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. 2026 Feb 24:S2352-3018(25)00330-3.
doi: 10.1016/S2352-3018(25)00330-3. Online ahead of print.

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

Inacio Mandomando  1 , Zachary J Madewell  2 , Portia C Mutevedzi  3 , Kitiezo Aggrey Igunza  4 , Dickens Onyango  5 , Emily A Rogena  6 , Joyce Were  4 , Tacilta Nhampossa  7 , David Torres-Fernandez  8 , Rosauro Varo  9 , Elisio G Xerinda  10 , Ziyaad Dangor  11 , Shabir A Madhi  12 , Sana Mahtab  11 , Gillian Sorour  13 , Megan Dempster  11 , Sulaiman Lakoh  14 , Soter Ameh  15 , Ikechukwu Udo Ogbuanu  16 , Julius Ojulong  17 , Solomon Samura  18 , Adama Mamby Keita  19 , Karen L Kotloff  20 , Diakaridia Sidibe  19 , Samba O Sow  19 , Milagritos D Tapia  20 , Nega Assefa  21 , Daniel Demessie  22 , Lola Madrid  21 , J Anthony G Scott  23 , Getahun Wakwaya  22 , Shams El Arifeen  24 , Emily S Gurley  25 , Beth A Tippett Barr  26 , Cynthia G Whitney  3 , Dianna M Blau  27 , Quique Bassat  28 , Victor Akelo  29 ; Child Health and Mortality Prevention Surveillance network
Collaborators, Affiliations

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

Inacio Mandomando et al. Lancet HIV. .

Abstract

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.

Funding: Bill & Melinda Gates Foundation.

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Conflict of interest statement

Declaration of interests KLK reports receiving institutional support from Emory University through the Bill & Melinda Gates Foundation for the work reported in this manuscript; additional institutional grants from the US National Institutes of Health; consulting fees paid to her institution from PaxVax for development of a next-generation COVID-19 vaccine; and service on the Vaccines and Related Biological Products Advisory Committee and the Antimicrobial Drugs Advisory Committee of the US Food and Drug Administration. SAM reports institutional grants from the Bill & Melinda Gates Foundation, GSK, Pfizer, Minervax, Merck, Providence, and Gritstone; and participation on data and safety monitoring boards for Program for Appropriate Technology in Health (Rotavirus vaccine), Centre for the AIDS Programme of Research in South Africa (HIV monoclonal antibody), and Bavarian Nordic (MVA-BN vaccine). JAGS reports institutional grants from Emory University (for the current work), the Wellcome Trust, the UK National Institute for Health and Care Research, and the Bill & Melinda Gates Foundation; and service as a member of the WHO Strategic Advisory Group of Experts on Immunization. All other authors declare no competing interests.

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