HIV-exposure as a risk factor for mortality among neonates with culture- confirmed bloodstream infection and meningitis in South Africa, 2019- 2020

Abstract

Background: HIV-exposed but uninfected neonates (HEU) are a growing population. Exposure to HIV has been associated with increased mortality and morbidity. We aimed to determine the effect of HIV-exposure as a risk factor for mortality in neonates admitted with bloodstream infections (BSIs) and/or meningitis at non-academic hospitals in South Africa. Methods: We conducted a retrospective cohort study using data from the Baby GERMS-SA surveillance project of hospitalised neonates with culture-confirmed BSI and meningitis at six non-academic hospitals in South Africa from October 2019 to September 2020. A multivariable Cox proportional hazards regression was used to determine the effect of HIV- exposure regardless of HIV-status as a risk factor for mortality. We further examined the effect of HIV-exposure using a multivariable logistics regression. Results: Of 697 neonates with a known maternal HIV status and in-hospital outcome, 34% (239/697) were exposed to HIV and 1% (4/239) were HIV PCR-positive. The HEU neonates had significant low gestational age (77% (184/239) vs. 66% (296/458), p=0.001) and very low birth weight (48% (115/239) vs. 40% (184/458), p=0.016) compared to HIV-unexposed uninfected (HUU) neonates. Exclusive breastfeeding was more common in HUU neonates (44% (202/458) vs. 32% (77/239)). We did not observe significant differences in age at the time of infection (median age 6 vs. 6 days p=0.14), and duration of hospitalisation (median length of 17 vs. 15 days p=0.12) between the HEU and HUU neonates. The crude in-hospital mortality among HIV-exposed neonates and HUU neonates was 26% (63/239) and 23% (104/458), respectively. After adjusting for relevant confounders such as birth weight, timing of infection, use of invasive devices, breastfeeding, and maternal age, there was no difference in the risk for mortality between HEU neonates and those who were HUU (HR 1.12, 95% CI: 0.76-1.67, p=0.549) at 28-days. The odds of mortality were 1.21 (95% CI 0.72–2.05, v p=0.467) times more among HEU neonates than among HUU neonates in the exploratory analysis. Conclusions: We did not find a difference in mortality between HEU and HUU neonates with culture-confirmed invasive infections in our study. Regardless of their HIV exposure status, approximately a quarter of these neonates died in hospital.