NEW PAPER FROM CHAMPS HIGHLIGHTS GAPS IN ADDRESSING HIV-RELATED DEATHS IN CHILDREN UNDER FIVE
- Nercio Machele
- Mar 25
- 4 min read
An article published under the CHAMPS network (Child Health and Mortality Prevention Surveillance) reveals that HIV remains one of the leading causes associated with mortality among children under five years of age in high-prevalence countries, including Mozambique, Kenya, Sierra Leone, and South Africa. The CHAMPS network, which implements post-mortem surveillance systems across eight countries, has operated in Mozambique since 2016, in the districts of Manhiça (Maputo Province) and Quelimane (Zambézia Province). Despite progress in preventing vertical transmission of HIV and expanding pediatric treatment programs, the findings indicate that significant challenges persist in diagnosis and timely access to antiretroviral treatment.
The article, whose first author is Senior Researcher at the Manhiça Health Research Centre (CISM), Inácio Mandomando, analyzed data from children under five years of age who died between December 2017 and December 2024. The study used a standardized approach that includes minimally invasive tissue sampling (MITS), histopathological examinations, microbiological and molecular testing, review of clinical records, and verbal autopsies, enabling a more accurate determination of causes of death.
At the CHAMPS network level, approximately 5,200 child deaths with assigned causes were analyzed, of which 164 (3.2%) included HIV in the chain of events leading to death. These cases included 2 children under 28 days of age and 162 children aged between 1 and 59 months.
According to Mandomando, “Prevalence for HIV in the causal chain among infant and child deaths was highest in Mozambique (38 [13%] of 296), followed by Kenya (41 [8%] of 499), Sierra Leone (39 [8%] of 500), Mali (13 [8%] of 168), and South Africa (30 [8%] of 399.” In contrast, Ethiopia reported only one case (1%), while no HIV-attributed deaths were identified in Bangladesh. According to the authors, these results reflect differences in national HIV prevalence across countries.
Age group analysis indicates that the proportion of HIV-associated deaths increases with age. Mozambique shows the highest prevalence, ranging from 0% (0/643) among neonates, to 10% (12/124) among children aged 1 to 11 months, and 15% (26/172) among those aged 12 to 59 months. These findings suggest a possible role of breastfeeding in late transmission, as well as gaps in the implementation of HIV protocols, particularly in testing and follow-up practices currently in place in the country, as also evidenced by data from the ongoing pilot study in Manhiça district.
According to Mandomando, “one of the most concerning findings highlighted in this article was the high proportion of children who, at the time of death, had no documented HIV status. Among the 162 cases in which HIV was part of the main chain of causes of death, 68 (42%) did not have a diagnosis documented prior to death and, consequently, did not have access to treatment. These findings suggest gaps in the testing and follow-up cascade, indicating that a significant proportion of children who died with HIV had not been diagnosed or were not receiving treatment, highlighting missed opportunities along the continuum of care.”
HIV-associated deaths rarely occurred in isolation. Most children presented multiple comorbidities and co-infections, particularly lower respiratory tract infections (52%), sepsis (43%), malaria (17%), diarrheal diseases (16%), anemia (14%), and meningitis or encephalitis (9%). Only three deaths were attributed to tuberculosis, despite comprehensive molecular and histopathological testing conducted as part of the surveillance.
Malnutrition emerged as a key contributing factor. More than half of HIV-attributed deaths (55%) included acute malnutrition or wasting associated with advanced disease. Post-mortem anthropometric measurements showed that 67% of children were underweight for their age, and 37% presented severe stunting. Researchers highlight the strong interconnection between HIV, malnutrition, and infections, creating a cycle that significantly compromises child survival.
The study also indicates that most HIV-attributed deaths were considered preventable by the multidisciplinary expert panel responsible for determining causes of death. The absence of diagnosis during life in more than 40% of cases, as well as the lack of antiretroviral treatment in about one-third of diagnosed children, highlights gaps in early testing, linkage to care, and treatment continuity. The authors also point to specific challenges in pediatric treatment, including the need for appropriate or adapted formulations, reliance on caregivers, and socioeconomic barriers that hinder adherence.
Funded by the Gates Foundation, the study concludes that pediatric HIV continues to significantly contribute to mortality among children under five in high-prevalence settings. The combination of late diagnosis, severe malnutrition, and multiple opportunistic infections creates a scenario of heightened vulnerability.
Strengthening early HIV detection, expanding access to antiretroviral treatment, preventing vertical transmission, integrating nutritional care, and improving infection control are identified as priority measures to reduce preventable deaths and help countries move closer to global HIV control targets.
Reference
Mandomando, I., Madewell, Z. J., Mutevedzi, P. C., Igunza, K. A., Onyango, D., Rogena, E. A., Were, J., Nhampossa, T., Torres-Fernandez, D., Varo, R., Xerinda, E. G., Dangor, Z., Madhi, S. A., Mahtab, S., Sorour, G., Dempster, M., Lakoh, S., Ameh, S., Ogbuanu, I. U., Ojulong, J., Samura, S., Keita, A. M., Kotloff, K. L., Sidibe, D., Sow, S. O., Tapia, M. D., Assefa, N., Demessie, D., Madrid, L., Scott, J. A., Wakaya, G., El Arifeen, S., Gurley, E. S., Tippett Barr, B. A., Whitney, C. G., Blau, D. M., Bassat, Q., Akelo, V., The Child Health and Mortality Prevention Surveillance network. (2026). Post-mortem characterisation of HIV-associated under-5 deaths in the CHAMPS network: Population-based mortality surveillance. The Lancet HIV. https://doi.org/10.1016/S2352-3018(25)00330-3
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