjan, C？te d'Ivoire, 2004-2009

All HIV-infected children enrolled from 2004-2009 in a prospective HIV programme in two health facilities in Abidjan, C？te d'Ivoire, were eligible from their time of inclusion. Risks of severe morbidity (the first clinical event leading to death or hospitalisation) and mortality were documented retrospectively and estimated using cumulative incidence functions. Associations with baseline characteristics were assessed by competing risk regression models between outcomes and antiretroviral initiation.405 children were included at a median age of 4.5 years; at baseline, 66.9% were receiving cotrimoxazole prophylaxis, and 27.7% met the 2006 WHO criteria for immunodeficiency by age. The risk of developing a severe morbid event was 14% (95%CI: 10.7 - 17.8) at 18 months; this risk was lower in children previously exposed to any prevention of mother-to-child-transmission (PMTCT) intervention (adjusted subdistribution hazard ratio [sHR]: 0.16, 95% CI: 0.04 - 0.71) versus those without known exposure. Cumulative mortality reached 5.5% (95%CI: 3.5 - 8.1) at 18 months. Mortality was associated with immunodeficiency (sHR: 6.02, 95% CI: 1.28-28.42).Having benefited from early access to care minimizes the severe morbidity risk for children who acquire HIV. Despite the receipt of cotrimoxazole prophylaxis, the risk of severe morbidity and mortality remains high in untreated HIV-infected children. Such evidence adds arguments to promote earlier access to ART in HIV-infected children in Africa and improve care interventions in a context where treatment is still not available to all.In 2008, UNAIDS reported 14% of new human immunodeficiency virus (HIV) infections occurring in children below 15 years of age throughout the world [1]. By the end of 2008, it was estimated that 91% of HIV-infected children lived in sub-Saharan Africa [1]. Before ART was introduced, infant mortality of HIV-infected children on the African continent was high and premature, reaching 35% among children less th