Growth failure as a prognostic indicator of mortality in pediatric HIV infection

Nutritional status of HIV-infected children at Federal University Teaching Hospital, Owerri, Nigeria: A prospective analysis of rural and urban dwellers

Malnutrition is a critical concern among children living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), particularly in regions heavily affected by the HIV epidemic, such as sub-Saharan Africa. In 2019, nearly 2.84 million children under 19 years of age were living with HIV globally, with over 90% residing in sub-Saharan Africa. Concurrently, malnutrition remains prevalent in the region, with approximately 49 million children under the age of 5 experiencing stunting and 149 million suffering from wasting in 2018. This burden of malnutrition is exacerbated by factors such as poverty, food insecurity, and HIV/AIDS, which collectively contribute to adverse health outcomes among affected children. The bidirectional relationship between HIV/AIDS and malnutrition is well-established, with HIV infection increasing the risk of malnutrition and malnutrition worsening the progression of HIV/AIDS. Studies have consistently demonstrated higher rates of stunting, underweight, and wasting among HIV-infected children compared to their uninfected counterparts. Moreover, malnutrition significantly impacts the disease progression, morbidity, and mortality of HIV-infected individuals, further underscoring the importance of addressing this issue in pediatric HIV care. A total of 99 HIV-infected children, aged 2 to 16 years, were consecutively recruited from the pediatric infectious disease clinic of the Federal University Teaching Hospital Owerri. Anthropometric measurements, including weight and height, were obtained using a stadiometer (RGZ-160 England). Weight status was categorized as normal, underweight, overweight, or obese, while height status was classified as stunted, normal, or tall stature. The study participants ranged in age from 2 to 16 years. Approximately 20.2% of the children were underweight, and 6.1% were classified as obese. Stunting was observed in 29.3% of the participants. Notably, all forms of malnutrition, including underweight and overweight, were more prevalent among children residing in rural areas. In addition, stunting was more common among rural dwellers. This study highlights the high prevalence of malnutrition among HIV-infected children attending the pediatric infectious disease clinic at the Federal University Teaching Hospital Owerri. The findings underscore the urgent need for targeted nutritional interventions, particularly in rural areas, to improve the health outcomes of HIV-infected children.

Growth Trajectories Over the First Year of Life Among Early-Treated Infants with Human Immunodeficiency Virus and Infants Who are Human Immunodeficiency Virus-Exposed Uninfected

OBJECTIVE

To investigate the role of early antiretroviral therapy (ART) on growth trajectories of infants with human immunodeficiency virus (IHIV) in the first year of life.

STUDY DESIGN

As part of a clinical trial of early ART in Johannesburg, South Africa (2015-2018), 116 IHIV diagnosed within 48 hours of birth were started on ART as soon as possible, and 80 uninfected infants born to mothers living with HIV (IHEU) were enrolled. Both groups were followed prospectively from birth through 48 weeks and growth parameters collected. The groups were compared and risk factors for poor growth investigated, in the full cohort and among IHIV separately.

RESULTS

IHIV had lower mean weight-for-age Z-scores (WAZ) than IHEU at 4 and 8 weeks (-1.17 [SE:0.14] vs -0.72 [0.14], P = .035 and -1.23 [0.15] vs -0.67 [0.14], P = .012). Although there was some closing of the gap over time, means remained lower in IHIV through 48 weeks. In length-for-age Z-scores (LAZ), differences widened over time and IHIV had lower Z-scores by 48 weeks (-1.41 [0.15] vs -0.80 [0.18], P = .011). Deficits in WAZ and LAZ in IHIV vs IHEU were most marked among girls. IHIV with pre-ART viral load ≥1000 copies/ml had significantly lower weight-for-length and mid-upper arm circumference Z-scores across all time points through 48 weeks.

CONCLUSIONS

IHIV on early ART had deficits in WAZ over the first 8 weeks of life and lower LAZ at 48 weeks than IHEU. Among IHIV, higher pre-ART viral load was associated with worse anthropometric indicators through 48 weeks.

Malnutrition in HIV infected children on antiretroviral drugs in a cohort of Ghanaian children

Background

HIV infected children are at increased risk of malnutrition which worsens the depressed immune system, leading to poor disease prognosis.

Aim

To assess the nutritional status of children between 6-12 years on antiretroviral drugs (ARV) at two health facilities in Accra.

Methods

The study design was cross sectional among children between 6 and 12 years being administered with antiretroviral drugs at two hospitals in Accra. A purposive sample of 100 children was used. Height and weight measurements were taken and used to compute z-scores for stunting, underweight and wasting. Haemoglobin status was obtained from their folders. A semi-structured questionnaire was used to obtain sociodemographic data and a 24-hour dietary intake used to assess nutrient intakes. Data was analyzed using IBM SPSS version 20.0. Nutrient analysis was done using Micro diet version 3.0. Data was summarized using means and percentages. Chi-squared test was used to test for associations and statistical significance set at p < 0.05.

Results

The prevalence of stunting, underweight and wasting was reported as 28%, 16% and 13% respectively. Girls were more stunted and wasted compared to boys. Mean haemoglobin concentration was 10.12 ± 2.77 g/dl. Mild, moderate and severe anaemia were reported in 14.2%, 41.1% and 12.5% of the children respectively. Apart from carbohydrates, less than 50% of the children were able to meet their requirements for the other nutrients”.

Conclusions

Our findings reveal high level of malnutrition among the children receiving ARV. There is the need for targeted nutrition interventions to improve the nutritional status of the children.

Growth and Metabolic Changes After Antiretroviral Initiation in South African Children

BACKGROUND

Poor growth and metabolic disturbances remain concerns for children living with HIV (CLHIV). We describe the impact of viral load (VL) on growth and lipid outcomes in South African CLHIV <12 years initiating World Health Organization recommended first-line antiretroviral therapy (ART) from 2012 to 2015.

METHODS

Z scores for length-for-age (LAZ), weight-for-age (WAZ) and body mass index-for-age were calculated. Lipids (total cholesterol, low-density lipoprotein and high-density lipoprotein) were measured. Hemoglobin A1C ≥5.8 was defined as at risk for type 2 diabetes. Mixed effects models were used to assess the association of VL at ART initiation with Z scores and lipids over time.

RESULTS

Of 241 CLHIV, 151 (63%) were <3 years initiating LPV/r-based ART and 90 (37%) were ≥3 years initiating EFV-based ART. Among CLHIV <3 years, higher VL at ART initiation was associated with lower mean LAZ (ß: -0.30, P=0.03), WAZ (ß: -0.32, P=0.01) and low-density lipoprotein (ß: -6.45, P=0.03) over time. Among CLHIV ≥3, a log 10 increase in pretreatment VL was associated with lower mean LAZ (ß: -0.29, P=0.07) trending towards significance and lower WAZ (ß: -0.32, P=0.05) as well as with more rapid increases in LAZ (ß: 0.14 per year, P=0.01) and WAZ (ß: 0.19 per year, P=0.04). Thirty percent of CLHIV were at risk for type 2 diabetes at ART initiation.

CONCLUSIONS

CLHIV initiating ART <3 years exhibited positive gains in growth and lipids, though high viremia at ART initiation was associated with persistently low growth and lipids, underscoring the need for early diagnosis and rapid treatment initiation. Future studies assessing the long-term cardiometabolic impact of these findings are warranted.

Unmapped exome reads implicate a role for Anelloviridae in childhood HIV-1 long-term non-progression

Human immunodeficiency virus (HIV) infection remains a significant public health burden globally. The role of viral co-infection in the rate of progression of HIV infection has been suggested but not empirically tested, particularly among children. We extracted and classified 42 viral species from whole-exome sequencing (WES) data of 813 HIV-infected children in Botswana and Uganda categorised as either long-term non-progressors (LTNPs) or rapid progressors (RPs). The Ugandan participants had a higher viral community diversity index compared to Batswana (p = 4.6 × 10-13), and viral sequences were more frequently detected among LTNPs than RPs (24% vs 16%; p = 0.008; OR, 1.9; 95% CI, 1.6-2.3), with Anelloviridae showing strong association with LTNP status (p = 3 × 10-4; q = 0.004, OR, 3.99; 95% CI, 1.74-10.25). This trend was still evident when stratified by country, sex, and sequencing platform, and after a logistic regression analysis adjusting for age, sex, country, and the sequencing platform (p = 0.02; q = 0.03; OR, 7.3; 95% CI, 1.6-40.5). Torque teno virus (TTV), which made up 95% of the Anelloviridae reads, has been associated with reduced immune activation. We identify an association between viral co-infection and prolonged AIDs-free survival status that may have utility as a biomarker of LTNP and could provide mechanistic insights to HIV progression in children, demonstrating the added value of interrogating off-target WES reads in cohort studies.

Glutathione Deficiency in HIV-1-Infected Children with Short Stature

Objective This study was aimed to determine if glutathione (GSH) deficiency occurs in children with HIV infection and whether GSH deficiency is associated with HIV-related short stature.

Methods We conducted a cross-sectional study with two age-matched comparison groups in an inner city hospital-based pediatric AIDS/HIV outpatient clinic. Ten perinatally HIV-infected children aged 6 to 49 months with short stature (height–age percentile ≤5) were studied together with age-matched 10 HIV-infected children with normal height and 10 HIV-seronegative children with normal height. Total erythrocyte GSH (GSH and GSH disulfide) levels were determined by a modification of the 5,5′-dithiobis-2-nitrobenzoic acid glutathione disulfide reductase method. Other measures included complete blood counts, lymphocyte subset analysis, plasma albumin, cholesterol, vitamins A and E, and determination of HIV disease stage.

Discussion Erythrocyte GSH levels were lower in HIV-infected children with short stature (mean ± standard deviation [SD]: 0.639 µmol/mL ± 0.189) compared with HIV-infected children with normal height (mean ± SD: 0.860 µmol/mL ± 0.358; p < 0.05) and HIV-negative controls (mean ± SD: 0.990 µmol/mL ± 0.343; p < 0.05). Plasma levels of cholesterol, albumin, and vitamins A and E did not differ between the short-stature group and either the HIV-infected normal-height group or HIV-negative controls.

Conclusion These results demonstrate a GSH deficiency in HIV-infected children with short stature and support the hypothesis that GSH balance is important in growth among HIV-infected children.

Universal antiretroviral therapy for HIV-infected children: a review of the benefits and risks to consider during implementation

Background: The 2016 World Health Organization (WHO) consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection, recommended to start all HIV-infected children on antiretroviral therapy (ART). Here, we explore the possible benefits and risks of implementing universal ART for all HIV-infected children and adolescents and outline some of the key considerations that led to the 2016 revision of WHO guidelines.

Methods: We conducted a review of the published data from 2000 to 2016, to ascertain the clinical and programmatic benefits, as well as the risks of implementing universal ART for all children.

Results and discussion: Universal ART for all children has the potential to increase treatment coverage, which in 2015 was only 51% globally, as well as providing several biological benefits, by preventing: premature death/loss to follow-up, progressive destruction of the immune system, poor growth and pubertal delay, poor neuro-cognitive outcomes and future burden to the health care system with complications of untreated HIV-infection. However, the strategy could be associated with risks, notably development of HIV drug resistance, antiretroviral drug toxicities and increased costs to an already stretched health system.

Conclusion: Overall, our findings suggest that the benefits could outweigh the risks and support universal ART for all HIV-infected children, but recognize that national programmes will need to put measures in place to minimize the risks if they choose to implement the strategy.

Child Growth According to Maternal and Child HIV Status in Zimbabwe

BACKGROUND

Growth failure is common among HIV-infected infants, but there are limited data on the effects of HIV exposure or timing of HIV acquisition on growth.

METHODS

Fourteen thousand one hundred ten infants were enrolled in the Zimbabwe Vitamin A for Mothers and Babies trial in Zimbabwe before the availability of antiretroviral therapy or co-trimoxazole. Anthropometric measurements were taken from birth through 12-24 months of age. Growth outcomes were compared between 5 groups of children: HIV-infected in utero (IU), intrapartum (IP) or postnatally (PN); HIV-exposed uninfected (HEU); and HIV unexposed.

RESULTS

Growth failure was common across all groups of children. Compared with HIV-unexposed children, IU-, IP- and PN-infected children had significantly lower length-for-age and weight-for-length Z scores throughout the first 2 years of life. At 12 months, odds ratios for stunting were higher in IU [6.25, 95% confidence interval (CI): 4.20-9.31] and IP infants (4.76, 95% CI: 3.58-6.33) than in PN infants (1.70, 95% CI: 1.16-2.47). Compared with HIV-unexposed infants, HEU infants at 12 months had odds ratios for stunting of 1.23 (95% CI: 1.08-1.39) and wasting of 1.56 (95% CI: 1.22-2.00).

CONCLUSIONS

HIV-infected infants had very high rates of growth failure during the first 2 years of life, particularly if IU or IP infected, highlighting the importance of early infant diagnosis and antiretroviral therapy. HEU infants had poorer growth than HIV-unexposed infants in the first 12 months of life.

A meta-analysis assessing all-cause mortality in HIV-exposed uninfected compared with HIV-unexposed uninfected infants and children

OBJECTIVE

Conduct a meta-analysis examining differential all-cause mortality rates between HIV-exposed uninfected (HEU) infants and children as compared with their HIV-unexposed uninfected (HUU) counterparts.

DESIGN

Meta-analysis summarizing the difference in mortality between HEU and HUU infants and children. Reviewed studies comparing children in the two groups for all-cause mortality, in any setting, from 1994 to 2016 from six databases.

METHODS

Meta-analyses were done estimating overall mortality comparing the two groups, stratified by duration of follow-up time from birth (0-12, 12-24 and >24 months) and by year enrollment ended in each study: less than 2002 compared with at least 2002, when single-dose nevirapine for prevention of mother-to-child transmission (PMTCT) commenced in low-income and middle-income countries.

RESULTS

Included 22 studies, for a total of 29 212 study participants [n = 8840 (30.3%) HEU; n = 20 372 (37.7%) HUU]. Random effects models showed HEU had a more than 70% increased risk of mortality vs. HUU. Stratifying by age showed that HEU vs. HUU had a significant 60-70% increased risk of death at every age strata. There was a significant 70% increase in the risk of mortality between groups before the implementation of PMTCT, which remained after 2002 [risk ratio: 1.46; 95% confidence interval (CI): 1.14-1.87], when the availability of PMTCT services was widespread, suggesting that prenatal antiretroviral therapy, and healthier mothers, does not fully eliminate this increased risk in mortality.

CONCLUSION

We show a consistent increase risk of mortality for HEU vs. HUU infants and children. Longitudinal research is needed to elucidate underlying mechanisms, such as maternal and infant health status and breast feeding practices, which may help explain these differences in mortality.

A Growth and Nutritional Study of HIV Seropositive Children from West Bengal under Direct Care of Medical Caregivers

AIM

To evaluate the nutritional status of HIV seropositive children, aged 2-10 years with age - matched controls and examine the role of nutritional intervention and HRT on their growth indices.

MATERIALS AND METHODS

It was a cross-sectional study done at a HIV Clinic of a teaching hospital. Fifty six seropositive children (age 2-10 year) classified as cases, and 60 seronegative age - matched controls were taken. Demographic and anthropometric characteristics were collected via valid instruments. HIV grading and adherence to HRT were assessed by using validated questionnaires.

RESULTS

Of the cases majority (87.5%) were infected by vertical transmission from mother to child, the remaining were infected by blood transfusion out of which 1.78% were haemophiliacs and remaining were thalassaemics. The prevalence of underweight among cases was 64.3%, compared to prevalence of 61% among controls. The prevalence of stunting was 44.6% among cases, while the prevalence of severe stunting was 14.3%. The prevalence of wasting among cases was 30.35%, while 7% cases were severely wasted. Only 23.33% controls were wasted. There was a significant difference in the Height- for-age between cases and controls, in the age of 4 years, 5 years and 6 years (p-value <0.05).

CONCLUSION

There was a significant difference in the Height- for-age between cases and controls, in the age of 4 years, 5 years and 6 years, indicating the need for proper nutritional intervention and timely HIV antiretroviral therapy to prevent stunting.

An Evaluation of Alternative Markers to Guide Initiation of Anti-retroviral Therapy in HIV-Infected Children in Settings where CD4 Assays are not Available

OBJECTIVES

In settings where CD4 testing is not available, alternative markers to start paediatric anti-retroviral therapy (ART) could be used. A comprehensive evaluation of these markers has not been performed.

METHODS

Prospective cross-sectional study of HIV-infected Malawian children not eligible for ART based on clinical criteria. Associations between CD4 and alternative markers [haemoglobin, total lymphocyte count (TLC), serum albumin, thrombocytes and growth parameters] were analysed, and accuracy of existing and new cut-offs were evaluated.

RESULTS

In all, 417 children were enrolled. Of 261 children aged ≥5 years, 155 (59%) qualified to start ART using CD4. In this group, only TLC was associated with CD4 (p < 0.001). Sensitivity for TLC was 21% (95% CI: 15-29%), using World Health Organization cut-offs. Improved cut-offs increased sensitivity to 73% (95% CI: 65-80%), specificity 62% (95% CI: 52-72%).

CONCLUSION

Clinical staging alone is an unreliable strategy to start ART in children. TLC is the only alternative marker for CD4, cut-offs need to be revised though.

Epidemiological Markers for Interactions Among Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus in Upper Respiratory Tract Carriage

BACKGROUND

Cocolonization by Streptococcus pneumoniae and Haemophilus influenzae among children has been noted in numerous studies, as has an inverse relationship involving colonization with these species and Staphylococcus aureus. Interactions among these pathogens could mediate unanticipated outcomes of clinical interventions, including changes in H. influenzae and S. aureus disease incidence following pneumococcal vaccine introduction. However, it remains unclear whether cocolonization patterns represent true interspecies interactions or whether they result from confounding factors.

METHODS

We investigated polymicrobial carriage using longitudinal data from 369 Bedouin children and 400 Jewish children in Israel who were enrolled in a 7-valent pneumococcal conjugate vaccine (PCV7) trial. Children were swabbed 10 times between 2 and 30 months of age.

RESULTS

The pathogens followed distinct age and seasonal distributions, but polymicrobial carriage associations persisted after controlling for these and other confounding factors. Receipt of PCV7 resulted in pneumococcal serotype replacement but did not influence total carriage of S. pneumoniae, H. influenzae, or S. aureus.

CONCLUSIONS

The fact that S. pneumoniae, H. influenzae, and S. aureus polymicrobial carriage patterns do not result from confounding by age and season supports the idea of active interspecies interactions. However, pneumococcal serotype replacement may prevent changes in H. influenzae and S. aureus carriage among PCV7 recipients.

The causal effect of childhood measles vaccination on educational attainment: A mother fixed-effects study in rural South Africa

Background

Because measles vaccination prevents acute measles disease and morbidities secondary to measles, such as undernutrition, blindness, and brain damage, the vaccination may also lead to higher educational attainment. However, there has been little evidence to support this hypothesis at the population level. In this study, we estimate the causal effect of childhood measles vaccination on educational attainment among children born between 1995 and 2000 in South Africa.

Methods and findings

We use longitudinal data on measles vaccination status and school grade attainment among 4783 children. The data were collected by the Wellcome Trust Africa Centre Demographic Information System (ACDIS), which is one of Africa's largest health and demographic surveillance systems. ACDIS is located in a poor, predominantly rural, Zulu-speaking community in KwaZulu-Natal, South Africa. Using mother fixed-effects regression, we compare the school grade attainment of siblings who are discordant in their measles vaccination status but share the same mother and household. This fixed-effects approach controls for confounding due to both observed and unobserved factors that do not vary between siblings, including sibling-invariant mother and household characteristics such as attitudes toward risk, conscientiousness, and aspirations for children. We further control for a range of potential confounders that vary between siblings, such as sex of the child, year of birth, mother's age at child's birth, and birth order. We find that measles vaccination on average increases school grade attainment by 0.188 grades (95% confidence interval, 0.0424–0.334; p = 0.011).

Conclusions

Measles vaccination increased educational attainment in this poor, largely rural community in South Africa. For every five to seven children vaccinated against measles, one additional school grade was gained. The presence of a measles vaccination effect in this community is plausible because (i) measles vaccination prevents measles complications including blindness, brain damage, and undernutrition; (ii) a large number of number of children were at risk of contracting measles because of the comparatively low measles vaccination coverage; and (iii) significant measles transmission occurred in the community where this study took place during the study observation period. Our results demonstrate for the first time that measles vaccination affects human development not only through its health effects but also through its effects on education.

Prevalence and risk factors of undernutrition among antiretroviral-therapy-naïve subjects aged under 5 years old in Makurdi, Nigeria: a retrospective study

Background

Undernutrition is common in human immunodeficiency virus (HIV) infection and it contributes significantly to its morbidity and mortality. However, as far as we are aware, few studies have described the risk factors of undernutrition among HIV-infected Nigerian children. The study reported here aimed to determine the prevalence and risk factors of undernutrition among HIV-infected, antiretroviral therapy (ART)-naïve children aged under 5 years old in Makurdi, Nigeria.

Methods

A retrospective, cross-sectional study was undertaken at the Federal Medical Centre, Makurdi, between June 2010 and June 2011. Logistic regression modelling was used to determine the risk factors of undernutrition.

Results

Data on 182 HIV-infected children (88 males and 94 females), aged between 6 weeks and 59 months were studied. The prevalence of undernutrition was 12.1%, 33.5%, and 54.4% for underweight, wasting, and stunting, respectively. In multivariate regression analyses, being female (adjusted odds ratio [AOR] 0.292, 95% [confidence interval] CI 0.104–0.820, P=0.019), the child’s caregiver being on ART (AOR 0.190, 95% CI 0.039–0.925, P=0.04), and the absence of tuberculosis in the child (AOR 0.034, 95% CI 0.003–0.357, P=0.005) were independently protective against underweight. Subjects who were exclusively breastfed in the first 6 months of life were protected from stunting (AOR 0.136, 95% CI 0.032–0.585, P=0.007). No factor impacted significantly on wasting in multivariate analyses.

Conclusion

Undernutrition among HIV-infected, ART-naïve children aged under 5 years old may be reduced if programmatic interventions are guided toward early initiation of ART among eligible HIV-infected caregivers and the promotion of HIV/tuberculosis coinfection control efforts. Also, the importance of exclusive breastfeeding in reducing undernutrition cannot be overemphasized.

Nutritional Status and Other Baseline Predictors of Mortality among HIV-Infected Children Initiating Antiretroviral Therapy in Tanzania

BACKGROUND

We assembled a prospective cohort of 3144 children less than 15 years of age initiating antiretroviral therapy (ART) in Dar es Salaam, Tanzania.

METHODS

The relationships of nutritional status and other baseline characteristics in relation to mortality were examined using Cox proportional hazards model.

RESULTS

Compared with children with weight for age (WAZ) > -1, those with WAZ ≤ -2 to < -3 had a nearly double risk of death (relative risk [RR], 1.85; 95% confidence interval [CI], 1.10-3.11), and among those with WAZ ≤ -3, the risk more than tripled (RR, 3.36; 95% CI, 2.12-5.32). Other baseline risk factors for overall mortality included severe anemia (P < .001), severe immune suppression (P = .02), history of tuberculosis (P = .01), opportunistic infections (P < .001), living in the poorest district (P < .001), and advanced World Health Organization stage (P = .003).

CONCLUSIONS

To sustain the obtained benefit of ART in this setting, interventions to improve nutritional status may be used as an adjunct to ART.

Impact of implementing performance-based financing on childhood malnutrition in Rwanda

Background

Malnutrition remains a serious concern in Rwanda, particularly among children under-5 years. Performance-based financing (PBF), an innovative health systems financing strategy, has been implemented at the national level since 2008. This study aimed to assess the impact of PBF and other factors associated with the prevalence of three classifications of malnutrition (stunting, wasting and underweight) in children under-5 years in Rwanda.

Methods

The study is a cross-sectional study comprising of 713 children under five years old from 557 households, whose anthropometric measurements (height, weight and age) had been obtained as part of the 2008 Rwanda General Health and HIV household survey. Z-scores for height-for-age, weight-for-age, weight-for-height, and body mass index-for-age were analyzed according to the World Health Organization 2006 Child Growth Standards. Random intercept logistic regression models were used to regress each anthropometric measure (WAZ, HAZ and WHZ) against child, maternal and household characteristics.

Results

Child participants ranged in age from 0 to 60 months, 20.2% of children were under 12 months and 5.1% were HIV positive. The prevalence of wasting was 8.8%; of stunting was 58.4%; and of underweight status was 20.7%. Maternal emotional and social wellbeing was protective of wasting in children under-5 years of age. Living in districts implementing PBF was protective of wasting (Adjusted Odds Ratio: 0.43; 95% confidence interval: 0.19-0.97). Living in a district with PBF was not found to be associated with either stunting or underweight status among children under-5.

Conclusions

PBF may have a protective association with particular forms of malnutrition among children under-5 years in Rwanda. These findings warrant further investigation in relation to the impact of implementing innovative financing schemes on health outcomes.

[Nutritional status of children aged 6 to 59 months with HIV but not on ARVs in Lubumbashi]

Introduction

L'infection par le VIH provoque et/ou aggrave les déficits nutritionnels de l'enfant. Ce travail avait pour objectif d'analyser l’état nutritionnel des enfants infectés par le VIH à Lubumbashi.

Méthodes

Une étude transversale portant sur 83 enfants âgés de 6 à 60 mois s'est déroulée de mai 2010 à mai 2011 dans trois(3) centres de prise en charge des Personnes Vivant avec le VIH(PVV), notamment le Centre d'Excellence(CE) de l'hôpital Sendwe, le Centre Amo-Congo de la Kenya et le Centre de Référence de la Kenya. Les statistiques descriptives usuelles ont été utilisées.

Résultats

La prévalence de la malnutrition globale était de 60,2% (n = 50) dont 8,4% de malnutrition sévère. Le poids moyen était de 11,6±4,1 kg avec un minimum de 5 kg et un maximum de 22 kg. Le taux d'hémoglobine moyen était d'environ 9,8± 2,0 g/dl avec une prévalence globale de l'anémie (hémoglobine < 11g/dl) à 69,9%. L’émaciation concernait 20,5% des enfants et 8,4% avaient un retard de croissance. Le retard de croissance (p = 0,007), l'insuffisance pondérale (p = 0,002) et l’émaciation (p = 0,046) étaient associés de façon significative à l’état avancé de l'infection à VIH. La survenue de l'anémie n’était pas associée au déficit nutritionnel (p = 0,6).

Conclusion

Ces résultats révèlent que l'infection à VIH modifie l’état nutritionnel des enfants à Lubumbashi avec 60,2% de malnutrition globale et 8,4% de retard de croissance. Les enfants au stade avancé de l'infection à VIH en sont plus affectés.

Undernutrition and anaemia among HAART-naïve HIV infected children in Ile-Ife, Nigeria: a case-controlled, hospital based study

INTRODUCTION

Case control studies that assess the burden and factors associated with undernutrition and anaemia among HAART naïve HIV infected children in Nigeria is very sparse. This will help to formulate nutritional programs among these children.

METHODS

Seventy HAART naive HIV infected children aged 18 months and above were as well as seventy age and sex matched HIV negative children were recruited from August 2007 to January 2009 at Paediatric Clinic of Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria. Their bio data, WHO clinical stage, anthropometric measurements, haematocrit, serum albumin and CD4 counts were taken with other parameters according to a study proforma.

RESULTS

The prevalence of stunting, underweight and wasting among the HIV infected subjects were 48. 6%,58. 6% and 31. 4% respectively which as significantly higher than 28. 1%, 7. 1% and 28. 1% among the HIV negative controls. 20. 1% of the HIV infected children were marasmic compared to 2. 3% of the controls. Triple anthropometric failure was found in 7. 1% of the subjects as compared to none among the controls. Anaemia is significantly more prevalent among the subjects than the controls (70. 0% vs 31. 4%; p<0. 001). The prevalence of anaemia was higher in the HIV infected subjects with undernutrition. Low socioeconomic status, hypoalbuminemia and severe immunosuppression are significantly associated with higher undernutrition prevalence.

CONCLUSION

Several years after availability of HAART, undernutrition and anaemia remain widely prevalent among newly presenting HAART naïve HIV infected Nigerian children. Nutritional supplementation and evaluation for anaemia still need close attention in the management of these children.

Immunologic outcomes of antiretroviral therapy among HIV-infected Nigerian children and its association with early infant feeding and nutritional status at treatment initiation

OBJECTIVES

To evaluate immunologic response to antiretroviral treatment (ART) among HIV-infected Nigerian children (<36 months old) and to assess its association with early infant feeding pattern and nutritional status at treatment initiation.

DESIGN

Mixed prospective and retrospective cohort study.

METHODS

One hundred fifty HIV-infected children were followed for 12 months from initiation of ART. CD4 count/CD4% was assessed at baseline and every 4-6 months. Nutritional status was assessed by height-for-age, weight-for-age and weight-for-height Z scores using the 2006 World Health Organization growth reference. Children were classified into 4 feeding groups--exclusively breast-fed, predominantly breast-fed, mixed fed and exclusively formula fed. Logistic regression was used to model odds of failure to reach CD4% of ≥ 25% at the 12-month follow-up. Linear random effects models were used to model the longitudinal change in CD4%.

RESULTS

There was a significant increase in CD4% for all children from 13.8% at baseline to 28.5% after 12 months (ΔCD4% = 14.7%, 95% confidence interval: 12.1%-17.4%). There was no association of feeding pattern with immunologic outcomes. In adjusted analyses, children who were underweight (weight-for-age < -2.0) or with CD4% <15% at baseline were 4.30 (95% confidence interval: 1.16, 15.87; P < 0.05) times and 3.41 (95% confidence interval: 1.10, 10.52; P < 0.05) times, respectively, more likely not to attain CD4% of ≥ 25% at 12 months.

CONCLUSION

Baseline nutritional status and CD4% were independently associated with failure to reach CD4% ≥ 25% at 12 months among HIV-infected Nigerian children on ART. These results emphasize the importance of early screening and initiation of ART among children in resource-poor settings before malnutrition and severe immunosuppression sets in.

Initiation of antiretroviral therapy before 6 months of age is associated with faster growth recovery in South African children perinatally infected with human immunodeficiency virus

OBJECTIVE

To describe the effects of age at antiretroviral therapy (ART) initiation on growth outcomes among children infected with HIV followed for 48 months after treatment initiation.

STUDY DESIGN

This secondary analysis describes anthropometric changes in children infected with HIV in Johannesburg, South Africa who initiated ritonavir-boosted lopinavir-based ART before 24 months of age and were randomized to continue ritonavir-boosted lopinavir or to receive nevirapine after achieving and maintaining virologic suppression. Weight, height, and head circumference were measured at visits over 48 months post-ART initiation. Growth patterns including weight-for-age z-scores (WAZs), height-for-age z-scores, body mass index-for-age z-scores, and head circumference for age z-score were compared between children initiating ART<6 months, 6-12 months, and 12-24 months of age.

RESULTS

A total of 195 children (mean±SD age 10.7±5.9 months), including 54 (27.7%)<6 months, 69 (35.4%) 6-12 months, and 72 (36.9%) 12-24 months of age at ART initiation, were evaluated. In the first 12 months on treatment, children<6 months of age at ART initiation experienced more rapid improvement in WAZ (1.98 vs 1.44, P=.084) and head circumference for age z-score (1.24 vs 0.45, P=.004) than children who initiated ART between 12-24 months of age. By 48 months on ART, growth outcomes were similar, regardless of age at ART initiation. WAZ approached population norms by 12 months on ART. Although improving, height-for-age z-scores remained on average 1.0 z-score below population norms at 48 months of therapy.

CONCLUSIONS

Initiation of ART before 6 months of age results in more rapid growth recovery in children infected with HIV. These data provide further evidence for the importance of prompt diagnosis and early initiation of ART for infants infected with HIV.

Multivitamin supplements have no effect on growth of Tanzanian children born to HIV-infected mothers

Growth faltering and micronutrient deficiencies commonly coexist in HIV-exposed children in sub-Saharan Africa, and correcting deficiencies, such as those of vitamins B-complex, C, and E, may improve HIV-related endpoints and child growth. We therefore examined the effect of daily oral supplementation of vitamins B-complex, C, and E on growth among 2341 children born to HIV-infected mothers in Tanzania. HIV-infected women pregnant at ≤32 wk of gestation were enrolled in the study. Children were randomized at age 6 wk to receive multivitamins or placebo until age 104 wk. All women received the same types of vitamins pre- and postnatally. At 6 wk, 256 children (11.1%) were HIV infected and the mean (SD) Z-scores for length for age (LAZ), weight for length (WLZ), and weight for age (WAZ) were -0.39 ± 1.20, -0.21 ± 1.23, and -0.52 ± 1.11, respectively. There was no overall treatment effect on LAZ, WLZ, or WAZ profiles during the follow-up (P ≥ 0.15). There was no treatment effect from 6 to 104 wk on LAZ [(95% CI: -0.14, 0.13); P = 0.94], WLZ [(95% CI: -0.17, 0.13); P = 0.78], or WAZ [(95% CI: -0.15, 0.16); P = 0.97] or on the incidence of growth failure, defined as respective Z-scores < -2 (P ≥ 0.29). Among the subgroup of HIV-uninfected children, there was no treatment effect from 6 to 104 wk on LAZ, WLZ, and WAZ (P ≥ 0.71) or on the incidence of growth failure (P ≥ 0.16). Multivitamin supplements had no effect on growth among children born to HIV-infected women who were themselves receiving multivitamins.

Burden of HIV among primary school children and feasibility of primary school-linked HIV testing in Harare, Zimbabwe: a mixed methods study

Population-based surveys in Southern Africa suggest a substantial burden of undiagnosed HIV-infected long-term survivors of mother-to-child transmission. We conducted an HIV prevalence survey of primary school pupils in Harare, Zimbabwe, and evaluated school-linked HIV counselling and testing (HCT) for pupils, their families and schoolteachers. Population-weighted cluster sampling was used to select six primary schools. Randomly selected class-grade pupils underwent anonymous HIV testing, with concurrent school-linked family HCT offered during the survey. Focus group discussions and interviews were conducted with pupils, parents/ guardians, counsellors, and schoolteachers. About 4386 (73%) pupils provided specimens for anonymous HIV testing. Median age was 9 years (IQR 8–11), and 54% were female. HIV prevalence was 2.7% (95% CI: 2.2–3.1) with no difference by gender. HIV infection was significantly associated with orphanhood, stunting, wasting, and being one or more class grades behind in school due to illness (p <0.001). After adjusting for covariates, orphanhood and stunting remained significantly associated with being HIV positive (p <0.001). Uptake of diagnostic HIV testing by pupils was low with only 47/4386 (1%) pupils undergoing HCT. The HIV prevalence among children under 15 years who underwent HIV testing was 6.8%. The main barrier to HIV testing was parents’ fear of their children experiencing stigma and of unmasking their own HIV status should the child test HIV positive. Most guardians believed that a child's HIV-positive result should not be disclosed and the child could take HIV treatment without knowing the reason. Increased recognition of the high burden of undiagnosed HIV infection in children is needed. Despite awareness of the benefits of HIV testing, HIV-related stigma still dominates parents/guardians' psychological landscape. There is need for comprehensive information and support for families to engage with HIV testing services.

The mediating effect of hostility toward women on the relationship between childhood emotional abuse and sexual violence perpetration

Some evidence suggests that childhood emotional abuse (CEA) may serve as a risk factor for sexual violence (SV) perpetration; however, little is known about the mechanisms by which CEA may influence SV. This study examined the relationship between CEA and SV by assessing the mediating role of hostility toward women (HTW) in a sample of adjudicated adult males (N = 360). Approximately 1 in 5 participants was classified as sexually violent based on self-reported behavior and/or criminal records. Results indicted that CEA significantly predicted HTW and SV, and HTW significantly predicted SV. As hypothesized, the relationship between CEA and SV was no longer significant after controlling for HTW, supporting the role of HTW as a mediator between CEA and SV. Efforts that aim to prevent CEA or that address early aggressive attitudes or behavior toward women may have a positive impact on preventing or reducing SV.

Cystatin C-Based Evaluation of Kidney Function of HIV-Infected Children in Benin City, Southern Nigeria

Background. Human immunodeficiency virus (HIV) is now a confirmed risk factor for kidney disease with an increased burden in persons of African descent. Method. We measured the serum cystatin C levels of 205 ART-naive, HIV-infected children by an ELISA technique and compared them with the levels of apparently healthy children. Result. The mean ± SD serum cystatin C level of children with HIV infection was 1.01 ± 0.44 mg/L, significantly higher than the mean value in the control group, that is, 0.72 ± 0.20 mg/L (P = 0.000). The mean ± SD cystatin C-based estimated GFR of children with HIV infection was 102.7 ± 31.0 mL/min/1.73 m(2), significantly lower than 126.9 ± 28.5 mL/min/1.73 m(2) in the control group, (P = 0.014). A significantly higher proportion of HIV-infected children compared to controls had eGFR < 90 mL/min/1.73 m(2) (21.5% versus 5.4%; P = 0.00). The prevalence of chronic kidney disease (CKD) among the HIV-infected children was 10.7%. The cystatin C-based eGFR of the HIV-infected children ≥5 years old correlated positively with their CD4 count (r = 0.23;  P = 0.022). Conclusion. There is a high prevalence of CKD among HIV-infected children, requiring regular monitoring of their kidney function using a cystatin C-based method.

Growth patterns among HIV-exposed infants receiving nevirapine prophylaxis in Pune, India

Background

India has among the highest rates of infant malnutrition. Few studies investigating the growth patterns of HIV-exposed infants in India or the impact of timing of HIV infection on growth in settings such as India exist.

Methods

We used data from the Six Week Extended Nevirapine (SWEN) trial to compare the growth patterns of HIV-infected and HIV-exposed but uninfected infants accounting for timing of HIV infection, and to identify risk factors for stunting, underweight and wasting. Growth and timing of HIV infection were assessed at weeks 1, 2, 4, 6, 10, 14 weeks and 6, 9, 12 months of life. Random effects multivariable logistic regression method was used to assess factors associated with stunting, underweight and wasting.

Results

Among 737 HIV-exposed infants, 93 (13%) were HIV-infected by 12 months of age. Among HIV-infected and uninfected infants, baseline prevalence of stunting (48% vs. 46%), underweight (27% vs. 26%) and wasting (7% vs. 11%) was similar (p>0.29), but by 12 months stunting and underweight, but not wasting, were significantly higher in HIV-infected infants (80% vs. 56%, 52% vs. 29%, p< 0.0001; 5% vs. 6%, p=0.65, respectively). These differences rapidly manifested within 4–6 weeks of birth. Infants infected in utero had the worst growth outcomes during the follow-up period. SWEN was associated with non-significant reductions in stunting and underweight among HIV-infected infants and significantly less wasting in HIV-uninfected infants. In multivariate analysis, maternal CD4 < 250, infant HIV status, less breastfeeding, low birth weight, non-vaginal delivery, and infant gestational age were significant risk factors for underweight and stunting.

Conclusion

Baseline stunting and underweight was high in both HIV-infected and uninfected infants; growth indices diverged early and were impacted by timing of infection and SWEN prophylaxis. Early growth monitoring of all HIV-exposed infants is an important low-cost strategy for improving health and survival outcomes of these infants.

Trial Registration

NCT00061321

Undernutrition among HIV-positive children in Dar es Salaam, Tanzania: antiretroviral therapy alone is not enough

Background

The prevalence of HIV/AIDS has exacerbated the impact of childhood undernutrition in many developing countries, including Tanzania. Even with the provision of antiretroviral therapy, undernutrition among HIV-positive children remains a serious problem. Most studies to examine risk factors for undernutrition have been limited to the general population and ART-naive HIV-positive children, making it difficult to generalize findings to ART-treated HIV-positive children. The objectives of this study were thus to compare the proportions of undernutrition among ART-treated HIV-positive and HIV-negative children and to examine factors associated with undernutrition among ART-treated HIV-positive children in Dar es Salaam, Tanzania.

Methods

From September to October 2010, we conducted a cross-sectional survey among 213 ART-treated HIV-positive and 202 HIV-negative children in Dar es Salaam, Tanzania. We measured the children's anthropometrics, socio-demographic factors, food security, dietary habits, diarrhea episodes, economic status, and HIV clinical stage. Data were analyzed using both univariate and multivariate methods.

Results

ART-treated HIV-positive children had higher rates of undernutrition than their HIV-negative counterparts. Among the ART-treated HIV-positive children, 78 (36.6%) were stunted, 47 (22.1%) were underweight, and 29 (13.6%) were wasted. Households of ART-treated HIV-positive children exhibited lower economic status, lower levels of education, and higher percentages of unmarried caregivers with higher unemployment rates. Food insecurity was prevalent in over half of ART-treated HIV-positive children's households. Furthermore, ART-treated HIV-positive children were more likely to be orphaned, to be fed less frequently, and to have lower body weight at birth compared to HIV-negative children.

In the multivariate analysis, child's HIV-positive status was associated with being underweight (AOR = 4.61, 95% CI 1.38-15.36 P = 0.013) and wasting (AOR = 9.62, 95% CI 1.72-54.02, P = 0.010) but not with stunting (AOR = 0.68, 95% CI 0.26-1.77, P = 0.428). Important factors associated with underweight status among ART-treated HIV-positive children included hunger (AOR = 9.90, P = 0.022), feeding frequency (AOR = 0.02, p < 0.001), and low birth weight (AOR = 5.13, P = 0.039). Factors associated with wasting among ART-treated HIV-positive children were diarrhea (AOR = 22.49, P = 0.001) and feeding frequency (AOR = 0.03, p < 0.001).

Conclusion

HIV/AIDS is associated with an increased burden of child underweight status and wasting, even among ART-treated children, in Dar es Salaam, Tanzania. In addition to increasing coverage of ART among HIV-positive children, interventions to ameliorate poor nutrition status may be necessary in this and similar settings. Such interventions should aim at promoting adequate feeding patterns, as well as preventing and treating diarrhea.

Growth of infants born to HIV-infected women in South Africa according to maternal and infant characteristics

OBJECTIVE

To evaluate growth parameters assessed by weight and length in HIV-infected and HIV-uninfected infants born to HIV-infected mothers in South Africa from birth to 6 months of age.

METHODS

We calculated z-scores for weight-for-age (WAZ), length-for-age (LAZ) and weight-for-length (WLZ) among a cohort of 840 mother-infant dyads. Multivariable Cox proportional hazards models with time-varying covariates were used to estimate the risk of falling <-2 z-scores for WAZ, LAZ, and WLZ as a function of infant and maternal characteristics.

RESULTS

By 6 months after birth, a fifth of infants had WAZ <-2, 19% had an LAZ <-2, and 29% had a WLZ <-2. WLZ and WAZ were significantly lower in HIV-infected infants than in uninfected infants by 3 months of age and LAZ by 6 months of age (P<0.001). The risk of WAZ falling <-2 was associated with decreasing maternal CD4 cell count (adj. HR for CD4 cell count <200 cells/μl: 1.64; 95% CI: 1.10-2.43), premature birth (adj. HR: 2.82; 95% CI: 2.06-3.86) and formula feeding (adj. HR: 3.35; 95% CI: 1.64-6.85). The risk of LAZ falling <-2 was associated with increasingly lower maternal age (adj. HR for<20 years: 0.54; 95% CI: 0.31-0.96), lower maternal CD4 cell count (adj. HR for CD4 cell count <200 cells/μl: 1.72; 95% CI: 1.14-2.59), premature birth (adj. HR: 2.37; 95% CI: 1.70-3.30) and formula feeding (adj. HR: 4.22; 95% CI: 1.85-9.62). The risk of WLZ falling <-2 was significantly associated with infant HIV infection (adj. HR: 1.64; 95% CI: 1.16-2.32) and formula feeding (adj. HR: 1.78; 95% CI: 1.11-2.83). The risk of WAZ and LAZ falling <-2 was more than two times greater for HIV-infected infants than for uninfected infants with gastrointestinal infections.

CONCLUSIONS

HIV-infected infants were more likely to be stunted and wasted than uninfected infants, which often occurred within 3 months after birth. Infants who were born to mothers with advanced HIV disease, formula-fed and co-infected with HIV and gastrointestinal infections were at greater risk for growth disturbances. Further interventions are needed to promptly initiate both HIV-infected mothers and infants on appropriate antiretroviral therapy and nutritional supplementation.

Longitudinal anthropometric assessment of infants born to HIV-1-infected mothers, Belo Horizonte, Southeastern Brazil

OBJECTIVE: To evaluate the growth parameters in infants who were born to HIV-1-infected mothers. METHODS: The study was a longitudinal evaluation of the z-scores for the weight-for-age (WAZ), weight-for-length (WLZ) and length-for-age (LAZ) data collected from a cohort. A total of 97 non-infected and 33 HIV-infected infants born to HIV-1-infected mothers in Belo Horizonte, Southeastern Brazil, between 1995 and 2003 was studied. The average follow-up period for the infected and non-infected children was 15.8 months (variation: 6.8 to 18.0 months) and 14.3 months (variation: 6.3 to 18.6 months), respectively. A mixed-effects linear regression model was used and was fitted using a restricted maximum likelihood. RESULTS: There was an observed decrease over time in the WAZ, LAZ and WLZ among the infected infants. At six months of age, the mean differences in the WAZ, LAZ and WLZ between the HIV-infected and non-infected infants were 1.02, 0.59, and 0.63 standard deviations, respectively. At 12 months, the mean differences in the WAZ, LAZ and WLZ between the HIV-infected and non-infected infants were 1.15, 1.01, and 0.87 standard deviations, respectively. CONCLUSIONS: The precocious and increasing deterioration of the HIV-infected infants' anthropometric indicators demonstrates the importance of the early identification of HIV-infected infants who are at nutritional risk and the importance of the continuous assessment of nutritional interventions for these infants.

Drug testing for newborn exposure to illicit substances in pregnancy: pitfalls and pearls

Estimates of the prevalence of drug usage during pregnancy vary by region and survey tool used. Clinicians providing care to newborns should be equipped to recognize a newborn who has been exposed to illicit drugs during pregnancy by the effects the exposure might cause at the time of delivery and/or by drug testing of the newborn. The purpose of this paper is to provide an overview of the literature and assess the clinical role of drug testing in the newborn. Accurate recognition of a newborn whose mother has used illicit drugs in pregnancy cannot only impact decisions for healthcare in the nursery around the time of delivery, but can also provide a key opportunity to assess the mother for needed services. While drug use in pregnancy is not an independent predictor of the mother's ability to provide a safe and nurturing environment for her newborn, other issues that often cooccur in the life of a mother with a substance abuse disorder raise concerns for the safety of the discharge environment and should be assessed. Healthcare providers in these roles should advocate for unbiased and effective treatment services for affected families.

Nutritional status and HIV in rural South African children

BACKGROUND

Achieving the Millennium Development Goals that aim to reduce malnutrition and child mortality depends in part on the ability of governments/policymakers to address nutritional status of children in general and those infected or affected by HIV/AIDS in particular. This study describes HIV prevalence in children, patterns of malnutrition by HIV status and determinants of nutritional status.

METHODS

The study involved 671 children aged 12-59 months living in the Agincourt sub-district, rural South Africa in 2007. Anthropometric measurements were taken and HIV testing with disclosure was done using two rapid tests. Z-scores were generated using WHO 2006 standards as indicators of nutritional status. Linear and logistic regression analyses were conducted to establish the determinants of child nutritional status.

RESULTS

Prevalence of malnutrition, particularly stunting (18%), was high in the overall sample of children. HIV prevalence in this age group was 4.4% (95% CI: 2.79 to 5.97). HIV positive children had significantly poorer nutritional outcomes than their HIV negative counterparts. Besides HIV status, other significant determinants of nutritional outcomes included age of the child, birth weight, maternal age, age of household head, and area of residence.

CONCLUSIONS

This study documents poor nutritional status among children aged 12-59 months in rural South Africa. HIV is an independent modifiable risk factor for poor nutritional outcomes and makes a significant contribution to nutritional outcomes at the individual level. Early paediatric HIV testing of exposed or at risk children, followed by appropriate health care for infected children, may improve their nutritional status and survival.

Net survival of perinatally and postnatally HIV-infected children: a pooled analysis of individual data from sub-Saharan Africa

BACKGROUND

Previously, HIV epidemic models have used a double Weibull curve to represent high initial and late mortality of HIV-infected children, without distinguishing timing of infection (peri- or post-natally). With more data on timing of infection, which may be associated with disease progression, a separate representation of children infected early and late was proposed.

METHODS

Paediatric survival post-HIV infection without anti-retroviral treatment was calculated using pooled data from 12 studies with known timing of HIV infection. Children were grouped into perinatally or post-natally infected. Net mortality was calculated using cause-deleted life tables to give survival as if HIV was the only competing cause of death. To extend the curve beyond the available data, children surviving beyond 2.5 years post infection were assumed to have the same survival as young adults. Double Weibull curves were fitted to both extended survival curves to represent survival of children infected perinatally or through breastfeeding.

RESULTS

Those children infected perinatally had a much higher risk of dying than those infected through breastfeeding, even allowing for background mortality. The final-fitted double Weibull curves gave 75% survival at 5 months after infection for perinatally infected, and 1.1 years for post-natally infected children. An estimated 25% of the early infected children would still be alive at 10.6 years compared with 16.9 years for those infected through breastfeeding.

CONCLUSIONS

The increase in available data has enabled separation of child mortality patterns by timing of infection allowing improvement and more flexibility in modelling of paediatric HIV infection and survival.

Growth, immune and viral responses in HIV infected African children receiving highly active antiretroviral therapy: a prospective cohort study

Background

Scale up of paediatric antiretroviral therapy in resource limited settings continues despite limited access to routine laboratory monitoring. We documented the weight and height responses in HIV infected Ugandan children on highly active antiretroviral therapy and determined clinical factors associated with successful treatment outcomes.

Methods

A prospective cohort of HIV infected children were initiated on HAART and followed for 48 weeks. Body mass index for age z scores(BAZ), weight and height-for-age z scores (WAZ & HAZ) were calculated: CD4 cell % and HIV-1 RNA were measured at baseline and every 12 weeks. Treatment outcomes were classified according to; both virological and immunological success (VS/IS), virological failure and immunological success (VF/IS). virological success and immunological failure (VS/IF) and both virological and immunological failure (VF/IF).

Results

From March 2004 until May 2006, 124 HIV infected children were initiated on HAART. The median age (IQR) was 5.0 years (2.1 - 7.0) and 49% (61/124) were female. The median [95% confidence interval (CI)] BAZ, WAZ and HAZ at baseline were 0.29 (-2.9, -1.2), -1.2 (-2.1, -0.5) and -2.06 (-2.9, -1.2) respectively. Baseline median CD4 cell % and log10 HIV-1 RNA were; 11.8% (7.5-18.0) and 5.6 (5.2-5.8) copies/ml. By 48 weeks, mean WAZ and HAZ in the VF/IS group, which was younger, increased from - 0.98 (SD 1.7) to + 1.22 (SD 1.2) and from -1.99 (1.7) to + 0.76 (2.4) respectively. Mean increase in WAZ and HAZ in the VS/IF group, an older group was modest, from -1.84 (1.3) to - 0.41 (1.2) and -2.25 (1.2) to -1.16 (1.3) respectively. Baseline CD4 cell % [OR 6.97 95% CI (2.6 -18.6)], age [OR 4.6 95% CI (1.14 -19.1)] and WHO clinical stage [OR 3.5 95%CI (1.05 -12.7)] were associated with successful treatment outcome.

Conclusions

HIV infected Ugandan children demonstrated a robust increase in height and weight z scores during the first 48 weeks of HAART, including those who failed to completely suppress virus. Older children initiating HAART with severe immune suppression were less likely to achieve a successful treatment outcome. These data emphasize the importance of initiating HAART early to ensure adequate immune and growth responses.

Effect of multiple micronutrient supplementation on survival of HIV-infected children in Uganda: a randomized, controlled trial

BACKGROUND

Micronutrient deficiencies compromise the survival of HIV-infected children in low-income countries. We assessed the effect of multiple micronutrient supplementation on the mortality of HIV-infected children in Uganda.

METHODS

In a randomized, controlled trial, 847 children aged one to five years and attending HIV clinics in Uganda were stratified by antiretroviral therapy (ART, n = 85 versus no ART, n = 762). The children were randomized to six months of either: twice the recommended dietary allowance of 14 micronutrients as the intervention arm (vitamins A, B1, B2, niacin, B6, B12, C, D and E, folate, zinc, copper, iodine and selenium); or the standard recommended dietary allowance of six multivitamins (vitamins A, D2, B1, B2, C and niacin) as a comparative "standard-of-care" arm. Mortality was analyzed at 12 months of follow up using Kaplan Meier curves and the log rank test.

RESULTS

Mortality at 12 months was 25 out of 426 (5.9%) children in the intervention arm and 28 out of 421 (6.7%) in the comparative arms: risk ratio 0.9 (95% CI 0.5 - 1.5). Two out of 85 (2.4%) children in the ART stratum died compared with 51 out of 762 (6.7%) in the non-ART stratum. Of those who died in the non-ART stratum, 25 of 383 (6.5%) were in the intervention arm and 26 of 379 (6.9%) in the comparative arm; risk ratio 1.0 (95% CI 0.6 - 1.6). There was no significant difference in survival at 12 months (p = 0.64, log rank test). In addition, there was no significant difference in mean weight-for-height at 12 months; 0.70 +/- 1.43 (95% CI 0.52 - 0.88) for the intervention versus 0.59 +/- 1.15 (95% CI 0.45 - 0.75) in the comparative arm. The mean CD4 cell count; 1024 +/- 592 (95% CI 942 - 1107) versus 1060 +/- 553 (95% CI 985 - 1136) was also similar between the two groups.

CONCLUSIONS

Twice the recommended dietary allowance of 14 micronutrients compared with a standard recommended dietary allowance of six multivitamins for six months was well tolerated, but it did not significantly alter mortality, growth or CD4 counts. Future intervention studies should carefully consider: (1) the composition and dosing of the supplements; and (2) the power needed to detect a difference between arms.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00122941.

Macronutrient supplementation and food prices in HIV treatment

Infection caused by HIV and malnutrition have a complex interaction and often coexist geographically. Malnutrition has synergistic immune effects and HIV affects nutritional status. HIV care and treatment programs are compelled to confront this dual burden to optimize HIV outcomes. In this article, we review the published literature concerning intervention studies in adults and children and the effect of food prices on HIV treatment programs. While the evidence base is relatively incomplete for specific macronutrient interventions in the context of HIV treatment, it is clear that a new standard of care is needed, guided by experience, rationale, and existing data, in which malnourished patients may easily access nutritional therapies within HIV treatment. From this clinical foundation, we may both treat patients and evaluate novel therapies. Some HIV care and treatment programs provide food-based supplements; however, rising food costs and economic instability may jeopardize the success of these programs. HIV treatment programs may struggle to meet the needs of patients with potential increased rates of malnutrition and food insecurity in the setting of high food prices.

The role of weight for age and disease stage in poor psychomotor outcome of HIV-infected children in Kilifi, Kenya

AIM

We aimed to investigate the contribution of disease stage and weight for age to the variability in psychomotor outcome observed among children with human immunodeficiency virus (HIV) infection.

METHOD

This cross-sectional study involved 48 Kenyan children (20 females, 28 males) aged 6 to 35 months (mean 19.9mo SD 8.9) exposed prenatally to HIV. Two subgroups of HIV-exposed children were seen: those who were HIV-infected and those who were uninfected. The reference population was composed of 319 children (159 females, 160 males) aged 6-35 months, (mean age = 19 months, SD=8.43) randomly selected from the community. Disease stage varied from stage 1 to stage 3, reflecting progression from primary HIV infection to advanced HIV infection and acquired immune deficiency syndrome. A locally developed and validated measure, the Kilifi Developmental Inventory, was used to assess psychomotor development.

RESULT

Using age-corrected psychomotor scores, a significant main effect of HIV status was observed (F((2,38.01))=7.89, p<0.001). Children in the HIV-infected group had lower mean psychomotor scores than the HIV-exposed children and the reference group. In the HIV-infected group, disease stage was a negative predictor and weight for age a positive predictor of psychomotor outcome.

INTERPRETATION

Weight for age and disease stage provide viable, easily measurable benchmarks to specify when frequent developmental monitoring and psychomotor rehabilitation are required. Nutritional intervention and other measures aimed at slowing disease progression may delay the onset and severity of psychomotor impairment in the paediatric HIV population in Africa.

Patterns and predictors of CD4 T-cell counts among children born to HIV-infected women in Tanzania

We assessed age-specific CD4 T-cell counts and their determinants among Tanzanian children born to HIV-infected mothers to address a major research gap. A total of 474 HIV-uninfected and 69 HIV-infected children were followed until age of 12 months. Maternal predictors were measured during pregnancy and child predictors at birth and throughout the follow up. Child CD4 T-cell counts were evaluated at the age of 3 months and subsequent 3-month intervals; they decreased linearly among HIV-infected (beta = -8 cells per week; 95% CI -12 to -4; P = 0.0003) and increased linearly among HIV-uninfected children (beta = 4 cells/week; 95% CI 2-7; P = 0.0008). Decreased child counts were predicted by low child anthropometry, maternal HIV stage > or =2, and maternal mid-upper arm circumference <27 cm among HIV-infected children; and by weight-for-height <-2 z-score, maternal HIV stage > or =2, maternal erythrocyte sedimentation rate <81 mm/h and maternal haemoglobin <8.5 g/dl among HIV-uninfected children. The maternal and child predictors described may serve as intervention targets among HIV-exposed children.

Patterns of postnatal growth in HIV-infected and HIV-exposed children

HIV infection can contribute to disturbances in both linear growth and weight gain in early childhood, with disturbances often apparent as early as 3 months of age. There is little evidence for a difference in the early growth of HIV-exposed but uninfected children compared to healthy controls. Owing to the close association of growth with immune function and clinical progression, an understanding of growth patterns may be an important tool to ensure the provision of appropriate care to HIV-infected and exposed children. Timely growth monitoring may be used to improve the clinical course and quality of life of these children.

Effect of pre-existing malnutrition on growth parameters in HIV-infected children commencing antiretroviral therapy

BACKGROUND

Growth in HIV-infected children generally improves with antiretroviral therapy (ART). Little is known about the effect of pre-existing malnutrition on response to treatment.

AIM

To evaluate prospectively the effect of pre-existing malnutrition on growth of HIV-infected children commenced on ART compared with those without pre-existing malnutrition.

METHODS

Inclusion criteria were children (2 months to 8.5 years) who were commenced on ART. Exclusion criteria were pre-treatment with ART, virological non-responders and co-existing tuberculous infection. Weight-for-age (WAZ) and height-for-age Z scores (HAZ) < or =-2 at the initiation of treatment were the criteria for malnutrition. Monthly height and weight measurements were made for 18 months (2007-2008) after initiation of ART. Z scores were used to express changes in standard deviation (SD) units for each of the children at 0 and 18 months of the study using WHO height and weight reference curves for age and gender. The changes in Z score were compared within the groups by paired t-test and in both groups by the Mann-Whitney U test.

RESULTS

The subjects were grouped as malnourished (G1) and not malnourished (G2) before initiation of treatment. There was a significant increase in HAZ score (mean -0.15, p=0.006) and WAZ score (mean -0.09, p=0.034) in G1 and also HAZ score (mean -0.29, p<0.001) and WAZ score (mean -0.30, p=0.001) in G2. There was a trend toward a significantly greater Z-score change in G2 than in G1 for height (p=0.027) and weight (p=0.046).

CONCLUSION

In HIV-infected children, pre-existing malnutrition may impair nutritional response to ART.

Longitudinal growth of infants born to HIV-1-infected mothers in Belo Horizonte, Brazil

Objective

To prospectively evaluate growth parameters assessed by weight and length in infected and uninfected infants born to HIV-1-infected mothers and followed from birth to 18 months.

Methods

A cohort consisting of ninety-seven uninfected and forty-two infected infants born to HIV-infected mothers enrolled from 1995 to 2004, and admitted during their first 3 months of life at a referral Pediatric AIDS Clinic in Belo Horizonte, Brazil. Infants were followed until 18 months of age. Data were analysed using mixed-effects linear regression models for weight and length fitted by restricted maximum likelihood.

Results

Infected infants contributed to 466 weight and 411 recumbent length measurements. Uninfected infants provided 924 weight and 907 length measurements. Mean birth weight and length were similar in both groups, 3·1 (sd 0·4) and 3·0 (sd 0·5) kg, and 48·7 (sd 1·4) and 48·8 (sd 2·9) cm for uninfected and infected infants, respectively. However, HIV-1 infection had an early impact in growth impairment: at 6 months of age, HIV-infected children were 1 kg lighter and 2 cm shorter than the uninfected.

Conclusions

Growth faltering in weight, but not length, in HIV-infected children in Brazil is more marked than that reported in a European cohort, probably reflecting background nutritional deficiencies and concomitant infections. In these settings, early and aggressive nutritional management in HIV-1-infected infants should be a priority intervention associated with the antiretroviral therapy.

Anti-retroviral therapy reduces incident tuberculosis in HIV-infected children

BACKGROUND

We aimed to estimate the effect of anti-retroviral therapy (ART) on incident tuberculosis (TB) in a cohort of HIV-infected children.

METHODS

We analysed data from ART-naïve, TB disease-free children enrolled between December 2004 and April 2008 into an HIV care program in Kinshasa, Democratic Republic of Congo. To estimate the effect of ART on TB incidence while accounting for time-dependent confounders affected by exposure, a Cox proportional hazards marginal structural model was used.

RESULTS

364 children contributed 596.0 person-years of follow-up. At baseline, the median age was 6.9 years; 163 (44.8%) were in HIV clinical stage 3 or 4. During follow-up, 242 (66.5%) children initiated ART and 81 (22.3%) developed TB. At TB diagnosis, 41 (50.6%) were receiving ART. The TB incidence rate in those receiving ART was 10.2 per 100 person-years [95% confidence interval (CI) 7.4-13.9] compared with 20.4 per 100 person-years (95% CI 14.6-27.8) in those receiving only primary HIV care. TB incidence decreased with time on ART, from 18.9 per 100 person-years in the first 6 months to 5.3 per 100 person-years after 12 months of ART. The model-estimated TB hazard ratio for ART was 0.51 (95% CI 0.27-0.94).

CONCLUSIONS

For HIV-infected children in TB-endemic areas, ART reduces the hazard of developing TB by 50%.

CD4 counts decline despite nutritional recovery in HIV-infected Zambian children with severe malnutrition

OBJECTIVE

The objective of this study was to establish the contribution that severe malnutrition makes to CD4 lymphopenia in HIV-infected and uninfected children and to determine the changes in CD4 count during nutritional rehabilitation.

METHODS

Fifty-six children with severe malnutrition and with and without HIV infection were recruited from a pediatric ward in Lusaka for measurement of CD4 counts on admission, on discharge, and at final nutritional recovery.

RESULTS

HIV-uninfected children with severe malnutrition had normal CD4 counts. In contrast, CD4 counts in HIV-infected children with severe malnutrition were reduced, more so in those without edema compared with those with edema. Mean CD4 count of HIV-infected SM children fell despite nutritional recovery so that at the time of full nutritional recovery, >85% of HIV-infected children required antiretroviral therapy.

CONCLUSIONS

Severe malnutrition did not reduce the CD4 counts of children without HIV. HIV-infected children with severe malnutrition may respond well to nutritional rehabilitation, despite low CD4 counts, but nearly all require early antiretroviral therapy to prevent disease progression.

Growth parameters in HIV-vertically-infected adolescents on antiretroviral therapy in Rio de Janeiro, Brazil

BACKGROUND

Growth failure in HIV-infected children is an important factor in either initiating or changing antiretroviral therapy (ART). This study assesses the impact of HIV infection on growth parameters of adolescents who acquired HIV vertically.

METHODS

This retrospective, longitudinal study involved adolescents aged 10-20 years with vertically-acquired HIV infection who were followed up in one of the three main referral centres for paediatric HIV/AIDS in Rio de Janeiro, Brazil. Length, weight and variables related to demographic, clinical and laboratory issues were analysed.

RESULTS

108 subjects were enrolled. Median age was 12.7 years, median duration of follow-up was 97.2 months and 61 (56.5%) were female. The difference between the baseline and final weight Z-scores was -0.31 (p=0.02). Patients with final weight Z-scores < or = -2 used more ART regimens (average 4.13) than those with Z-scores > -2 (average 2.90, p<0.01) and also had a lower final CD4+ cell percentage--average 19% vs 24% (p<0.01), respectively. The difference between baseline and final-height Z-scores was -0.27 (p<0.01). Several factors were associated with a final-height Z-score < or = -2: clinical stage C during follow-up (RR 1.60, 95% CI 1.11-2.31), chronic diarrhoea during follow-up (RR 2.02, 95% CI 1.04-3.90), HAART use (RR 1.41, 95% CI 1.16-1.71), number of ART regimens (p<0.01) and final CD4+ cell percentage (p<0.01). In multivariate analysis, presentation in clinical stage C during follow-up was the only significant variable (OR 4.04, 95% CI 1.23-13.28).

CONCLUSION

Even on HAART, HIV-infected adolescents have lower growth parameters than the normal population and this is associated with a worse prognosis.

Growth in HIV-infected children receiving antiretroviral therapy at a pediatric infectious diseases clinic in Uganda

Antiretroviral therapy (ART) improves growth and survival of HIV-infected individuals. We designed a retrospective cohort study to assess clinical factors associated with growth in HIV-infected children on ART in Uganda between July 2003 and March 2006. Height and weight measurements taken pre- and post-ART initiation for at least 6 months were age- and gender-standardized to CDC 2000 reference. We analyzed medical records of 749 children receiving ART. Descriptive and logistic regression analyses were conducted to identify covariates associated with risk of either stunting or being underweight. Longitudinal regression analysis with a mixed model using autoregressive covariance structure was used to compare change in height and weight before and after initiation of ART. The mean age of the study population at first visit was 7.5 years. Mean height-for-age, weight-for-age, and weight-for-height percentiles at first visit were 8.6, 7.7, and 7.9, respectively. At last visit mean height-for-age, weight-for-age, and weight-for-height percentiles were 8.6, 13.3, and 13.8, respectively. Baseline weight-for-age z score of 1 or more was protective against stunting (odds ratio [OR] 0.25, confidence interval [CI] 0.18-0.35) while baseline height-for-age z score of 1 or more was protective against becoming underweight (OR 0.75, CI 0.63-0.88). Children in World Health Organization (WHO) stages II, III, and IV at baseline were 1.5 times more likely to become underweight (OR 1.51, CI 1.07-2.14). Initiation of ART resulted in improvement in mean standardized weight-for-age z score and weight-for-age percentiles (p < 0.001). Weight-for-age percentile and z score improved significantly after initiation of ART. This pediatric population gained weight more rapidly than height after initiation of ART.

Maternal disease stage and child undernutrition in relation to mortality among children born to HIV-infected women in Tanzania

OBJECTIVE

To examine whether maternal HIV disease stage during pregnancy and child malnutrition are associated with child mortality.

DESIGN

Prospective cohort study in Tanzania.

METHODS

Indicators of disease stage were assessed for 939 HIV-infected women during pregnancy and at delivery, and children's anthropometric status was obtained at scheduled monthly clinic visits after delivery. Children were followed up for survival status until 24 months after birth.

RESULTS

Advanced maternal HIV disease during pregnancy (CD4 count <350 vs. >or=350 cells/mm) was associated with increased risk of child mortality through 24 months of age (hazard ratio [HR] = 1.74, 95% confidence interval [CI]: 1.32 to 2.30). CD4 count <350 cells/mm was also associated with an increased risk of death among children who remained HIV-negative during follow-up (HR = 2.00, 95% CI: 1.36 to 2.94). Low maternal hemoglobin concentration and child undernutrition were related to an increased risk of mortality in this cohort of children.

CONCLUSIONS

Low maternal CD4 cell count during pregnancy is related to increased risk of mortality in children born to HIV-infected women. Care and treatment for HIV disease, including highly active antiretroviral therapy to pregnant women, could improve child survival. Prevention and treatment of undernutrition in children remain critical interventions in settings with high HIV prevalence.

International perspectives, progress, and future challenges of paediatric HIV infection

Paediatric HIV infection is a growing health challenge worldwide, with an estimated 1500 new infections every day. In developed countries, well established prevention programmes keep mother-to-child transmission rates at less than 2%. However, in developing countries, where transmission rates are 25-40%, interventions are available to only 5-10% of women. Children with untreated natural infection progress rapidly to disease, especially in resource-poor settings where mortality is greater than 50% by 2 years of age. As in adult infection, antiretroviral therapy has the potential to rewrite the natural history of HIV, but is accessible only to a small number of children needing therapy. We focus on the clinical and immunological features of HIV that are specific to paediatric infection, and the formidable challenges ahead to ensure that all children worldwide have access to interventions that have proved successful in developed countries.