Severe, primary, and incidental COVID-19 in hospitalised children, South Africa: 2020–2023

In a high HIV prevalence country, approximately 70% of children with a positive SARS-CoV-2 test were hospitalised for COVID-19 treatment; almost 70% of these children were severely ill. Controlling for other factors, disease severity was highest in the hypothesised pre-immunity Ancestral period. HIV infection and delayed ART initiation were associated with severe signs. In such settings, strengthening general child health programmes to reduce underweight and prevent or treat paediatric HIV may reduce the severity of new diseases of pandemic proportion.