Association Between Weight Gain and Clinical Outcomes Among Malnourished Adults Initiating Antiretroviral Therapy in Lusaka, Zambia

Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
JAIDS Journal of Acquired Immune Deficiency Syndromes (Impact Factor: 4.56). 09/2009; 53(4):507-13. DOI: 10.1097/QAI.0b013e3181b32baf
Source: PubMed


To describe the association between 6-month weight gain on antiretroviral therapy (ART) and subsequent clinical outcomes.
A retrospective analysis of a large programmatic cohort in Lusaka, Zambia.
Using Kaplan-Meier analysis and Cox proportional hazards models, we examined the association between 6-month weight gain and the risk of subsequent death and clinical treatment failure. Because it is a known effect modifier, we stratified our analysis according to body mass index (BMI).
Twenty-seven thousand nine hundred fifteen adults initiating ART were included in the analysis. Patients in the lower BMI categories demonstrated greater weight gain. In the post 6-month analysis, absolute weight loss was strongly associated with mortality across all BMI strata, with the highest risk observed among those with BMI <16 kg/m (adjusted hazard ratio 9.7; 95% CI: 4.7 to 20.0). There seemed to be an inverse relationship between weight gain and mortality among patients with BMI <16 kg/m. Similar trends were observed with clinical treatment failure.
Weight gain after ART initiation is associated with improved survival and decreased risk for clinical failure, especially in the lower BMI strata. Prospective trials to promote weight gain after ART initiation among malnourished patients in resource-constrained settings are warranted.

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Available from: John R Koethe, Apr 20, 2015
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    • "Nutrition and immunity are linked, with impaired immune function from suboptimal nutrition status hastening progression of HIV [1]. People living with HIV (PLHIV) have increased nutritional needs, due to malabsorption of nutrients, parasitic infection, and increased resting energy expenditure, among others [2-4]. Poor nutrition status is an independent predictor of mortality for PLHIV undergoing antiretroviral therapy (ART), and adequate diet has been shown to improve adherence to ART [5,6]. "
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    ABSTRACT: There is little evidence to date of the potential impact of vegetable gardens on people living with HIV (PLHIV), who often suffer from social and economic losses due to the disease. From 2008 through 2011, Action Contre la Faim France (ACF) implemented a project in Chipinge District, eastern Zimbabwe, providing low-input vegetable gardens (LIGs) to households of PLHIV. Program partners included Médecins du Monde, which provided medical support, and Zimbabwe's Agricultural Extension Service, which supported vegetable cultivation. A survey conducted at the end of the program found LIG participants to have higher Food Consumption Scores (FCS) and Household Dietary Diversity Scores (HDDS) relative to comparator households of PLHIV receiving other support programs. This study assessed the incremental cost-effectiveness of LIGs to improve FCS and HDDS of PLHIV compared to other support programs. This analysis used an activity-based cost model, and combined ACF accounting data with estimates of partner and beneficiary costs derived using an ingredients approach to build an estimate of total program resource use. A societal perspective was adopted to encompass costs to beneficiary households, including their opportunity costs and an estimate of their income earned from vegetable sales. Qualitative methods were used to assess program benefits to beneficiary households. Effectiveness data was taken from a previously-conducted survey. Providing LIGs to PLHIV cost an additional 8,299 EUR per household with adequate FCS and 12,456 EUR per household with HDDS in the upper tertile, relative to comparator households of PLHIV receiving other support programs. Beneficiaries cited multiple tangible and intangible benefits from LIGs, and over 80% of gardens observed were still functioning more than one year after the program had finished. Cost outcomes were 20-30 times Zimbabwe's per capita GDP, and unlikely to be affordable within government services. This analysis concludes that LIGs are not cost-effective or affordable relative to other interventions for improving health and nutrition status of PLHIV. Nonetheless, given the myriad benefits acquired by participant households, such programs hold important potential to improve quality of life and reduce stigma against PLHIV.
    Full-text · Article · Apr 2014 · Cost Effectiveness and Resource Allocation
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    • "Inadequate protein and energy intake accelerates HIV-associated weight loss and immunosuppression, and a low body mass index (BMI; <18.5 kg/m2) at treatment initiation is associated with 2 to 6 fold increased mortality within 90 days compared to higher BMI in several analyses from the region [3-6]. In an analysis from Zambia, 20% of persons with a pre-treatment BMI <16 kg/m2, indicative of severe malnutrition by World Health Organization (WHO) criteria, were deceased after 6 months of ART and an additional 18% were lost to follow-up [7]. While the etiology of these early deaths is poorly understood, weight gain in the immediate post-ART period is a predictor of long-term survival in low BMI adults, suggesting that interventions to promote nutritional rehabilitation on ART may impact long-term outcomes [7-9]. "
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    ABSTRACT: Background Low body mass index (BMI) individuals starting antiretroviral therapy (ART) for HIV infection in sub-Saharan Africa have high rates of death and loss to follow-up in the first 6 months of treatment. Nutritional supplementation may improve health outcomes in this population, but the anticipated benefit of any intervention should be commensurate with the cost given resource limitations and the need to expand access to ART in the region. Methods We used Markov models incorporating historical data and program-wide estimates of treatment costs and health benefits from the Zambian national ART program to estimate the improvements in 6-month survival and program retention among malnourished adults necessary for a combined nutrition support and ART treatment program to maintain cost-effectiveness parity with ART treatment alone. Patients were stratified according to World Health Organization criteria for severe (BMI <16.0 kg/m2), moderate (16.00-16.99 kg/m2), and mild (17.00-18.49 kg/m2) malnutrition categories. Results 19,247 patients contributed data between May 2004 and October 2010. Quarterly survival and retention were lowest in the BMI <16.0 kg/m2 category compared to higher BMI levels, and there was less variation in both measures across BMI strata after 180 days. ART treatment was estimated to cost $556 per year and averted 7.3 disability-adjusted life years. To maintain cost-effectiveness parity with ART alone, a supplement needed to cost $10.99 per quarter and confer a 20% reduction in both 6-month mortality and loss to follow-up among BMI <16.0 kg/m2 patients. Among BMI 17.00-18.49 kg/m2 patients, supplement costs accompanying a 20% reduction in mortality and loss to follow-up could not exceed $5.18 per quarter. In sensitivity analyses, the maximum permitted supplement cost increased if the ART program cost rose, and fell if patients classified as lost to follow-up at 6 months subsequently returned to care. Conclusions Low BMI adults starting ART in sub-Saharan Africa are at high risk of early mortality and loss to follow-up. The expense of providing nutrition supplementation would require only modest improvements in survival and program retention to be cost-effective for the most severely malnourished individuals starting ART, but interventions are unlikely to be cost-effective among those in higher BMI strata.
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    • "These findings are in keeping with what is expected when immunity builds up and HIV infection is controlled in a PLHIV on treatment. [5, 6, 30] These desired outcomes are made possible when clients are managed according to national guidelines, barriers to taking treatment are addressed and treatment is taken as prescribed.[17] As Ghana continues to scale up and aims for universal access to HIV prevention, treatment and care services, it is encouraging to note that those enrolled in the program are making good progress. "
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