malnourished children in urban Malawi who got ART within three weeks of
therapeutic feeding were more likely to recover nutritionally (86% compared to
60%, p<0.01) and gained over twice as much weight (3.6 compared to 1.6
g/k/day; p=0.02) than those who started ART later, researchers report in a retrospective
observational study in the advance online edition of the Journal of Acquired Immune Deficiency Syndromes.
among children in sub-Saharan Africa is often
combined with malnutrition. This can lead to longer and lower rates of
nutritional recovery as well as an increased risk of death in cases of severe
and acute malnutrition.
those areas where HIV is prevalent and food insecurity is the main cause of
childhood malnutrition, malnutrition is usually treated first. Only when the
child has failed to improve in a feeding programme will HIV be taken into
account and ART started. This often results in a very high death rate.
HIV-infected children early with ART has been shown to improve survival as well
as their nutritional status. Yet severe wasting is also seen in children after
having started ART.
authors note little data exists on the best time to start ART in HIV-infected
and malnourished children. So they chose to look at a cohort of HIV-infected
malnourished children, of which some had started ART together with nutritional
therapy (prompt ART), to compare the effect of prompt ART on nutritional
recovery and rates of weight gain and death.
ART was defined as having started ART within 21 days of starting ready-to-use
therapeutic food (RUTF). This time frame was chosen by taking into account the
time it takes to diagnose the need for ART in a clinic setting, identification
of caregivers and training them on correct ART administration.
HIV-infected children aged six to 60 months with uncomplicated acute
malnutrition and a good appetite who were outpatients between February 2007 and
February 2008 at the Baylor College of Medicine-Abbott Fund-Children’s Clinical
Center of Excellence (COE) in Lilongwe,
included in the analysis. COE, offering free care in the largest urban area of Malawi, is the
main referral centre for complicated paediatric HIV cases in the country. HIV
care is integrated with malnutrition treatment.
appetite was defined as being able to consume 30 grammes of RUTF when offered
at admission. Children who got ART for more than 21 days before entering the
feeding programme were excluded.
collected included electronic medical records and the children’s written
medical records. Children with severe malnutrition were seen weekly and those
with moderate malnutrition every two weeks. Weight, height, mid-upper arm
circumference (MUAC), appetite, symptoms, ART status, CD4 count and CD4 percentage
were recorded. Use of RUTF was reviewed. 200 kcal/kg each day of RUTF was
given. Nutritional recovery was defined as children having reached 85% weight
for height, MUAC greater than 12 centimetres with a resolution of any swelling
got cotrimoxazole prophylaxis. ART was available for children during the time
of the study.
the 140 children included in the analysis 79% (111) were eligible for ART, only
39% (55) started ART within 21 days of the start of RUTF. A higher proportion of
children on prompt ART recovered nutritionally and none developed edema.
children died: four children among those who got prompt ART in which three had
multiple underlying problems; of the remaining 12 who did not receive prompt
ART all had underlying problems.
ART was the most significant factor associated with nutritional recovery.
authors note that because they represent a retrospective comparison, the
findings are preliminary. The relatively small sample size representing a
referral population to an urban speciality HIV clinic does not account for
socio-economic factors or the severity of HIV. This
population, then, is not representative of either all HIV-infected or all
malnourished children in Malawi.
observations have prompted some to suggest that some development of edema in
severely malnourished HIV-infected children upon starting ART is an example of
Immune Reconstitution Inflammatory Syndrome (IRIS).
authors note in their study no child developed edema and very few needed hospitalisation.
They suggest this may be because of their young age and an absence of any
serious clinical illness.
this cohort of children had uncomplicated acute malnutrition, 14% nonetheless
died while getting RUTF and even among those not eligible for ART nutritional
recovery was poor.
authors stress this highlights ‘the critically ill nature of the malnourished,
HIV-infected child and the need for comprehensive, coordinated care for
malnutrition, HIV, TB and opportunistic infections. This is best provided
during a single clinic visit at the same location.” Investing resources, they
add, for better coordination is key if child survival and growth is to be
the start of ART to see if wasting was related to causes other than HIV was
common in this study. This practice, they caution, results in a significant
increased risk of death among HIV-infected children “and needs urgent
authors conclude “this preliminary evidence suggests that prompt ART is associated
with improved outcomes in HIV-infected Malawian children with uncomplicated