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Respiratory syncytial virus (RSV) causes increased morbidity and mortality in immunocompromised children. The outcome of RSV-associated lower respiratory tract infections (LRTI) in HIV-infected children, is less well described.Children from a prospective study evaluating the etiology of LRTI in African children, Soweto, South Africa, between March, 1997, and March, 1999, from whom RSV was isolated are included in this report. RSV was identified by mouse anti-RSV monoclonal fluorescent antibody and subgroups were identified by reverse transcription polymerase chain reaction.The prevalence of HIV infection was 14.6% (39 of 268) in children with RSV-associated severe LRTI. HIV-infected children were older than HIV-uninfected children [median, (25th to 75th quartiles)], 7.0 (3.0 to 12.0) vs. 4.0 (2.0 to 8.0) months, respectively, P = 0.003. Traditionally recognized risk factors for severe RSV disease were present in 23.1 and 24.5% of HIV-infected and -uninfected children respectively. HIV-infected children (92.3%) were more likely to present with pneumonia than HIV-uninfected children (68.6%, P < 0.002). Furthermore concurrent bacteremia (15.4%vs. 2.6%, P = 0.003), axillary temperatures of >38°C (32.3%vs. 18.8%, P = 0.03) and leukocyte count >15 000/mm3 (41.0%vs. 25.3%, P = 0.04) occurred more often in HIV-infected than in HIV-uninfected children, respectively. The case fatality rate was also greater in HIV-infected than in HIV-uninfected children (7.6%vs. 1.7%, respectively; relative risk, 4.40; 95% confidence intervals, 1.02 to 18.92).HIV-infected children remain predisposed to developing RSV-associated severe LRTI beyond the first six months of life and are more likely to present with pneumonia, have greater evidence of bacterial coinfection and greater mortality than HIV-uninfected children.