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Published on: October 6, 2022
Hospitalization for severe malnutrition among HIV-infected children starting antiretroviral therapy
Andrew Prendergast1, Mutsa F Bwakura-Dangarembizi, Adrian D Cook
1MRC Clinical Trials Unit, 222 Euston Road, London, UK. ajp@ctu.mrc.ac.uk
Insights
Early hospitalization for severe malnutrition in children with advanced HIV is common after starting antiretroviral therapy (ART). These children face a significantly higher mortality risk, underscoring the need for integrated care.
Area of Science:
- Pediatric Infectious Diseases
- Nutritional Immunology
- Global Health
Background:
- Severe malnutrition is a critical concern in children with advanced Human Immunodeficiency Virus (HIV).
- Initiating antiretroviral therapy (ART) in this population requires careful monitoring for adverse events, including nutritional decline.
Purpose of the Study:
- To describe the incidence and characteristics of early hospitalization for severe malnutrition in HIV-infected children starting ART.
- To assess the impact of such hospitalizations on clinical outcomes, including mortality and nutritional status.
Main Methods:
- A randomized trial involving 1207 HIV-infected children across four tertiary hospitals in Uganda and Zimbabwe.
- Children received standard ART regimens, with some receiving intensive induction-maintenance therapy.
- Nutritional status was assessed using weight-for-age Z-scores (WAZ) and CD4 cell percentages; hospitalization for severe malnutrition was a primary outcome.
Main Results:
- 3.2% of children were hospitalized for severe malnutrition (marasmus or kwashiorkor) within months of ART initiation.
- Hospitalized children had poorer baseline nutritional status and a greater increase in WAZ post-ART compared to non-hospitalized children.
- Mortality at 24 weeks was substantially higher for children hospitalized with severe malnutrition (32% for marasmus, 20% for kwashiorkor) compared to those not hospitalized (1.7%).
Conclusions:
- Early hospitalization for severe malnutrition affects a significant proportion of advanced HIV-infected children initiating ART.
- These hospitalizations are associated with a dramatically increased risk of mortality, highlighting a critical gap in care.
- Integrated HIV and malnutrition services, alongside research into optimal ART timing and supportive interventions, are urgently needed.
Objective:
To describe early hospitalization for severe malnutrition in HIV-infected children initiating antiretroviral therapy (ART).
Design:
Randomized trial of induction-maintenance and monitoring strategies in HIV-infected children.
Setting:
Three tertiary hospitals in Uganda and one in Zimbabwe.
Participants:
1207 HIV-infected children, median age 6 years (range, 3 months to 17 years).
Intervention:
Abacavir, lamivudine and nevirapine or efavirenz were given; children in induction-maintenance arms also received zidovudine to week 36. Pre-ART inpatient/outpatient nutritional rehabilitation for children with baseline severe malnutrition.
Main Outcome Measures:
: Hospitalization for severe malnutrition and change in CD4 cell percentage by week 12 after ART. Mortality and change in weight-for-age Z-score (WAZ) by week 24 after ART.
Results:
Thirty-nine of 1207 (3.2%) children were hospitalized for severe malnutrition (20 with oedema), median 28 days [interquartile range (IQR) 14, 36] after ART for marasmus and 26 days (IQR 14, 56) after ART for kwashiorkor. Hospitalized children had lower baseline and greater 24-week rise in WAZ than nonhospitalized children (P < 0.001). Twenty-nine of 39 (74%) children admitted for severe malnutrition had underlying infections. Of 220 children with advanced disease (baseline WAZ and CD4 cell Z-scores both <-3), 7.3% [95% confidence interval (CI) 3.8, 10.7] developed kwashiorkor and 3.6% (95% CI 1.2, 6.1) developed marasmus by week 12. CD4 cell percentage rise was similar among groups (P = 0.37). Twenty-four-week mortality was 32, 20 and 1.7% among children hospitalized with marasmus, kwashiorkor and not hospitalized, respectively, (P < 0.001).
Conclusion:
One in nine children with advanced HIV required early hospitalization for severe malnutrition after ART, with a 15-fold increase in 6-month mortality compared with nonhospitalized children. Integration of HIV/malnutrition services and further research to determine optimal ART timing, role of supplementary feeding and antimicrobial prophylaxis are urgently required.
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