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Most information about children living with HIV is based on follow up from children identified through mother-to-child transmission studies. Children identified through voluntary counseling and testing (VCT) represent a unique cohort that has not been previously described in the literature.Children who were found to have HIV infection through VCT were offered enrollment in this study. They were evaluated monthly and encouraged to return to the clinic any time they were ill. Thorough evaluation was performed for every illness.Forty-five children were enrolled in the study. Many of the participants (33%) had a serious acute disease at the time of enrollment. The most common diagnoses were symptomatic malaria and pneumonia. The children were more ill than adults who were enrolled in a simultaneous study and had a higher death rate (37 versus 15 deaths per 100 person-years of observation). The mortality rate was 22%. Undernutrition and low CD4 cell count were independently associated with increased risk of death.Malawian children found to be HIV-infected through VCT had a high morbidity and mortality rate, highlighting the potential benefit of trimethoprim–sulfamethizole prophylaxis and available antiretroviral therapy.