Post-mortem characterisation of HIV-associated under-5 deaths in the CHAMPS network: population-based mortality surveillance

Background Despite widespread implementation of vertical transmission prevention and paediatric HIV programmes, HIV remains a leading cause of child mortality. We analysed HIV-attributed deaths in the Child Health and Mortality Prevention Surveillance (CHAMPS) network, focusing on comorbidities, co-infections, and care gaps. 

Methods: We conducted a prospective, descriptive analysis of deaths in children younger than 5 years (under-5) recorded from Dec 3, 2016, to Dec 31, 2024, across seven CHAMPS sites in Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, South Africa, and Bangladesh. Causes of death were determined through standardised post-mortem investigations using minimally invasive tissue sampling, histopathology, molecular testing, clinical record abstraction, and verbal autopsy. Multidisciplinary panels adjudicated causes of death, and descriptive statistics were used to summarise demographic, clinical, and laboratory findings.

Findings Of 5200 under-5 deaths with an assigned cause, 164 (3·2%) had HIV in the causal chain—two neonatal and 162 infant or child deaths. 31 additional infants and children with HIV had HIV listed as a contributing condition only. Among infants and children, HIV-attributed mortality was highest in Mozambique (38 [13%] of 296), Kenya (41 [8%] of 499), Sierra Leone (39 [8%] of 500), Mali (13 [8%] of 168), and South Africa (30 [8%] of 399), and was rare in Ethiopia (one [1%] of 140) and absent in Bangladesh (none of 15). Only 94 (58%) of 162 HIV-attributed cases had documented antemortem diagnoses; of those, 63 (67%) had received antiretroviral therapy. Comorbidities included lower respiratory infections (84 [52%] of 162), sepsis (70 [43%]), malaria (27 [17%]), diarrhoeal diseases (26 [16%]), anaemia (22 [14%]), other infections (22 [14%]), and meningitis or encephalitis (15 [9%]). Wasting syndrome was present in 89 (55%) of 162, and 144 (89%) of 162 had other infections in the causal chain, including cytomegalovirus (48 [30%] of 162), Klebsiella pneumoniae (48 [30%]), Streptococcus pneumoniae (30 [19%]), and Pneumocystis jirovecii (24 [15%]). 

Interpretation Paediatric HIV remains a major contributor to under-5 mortality in high-burden settings, often alongside co-infections and malnutrition. Low diagnosis and treatment rates reflect missed care opportunities. Strengthening early detection, treatment, and maternal–child health services is essential to reducing deaths and achieving global HIV targets.