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Acceptability of Outpatient Ready-To-Use Food-Based Protocols in HIV-Infected Senegalese Children and Adolescents Within the MAGGSEN Cohort Study
Abstract
Objectives:
To assess the acceptability of ready-to-use food (RUF)-based outpatient protocols in HIV-infected children and adolescents with severe acute malnutrition (SAM) and moderate acute malnutrition (MAM).
Methods:
Plumpy Nut and Plumpy Sup were supplied every 2 weeks and prescribed by weight to SAM and MAM children, respectively. Forty-three children, 24 MAM and 19 SAM, were enrolled. Organoleptic appreciation, feeding modalities, and perceptions surrounding RUF were recorded at week 2. Sachets were counted to measure adherence throughout the study.
Results:
Median age was 12.2 years (interquartile range: 9.3-14.8), and 91% were on antiretroviral treatment. Overall, 80%, 76%, 68%, and 68% of children initially rated RUF color, taste, smell, and mouth feeling as good. However, feelings of disgust, refusal to eat, fragmentation of intake, self-stigma, and sharing within the household were commonly reported. Eighteen MAM and 7 SAM experienced weight recovery. Recovery duration was 54 days (31-90) in MAM versus 114 days (69-151) in SAM children (P = .02). Their rate of RUF consumption compared to amount prescribed was approximately 50% from week 2 to week 10. Nine failed to gain weight or consume RUF and were discontinued for clinical management, and 9 dropped out due to distance to the clinic.
Conclusion:
Initial RUF acceptability was satisfactory. More than half the children had successful weight recovery, although adherence to RUF prescription was suboptimal. However, further research is needed to propose therapeutic foods with improved palatability, alternative and simpler intervention design, and procedures for continuous and tailored psychosocial support in this vulnerable population.
Trial registration:
NCT01771562 (Current Controlled Trials).
... Qualitative studies conducted in Southern Africa reported poor overall acceptability of RUF [16][17][18], whereas its organoleptic qualities were rated as good in studies from Vietnam [19] and Haiti [20]. Assessment of a pilot nutrition support providing RUF to 43 HIVinfected children and adolescents with acute malnutrition in two HIV clinics in Senegal shown that beneficiaries consumed 50% of their RUF on average and 20% defaulted from the programme [21]. Following this pilot study, the SNACS Study was implemented to assess the acceptability, effectiveness, and feasibility of outpatient RUF-based nutritional therapy among HIV-infected children and adolescents presenting with acute malnutrition across Senegal. ...
... Early RUF adherence, while participants went through an adaptation phase, might not be representative of the overall RUF consumption. However, this methodological choice is justified for several reasons: (i) this avoided analytical bias due to cohort attrition (the first recoveries and defaults occurred at week 2), (ii) as in other studies [21,32], adherence to RUF was rather stable over time among the remaining participants, (iii) adherence data coincide with acceptability data collected once at week 2. Third, we recruited participants in Dakar for the FGDs as these central sites have a longstanding and routine practice of hosting discussion groups as part of follow-up for older children and adolescents. By contrast, the regional sites had no comparable experience or practices. ...
Background:
Ready-to-use food (RUF) is increasingly used for nutritional therapy in HIV-infected individuals. However, practical guidance advising nutrition care to HIV-infected adolescents is lacking, so that little is known about the acceptability of such therapy in this vulnerable population. This study assesses the overall acceptability and perception of a RUF-based therapy and risk factors associated with sub-optimal RUF intake in HIV-infected undernourished adolescents in Senegal.
Methods:
Participants 5 to 18 years of age with acute malnutrition were enrolled in 12 HIV clinics in Senegal. Participants were provided with imported RUF, according to WHO prescription weight- and age-bands (2009), until recovery or for a maximum of 9-12 months. Malnutrition and recovery were defined according to WHO growth standards. Adherence was assessed fortnightly by self-reported RUF intake over the period. Sub-optimal RUF intake was defined as when consumption of the RUF provision was < 50%. RUF therapy acceptability and perceptions were assessed using a structured questionnaire at week 2 and focus group discussions (FGDs) at the end of the study. Factors associated with sub-optimal RUF intake at week 2 were identified using a stepwise logistic regression model.
Results:
We enrolled 173 participants, with a median age of 12.5 years (Interquartile range: 9.5-14.9), of whom 61% recovered from malnutrition within the study period. Median follow-up duration was 66 days (21-224). RUF consumption was stable, varying between 64 and 57% of the RUF provided, throughout the follow-up. At week 2, sub-optimal RUF intake was observed in 31% of participants. Dislike of the taste of RUF (aOR = 5.0, 95% CI: 2.0-12.3), HIV non-disclosure (5.1, 1.9-13.9) and food insecurity (2.8, 1.1-7.2) were the major risk factors associated with sub-optimal RUF intake at week 2. FGDs showed that the need to hide from others to avoid sharing and undesirable effects were other constraints on RUF feeding.
Conclusions:
This study revealed several factors reducing the acceptability and adherence to RUF therapy based on WHO guidelines in HIV-infected adolescents. Tailoring prescription guidance and empowering young patients in their care are crucial levers for improving the acceptability of RUF-based therapy in routine care.
Trial registration:
ClinicalTrials.gov identifier: NCT03101852, 04/04/2017.
... Qualitative studies conducted in Southern Africa reported poor overall acceptability of RUF (16)(17)(18), whereas its organoleptic qualities were rated as good in studies from Vietnam (19) and Haiti (20). Assessment of a pilot nutrition support providing RUF to 43 HIV-infected children and adolescents with acute malnutrition in two HIV clinics in Senegal shown that beneficiaries consumed 50% of their RUF on average and 20% defaulted from the programme (21). Following this pilot study, the SNACS Study was implemented to assess the acceptability, effectiveness, and feasibility of outpatient RUF-based nutritional therapy among HIV-infected children and adolescents presenting with acute malnutrition across Senegal. ...
... Early RUF adherence, while participants went through an adaptation phase, might not be representative of the overall RUF consumption. However, this methodological choice is justified for several reasons: (i) this avoided analytical bias due to cohort attrition (the first recoveries and defaults occurred at week 2), (ii) as in other studies (21,32), adherence to RUF was rather stable over time among the remaining participants, (iii) adherence data coincide with acceptability data collected once at week 2. Third, we recruited participants in Dakar for the FGDs as these central sites have a longstanding and routine practice of hosting discussion groups as part of follow-up for older children and adolescents. By contrast, the regional sites had no comparable experience or practices. ...
Background: Ready-to-use food (RUF) is increasingly used for nutritional therapy in HIV-infected individuals. However, practical guidance advising nutrition care to HIV-infected adolescents is lacking, so that little is known about the acceptability of such therapy in this vulnerable population. This study assesses the overall acceptability and perception of a RUF-based therapy and risk factors associated with sub-optimal RUF intake in HIV-infected undernourished adolescents in Senegal.
Methods: Participants 5 to 18 years of age with acute malnutrition were enrolled in 12 HIV clinics in Senegal. Participants were provided with imported RUF, according to WHO prescription weight- and age-bands (2009), until recovery or for a maximum of 9-12 months. Malnutrition and recovery were defined according to WHO growth standards. Adherence was assessed fortnightly by self-reported RUF intake over the period. Sub-optimal RUF intake was defined as when consumption of the RUF provision was < 50%. RUF therapy acceptability and perceptions were assessed using a structured questionnaire at week 2 and focus group discussions (FGDs) at the end of the study. Factors associated with sub-optimal RUF intake at week 2 were identified using a stepwise logistic regression model.
Results: We enrolled 173 participants, with a median age of 12.5 years (Interquartile range: 9.5 – 14.9), of whom 61% recovered from malnutrition within the study period. Median follow-up duration was 66 days (21 – 224). RUF consumption was stable, varying between 64% and 57% of the RUF provided, throughout the follow-up. At week 2, sub-optimal RUF intake was observed in 31% of participants. Dislike of the taste of RUF (aOR=5.0, 95% CI: 2.0 – 12.3), HIV non-disclosure (5.1, 1.9 – 13.9) and food insecurity (2.8, 1.1 – 7.2) were the major risk factors associated with sub-optimal RUF intake at week 2. FGDs showed that the need to hide from others to avoid sharing and undesirable effects were other constraints on RUF feeding.
Conclusions: This study revealed several factors reducing the acceptability and adherence to RUF therapy based on WHO guidelines in HIV-infected adolescents. Tailoring prescription guidance and empowering young patients in their care are crucial levers for improving the acceptability of RUF-based therapy in routine care.
ClinicalTrials.gov identifier: NCT03101852, 04/04/2017
... The observed level of adherence in this study is higher than the previous study conducted in the study area where 36.3% of the PLWHA were found to be adherent to the FBP program (Kebede and Haidar, 2014). However, the equivalent finding was reported from Senegal where the rate of RUTF consumption compared to the prescribed amount was approximately 50% among the study subjects (Cames et al., 2017). A qualitative study conducted in Kenya also revealed that half of malnourished AIDS adult patients failed to consume the daily prescription of RUTF (Dibari et al., 2011). ...
... The study conducted in Addis Ababa City also reported sharing the product with children and with other HIV-infected friends (Kebede and Haidar, 2014). The practice of sharing the RUTF with household members was also reported from similar studies conducted elsewhere (Gerberg and Stansbury, 2010;Dibari et al., 2011;Cames et al., 2017). The scarcity of food at the level of households, poverty, household food insecurity, and cultural issues are among the reasons behind sharing RUTF (Rodas-Moya et al., 2015;Food and Nutrition Technical Assistance, 2009;Kebede and Haidar, 2014). ...
... Qualitative studies conducted in Southern Africa reported poor overall acceptability of RUF (16-18), whereas its organoleptic qualities were rated as good in studies from Vietnam (19) and Haiti (20). Assessment of a pilot nutrition support providing RUF to 43 HIV-infected children and adolescents with acute malnutrition in two HIV clinics in Senegal shown that bene ciaries consumed 50% of their RUF on average and 20% defaulted from the programme (21). Following this pilot study, the SNACS Study was implemented to assess the acceptability, effectiveness, and feasibility of outpatient RUF-based nutritional therapy among HIV-infected children and adolescents presenting with acute malnutrition across Senegal. ...
... Early RUF adherence, while participants went through an adaptation phase, might not be representative of the overall RUF consumption. However, this methodological choice is justi ed for several reasons: (i) this avoided analytical bias due to cohort attrition (the rst recoveries and defaults occurred at week 2), (ii) as in other studies (21,32), adherence to RUF was rather stable over time among the remaining participants, (iii) adherence data coincide with acceptability data collected once at week 2. Third, we recruited participants in Dakar for the FGDs as these central sites have a longstanding and routine practice of hosting discussion groups as part of follow-up for older children and adolescents. By contrast, the regional sites had no comparable experience or practices. ...
Background : Ready-to-use food (RUF) is increasingly used for nutritional therapy in HIV-infected individuals. However, practical guidance advising nutrition care to HIV-infected adolescents is lacking, so that little is known about the acceptability of such therapy in this vulnerable population. This study assesses the overall acceptability and perception of a RUF-based therapy and risk factors associated with sub-optimal RUF intake in HIV-infected undernourished adolescents in Senegal. Methods : Participants aged 5 to 18 with acute malnutrition were enrolled in 12 HIV clinics in Senegal. Participants were provided with imported RUF, according to WHO prescription weight- and age-bands (2009), until recovery or for a maximum of 9-12 months. Malnutrition and recovery were defined according to WHO growth standards. Adherence was assessed fortnightly by self-reported RUF intake over the period. Sub-optimal RUF intake was defined as when consumption of the RUF provision was
... Adherence to nutritional products was not optimal in our study. These results were also documented for the use of RUTF in acutely malnourished children and adolescents living with HIV in Senegal [34,35], with for example reports of disgust feelings, self-stigma and practices of sharing with the households. In Mali, the RUTF consumption was also reported as incomplete for one third of the study population [29]. ...
Background:
Nutritional care is not optimally integrated into pediatric HIV care in sub-Saharan Africa. We assessed the 6-month effect of a nutritional support provided to children living with HIV, followed in a multicentric cohort in West Africa.
Methods:
In 2014-2016, a nutritional intervention was carried out for children living with HIV, aged under 10 years, receiving antiretroviral therapy (ART) or not, in five HIV pediatric cohorts, in Benin, Togo and Côte d'Ivoire. Weight deficiency was assessed using two definitions: wasting (Weight for Height Z-score [WHZ] for children<5 years old or Body-Mass-Index for Age [BAZ] for ≥5 years) and underweight (Weight for Age Z-score [WAZ]) (WHO child growth standards). Combining these indicators, three categories of nutritional support were defined: 1/ children with severe malnutrition (WAZ and/or WHZ/BAZ <-3 Standard Deviations [SD]) were supported with Ready-To-Use Therapeutic Food (RUTF), 2/ those with moderate malnutrition (WAZ and/or WHZ/BAZ = [-3;-2[ SD) were supported with fortified blended flours produced locally in each country, 3/ those non malnourished (WAZ and WHZ/BAZ ≥-2 SD) received nutritional counselling only. Children were followed monthly over 6 months. Dietary Diversity Score (DDS) using a 24h recall was measured at the first and last visit of the intervention.
Results:
Overall, 326 children were included, 48% were girls. At baseline, 66% were aged 5-10 years, 91% were on ART, and 17% were severely immunodeficient (CD4 <250 cells/mL or CD4%<15). Twenty-nine (9%) were severely malnourished, 63 (19%) moderately malnourished and 234 (72%) non-malnourished. After 6 months, 9/29 (31%) and 31/63 (48%) recovered from severe and moderate malnutrition respectively. The median DDS was 8 (IQR 7-9) in Côte d'Ivoire and Togo, 6 (IQR 6-7) in Benin. Mean DDS was 4.3/9 (sd 1.2) at first visit, with a lower score in Benin, but with no difference between first and last visit (p=0.907), nor by intervention groups (p-value=0.767).
Conclusions:
This intervention had a limited effect on nutritional recovery and dietary diversity improvement. Questions remain on determining appropriate nutritional products, in terms of adherence, proper use for families and adequate energy needs coverage for children living with HIV.
Trial registration:
PACTR202001816232398 , June 01, 2020, retrospectively registered.
... Several previous studies and systematic review have shown the efficacy of RUTF in the treatment of children with SAM (Schoonees et al., 2019), the acceptability of RUTF by patients (Brown et al., 2015;Cames et al., 2017;Nga et al., 2013) and described RUTF sharing practices and perceptions (Tadesse et al., 2015). The success of SAM treatment at community level with RUTF could depend on the availability, use and consumption practices of RUTF within the household, and perception of caregivers on the quantity of RUTF received. ...
Ready-to-use-therapeutic-foods (RUTF) was designed for the nutritional management of children with uncomplicated severe acute malnutrition (SAM) treated as outpatients. However, to our knowledge, no study has evaluated the availability, use and consumption of RUTF within the beneficiary household in programs and in the context of a reduction in the dose of RUTF.
This study, assessed the effect of a reduction in RUTF dose on the availability, use, consumption, and perceptions of caregivers on RUTF prescribed to 516 children treated for SAM, aged 6–59 months in Burkina Faso.
Children received a weekly dose of RUTF according to their treatment arm until recovery. Data were collected by structured individual in-depth interviews, with caregivers one month and two months post-admission. Differences between children receiving reduced RUTF (intervention arm) and those receiving standard RUTF (control arm) were assessed by Poisson, logistic, and ordered logistic regression model.
RUTF was available for the whole week in 95% in intervention arm compared to about 98% in control arm (p > 0.05). Starting from week 3 onwards, children in intervention arm consumed an average of 9 sachets of RUTF per week compared to 15 sachets in control arm (p < 0.001) and 5% of children in intervention arm reported leftover compared to 11% in control arm (p < 0.05). About 40% of children in intervention arm consumed RUTF at least 3-times per day compared to 82% in control arm (p < 0.001). The amount of RUTF prescribed was perceived as sufficient in 93% by caregivers in intervention arm against 97% in control arm (p > 0.05).
In conclusion, reducing the dose of RUTF did not affect the availability of RUTF during treatment but did reduce leftover and the frequency of consumption of RUTF.
... There is an urgent need for improved approaches to address specific health and nutritional needs in HIV-infected adolescents, which cannot be derived from studies of children or adults. We recently reported pilot data highlighting a mixed reception of RUF use, and high default rate among HIV-infected adolescents living in Dakar, the capital city of Senegal (20). Following this pilot programme, the SNACS Study was implemented to assess the acceptability, effectiveness, and feasibility of RUF-based nutritional therapy among young HIV-patients across Senegal. ...
Background: Ready-to-use food (RUF) is increasingly used for nutritional therapy in HIV-infected individuals. However, practical guidance advising nutrition care to HIV-infected adolescents is lacking, and little is known about the acceptability of such therapy in this vulnerable population. This SNACS study assesses the overall acceptability and perception of a RUF-based therapy and risk factors associated with sub-optimal RUF intake in HIV-infected undernourished adolescents in Senegal.
Methods: Participants aged 5 to 18 with acute malnutrition were enrolled in 12 HIV clinics in Senegal. Participants were provided with imported RUF, according to WHO prescription weight- and age-bands (2009), until recovery or for a maximum of 9-12 months. Malnutrition and recovery were defined according to WHO growth standards. Adherence was assessed fortnightly by self-reported RUF intake over the period. Sub-optimal RUF intake was defined as when consumption of the RUF provision was < 50%. RUF therapy acceptability and perceptions were assessed using a structured questionnaire (week 2) and focus group discussions (end of the study). Factors associated with sub-optimal RUF intake at week 2 were identified using stepwise logistic regression model.
Results: We enrolled 173 participants, with a median age of 12.5 years (Interquartile range: 9.5 – 14.9), of whom 61% recovered from malnutrition within the study period. Median follow-up duration was 66 days (21 – 224). At week 2, sub-optimal RUF intake was observed in 31% of participants. Dislike of the taste of RUF (aOR=5.0, 95% CI: 2.0 – 12.3), HIV non-disclosure (5.1, 1.9 – 13.9) and food insecurity (2.8, 1.1 – 7.2) were the major risk factors associated with sub-optimal RUF intake. Most participants initially reported a positive organoleptic appreciation of RUF. Constraints on RUF feeding were the need to hide from others to avoid sharing and limited time available. Among sub-optimal consumers, disgust and adverse effects attributed to RUF were perceived as barriers impossible to overcome.
Conclusions: This study revealed several factors reducing the acceptability and adherence to RUF therapy based on WHO guidelines in HIV-infected adolescents. Strengthening counselling capacity of HIV clinics, tailoring prescriptions and empowering young patients, are crucial for improving acceptability of RUF-based therapy in routine care.
... The SNACS study was an interventional, multicentre research programme designed to assess the effectiveness and acceptability of the WHO guidelines for outpatient nutritional rehabilitation among undernourished HIVinfected children and adolescents [25]. The study was implemented in Senegal after a report of a high prevalence of HIV-related wasting among children and adolescents in Dakar [26,27]. A low HIV disclosure rate, of fewer than 20% of children aged 10-14 years within the routine healthcare system [28], brought forth a major ethical dilemma of providing research information to mostly HIV-undisclosed children eligible to participate in a study with objectives directly related to HIV infection. ...
... Having excluded children with severe wasting from our study population, moderate wasting remained at rather high level, particularly among adolescents, and is consistent with figures reported from a recent study conducted in similar context in Mali [41]. Explanations for persistent wasting in the Senegalese adolescents on ART may lie in a therapeutic history of drug resistance development and late switch to second-line ART [19], a potentially high level of household food insecurity [42] and a substantial level of undernutrition in the general school population of the Dakar suburbs [43]. However, wasting was not associated with lipoatrophy in either univariable or multivariable analyses. ...
Background:
The long-term benefits of antiretroviral treatment (ART) are associated with metabolic complications, especially lipodystrophy, which has been well described among HIV-infected adults and children on ART in developed settings. Specifically, stavudine, and to a lesser extent zidovudine and protease inhibitors (PI), have been consistently implicated in the development of lipodystrophy. In 2006, following advice from the WHO, Senegal began phasing out stavudine from first-line ART. The objectives of this cross-sectional analysis are to assess and identify risk factors affecting the prevalence of lipodystrophy in Senegalese children and adolescents on long-term ART participating in a cohort study.
Methods:
Lipodystrophy was clinically assessed in two- to 18-year-old children on ART for at least six months and with no concurrent severe acute malnutrition. Risk factors for lipodystrophy were identified using stepwise multivariable logistic regression. Explanatory variables included clinical and personal data, immunovirologic status, and therapeutic history.
Results:
Overall, 254 children were assessed for lipodystrophy. The median age was 10.9 years (IQR: 8.1-14.2) and the median duration on ART was 54 months (32-84). Only 18% had been previously treated with stavudine, with a median treatment duration of 8 months (5-25). Ongoing treatment included 76% of children receiving zidovudine (median duration of 48 months (26-74)) and 27% receiving PI (lopinavir/ritonavir; median duration of 49 months (23-59)). Mild signs of lipodystrophy were observed in 33 children (13%): 28 with lipoatrophy, 4 with lipohypertrophy and one with combined type. Boys were more likely to present with lipoatrophy than girls (aOR: 4.3, 95% CI: 1.6-11.7). Children previously treated with stavudine for ≥1 year had a greater risk for lipoatrophy than those never exposed (3.8, 1.0-14.0), although the association was weak. There was no association between lipodystrophy and age or current or cumulative treatment with lopinavir/ritonavir or zidovudine.
Conclusions:
We report low prevalence of mild lipodystrophy in children and adolescents on long-term ART receiving a stavudine-sparing regimen. These findings are reassuring for clinicians in low-income settings where zidovudine is massively prescribed and lopinavir/ritonavir is the only widely available PI.
Trial registration:
ClinicalTrials.gov identifier: NCT01771562 (registration date: 01/18/2013).
La malnutrition est une pathologie récurrente en Afrique, qui touche particulièrement les enfants et adolescents vivant avec le VIH. Le Sénégal a été l’un des premiers pays africains à mettre en œuvre un programme national d’accès aux antirétroviraux à partir de 1998. Néanmoins, comme dans la majorité des pays, la prise en charge pédiatrique a connu un retard par rapport à celle des adultes. La malnutrition et l’infection à VIH agissent en interaction et aggravent le risque de morbidité et de mortalité des enfants. Pour autant, les recommandations internationales se sont surtout intéressées à la prise en charge de la malnutrition chez les enfants de moins de cinq ans. Il existe peu de directives concernant les modalités de récupération nutritionnelle chez les enfants de plus de cinq ans et les adolescents infectés par le VIH.C’est dans ce contexte qu’a été mise en place l’étude Snac’s qui avait pour objectif d’évaluer l’efficacité et l’acceptabilité de la récupération nutritionnelle ambulatoire par l’administration d’Aliments prêts à l’emploi (APE) chez les enfants et adolescents infectés par le vih dans 12 sites de prise en charge à Dakar et dans les régions du Sénégal. Cette thèse a pour objectif d’évaluer, dans le cadre de cette étude 1/l’acceptabilité d’un dispositif innovant d’information des enfants et des parents pour la participation à la recherche 2/ l’acceptabilité de l’intervention de récupération nutritionnelle chez les enfants et adolescents et d’identifier les facteurs et obstacles à cette acceptabilité 3/ l’acceptabilité de l’intervention chez les soignants impliqués dans l’étude.Trois enquêtes ont été menées au cours du projet Snac’s, dans les deux sites de Dakar et les dix sites régionaux auprès des enfants, des parents/tuteurs et des professionnels de santé. Les entretiens avec les enfants en succès ou en échec de traitement de la malnutrition et avec les parents se sont déroulés par focus group. Ils ont concerné 112 enfants au moment de l’inclusion et 71 enfants au moment de la sortie de l’étude. Des entretiens individuels ont concerné 30 professionnels de santé.Le Dispositif standardisé d’information à la recherche (dsir) avait pour intérêt de standardiser et rendre facilement compréhensible l’information des participants. Il a été apprécié par les enfants/adolescents, et par les parents/tuteurs. 68 % des parents/tuteurs et 58 % des enfants/adolescents, ont répondu correctement à au moins 7/8 questions. La notion qui a été la moins bien comprise par les parents/tuteurs et les enfants/adolescents était le droit de quitter l’étude, avec des taux respectifs de réponses correctes de 54 % et 36 %. L’enquête sur l’acceptabilité à permis d’identifier trois déterminants qui peuvent représenter un obstacle à l’adhésion des enfants/adolescents à une prise en charge nutritionnelle ambulatoire à base d’ape : le dégoût des ape, les effets secondaires et la durée de l’attente avant la consultation. Les entretiens avec les équipes soignantes ont mis en évidence les difficultés rencontrées dans la prise en charge du VIH pédiatrique. Les analyses ont montré une bonne acceptabilité de l’intervention, mais une incertitude quant à la possibilité de la pérenniser à la fin du projet.Ce travail a permis d’expérimenter la mise en place du dsir, qui s’avère intéressant même s’il demande à être amélioré. Il a permis de décrire les difficultés et les enjeux de la prise en charge de l’infection à vih pédiatrique notamment en région, qui constituent l’environnement des interventions de récupération nutritionnelle. Les résultats de cette étude montrent que le dispositif de récupération nutritionnelle ambulatoire est acceptable par les principaux acteurs (enfants/adolescents, parents/tuteurs et équipes soignantes), mais que sa pérennisation n’est envisageable qu’avec l’appui et l’engagement des autorités sanitaires, la mise en place d’un approvisionnement régulier en ape et d’un accompagnement, notamment financier, adéquat.
HIV infection and poor nutrition status are interlinked. HIV infected individuals are more vulnerable to malnutrition than the general population. Poor nutrition status in HIV infected individuals is associated with disease progression, increased morbidity and reduced survival even when antiretroviral treatment is available. Adequate nutrition is necessary to maintain the immune system, manage opportunistic infections, optimize response to medical treatment, sustain healthy levels of physical activity and support optimal quality of life in individuals infected with HIV. WHO recommends incorporation of nutritional care and support as an integral part of a comprehensive response to HIV/AIDS. Ready-to-Use Therapeutic Food (RUTF) is widely in use in management of wasting among HIV infected adults. In Ethiopia, there was paucity of data on adults' views and experiences of RUTF though patients' perceived values of use and perceptions on a service are important factors in treatment success. The objective of this study was to explore views and experiences of HIV infected adults treated with RUTF in Addis Ababa, Ethiopia, 2012. The study explored issues related with attitude, believes, perceived benefits of use, misuses and challenges related with RUTF use. Phenomenological qualitative study based on in-depth interview and focus groups discussion was conducted on purposefully selected sample of 23 HIV positive adults on RUTF treatment in Zewditu hospital and Woreda-7 health center. The data collected was audio recoded, uploaded into opencode and analyzed using themes emerged from the data during constant comparative analysis. HIV infected adults had positive attitude, perceived many benefits of use and experienced favorable outcomes of RUTF use. Intention to use RUTF was also high. However, patients encountered significant challenges associated with their use of RUTF. They experienced side effects, felt more stigmatized and discriminated, encountered problems during handling and transportation. RUTF misuse was practiced frequently and in variety of forms. Modification of the current formulation and its prescription protocol, systematic control measures, provision of comprehensive nutrition counseling, harmonization of RUTF and other HIV clinical care appointments; and assessment and training on nutritional counseling skills of the health workers should be considered.
Ready-to-use therapeutic food (RUTF) has been found effective in treating severe acute malnutrition. Vietnam's National Institute of Nutrition (NIN), the Institut de Recherche pour le Développement (IRD), and UNICEF collaborated to formulate a local RUTF called High-Energy Bar for Integrated Management of Acute Malnutrition (HEBI). RUTF might be useful to address malnutrition in HIV patients.
To compare the acceptability of the local RUTF and an imported RUTF among malnourished people with HIV in Vietnam Methods: The acceptability of HEBI and Plumpy'Nut was studied among 80 HIV-positive children and 80 HIV-positive adults. In a crossover design, participants were randomly assigned to receive either Plumpy'Nut or HEBI for 2 weeks and were switched to the other product for the subsequent 2 weeks. A third (control) group of about 40 HIV-positive participants in each study was randomly assigned to receive no RUTF. Nurses took anthropometric measurements weekly, and the subjects or their caregivers monitored daily RUTF intake.
Children consumed 69% of HEBI and 65% of Plumpy'Nut (p = .13). Adults consumed 91% of HEBI and 81% of Plumpy'Nut (p = .059). Both children (p = .058) and adults (p ≤ .0001) preferred HEBI. Significant gains were observed in percent weight (p = .035), weight-for-age (p = .014), and body mass index (BMI)-for-age (p = .036) in children who received RUTF and in percent weight (p = .017) and BMI (p = .0048) in adults who received RUTF compared with the control groups.
In this study in Vietnam, both HEBI and Plumpy'Nut were found acceptable by people with HIV.
© The Author(s) 2015.
The burden of malnutrition among HIV-infected children is not well described in sub-Saharan Africa, even though it is an important problem to take into account to guarantee appropriate healthcare for these children. We assessed the prevalence of malnutrition and its associated factors among HIV-infected children in HIV care programmes in Central and West-Africa.
A cross-sectional study was conducted from September to December 2011 among the active files of HIV-infected children aged 2-19 years old, enrolled in HIV-care programmes supported by the Sidaction Growing Up Programme in Benin, Burundi, Cameroon, Côte d'Ivoire, Mali, Chad and Togo. Socio-demographics characteristics, anthropometric, clinical data, and nutritional support were collected. Anthropometric indicators, expressed in Z-scores, were used to define malnutrition: Height-for-age (HAZ), Weight-for-Height (WHZ) for children < 5 years and BMI-for-age (BAZ) for children ≥5 years. Three types of malnutrition were defined: acute malnutrition (WHZ/BAZ < -2 SD and HAZ ≥ -2 SD), chronic malnutrition (HAZ < -2 SD and WHZ/BAZ ≥ -2 SD) and mixed malnutrition (WHZ/BAZ < -2 SD and HAZ < -2 SD). A multinomial logistic regression model explored associated factors with each type of malnutrition.
Overall, 1350 HIV-infected children were included; their median age was 10 years (interquartile range [IQR]: 7-13 years), 49 % were girls. 80 % were on antiretroviral treatment (ART), for a median time of 36 months. The prevalence of malnutrition was 42 % (95 % confidence interval [95% CI]: 40-44 %) with acute, chronic and mixed malnutrition at 9 % (95% CI: 6-12 %), 26 % (95% CI: 23-28 %), and 7 % (95% CI: 5-10 %), respectively. Among those malnourished, more than half of children didn't receive any nutritional support at the time of the survey. Acute malnutrition was associated with male gender, severe immunodeficiency, and the absence of ART; chronic malnutrition with male gender and age (<5 years); and mixed malnutrition with male gender, age (<5 years), severe immunodeficiency and recent ART initiation (<6 months). Orphanhood and Cotrimoxazole prophylaxis were not associated with any type of malnutrition.
The prevalence of malnutrition in HIV-infected children even on ART remains high in HIV care programmes. Anthropometric measurements and appropriate nutritional care of malnourished HIV-infected children remain insufficient and a priority to improve health care of HIV-infected children in Africa.
In low income countries, severe acute malnutrition remains a major problem for HIV-infected children and an important risk factor for mortality. This study aims to analyze HIV impact on mortality rate and nutritional recovery among severely malnourished HIV/AIDS uninfected and infected children. This was a retrospective cohort study conducted from data of 521 hospitalized severely malnourished children. We used Pearson’s Chi square test to compare proportions; and Student’s independent t-test to compare means; general linear model to analyze repeated measurements. We used mortality relative risk with confidence interval (CI 95%), Kaplan-Meir survival curves and Cox proportional hazard models to analyze the HIV impact on mortality rate. Case fatality rate differed significantly from SAM HIV uninfected (10.7%) and HIV infected children (39.7%), p < 0.001. Mortality relative risk was 3.71, 95% IC [2.51 - 5.47] for HIV infected children. Kaplan-Meir survival curves differed significantly between the two groups, (p Log Rank < 0.001). Cox regression adjusted mortality relative risk of HIV infected children was 4.27, CI: 2.55 - 7.15, p < 0.001. Mean weight gain differed significantly among infected children, p < 0.001. Anthropometric Z-scores means evolution differed significantly between HIV infected and uninfected children and within each group’s subjects for WHZ (p < 0.001) and WAZ (p < 0.001). Mortality relative risk was 3.71 times higher for HIV infected children. Multiples infections and metabolic compli
Background
One way of addressing malnutrition among HIV/AIDS patients is through the Food by Prescription program (FBP) and many studies have explained the treatment outcomes after therapeutic food supplementation, though available evidences on adherence levels and factors associated with these sorts of programs are limited. The findings of this study would therefore contribute to the existing knowledge on adherence to Ready-to-Use Therapeutic/Supplementary Food (RUF) in Ethiopia.
Methods
A facility-based, cross-sectional study supplemented with qualitative methods was conducted among 630 adult HIV + patients. Their level of adherence to RUF was measured using the Morisky 8-item Medication Adherence Scale (MMAS-8). The total score on the MMAS-8 ranges from 0 to 8, with scores of <6, 6 to <8, and 8 reflecting low, medium, and high adherence, respectively. Patients who had a low or a moderate rate of adherence were considered non-adherent.
Results
The level of adherence was found to be 36.3% with a 95.0% response rate. With the exception of the educational status, other socio-demographic variables had no significant effect on adherence. Those who knew the benefits of the FBP program were 1.78 times more likely to adhere to the therapy than the referent groups. On the other hand, patients who were not informed on the duration of the treatment, those prescribed with more than 2 sachets/day and had been taking RUF for more than 4 month were less likely to adhere. The main reasons for non-adherence were not liking the way the food tasted and missing follow-up appointments. Stigma and sharing and selling food were the other reasons, as deduced from the focus group discussion (FGD) findings.
Conclusion
The observed level of adherence to the FBP program among respondents enrolled in the intervention program was low. The major factors identified with a low adherence were a low level of education, poor knowledge on the benefits of RUF, the longer duration of the program, consuming more than two prescribed sachets of RUF per day, and not being informed about the duration of the treatment. Therefore, counseling patients on the program’s benefits, including the treatment plans, would likely contribute to improved adherence.
Ready-to-use supplementary foods (RUSF) are used increasingly in human immunodeficiency virus (HIV) programs, but little is known about how it is used and viewed by patients. We used qualitative methods to explore the use, perceptions, and acceptability of RUSF among adult HIV patients in Jimma, Ethiopia.
The study obtained data from direct observations and 24 in-depth interviews with HIV patients receiving RUSF.
Participants were generally very motivated to take RUSF and viewed it as beneficial. RUSF was described as a means to fill a nutritional gap, to "rebuild the body," and protect it from harmful effects of antiretroviral treatment (ART). Many experienced nausea and vomiting when starting the supplement. This caused some to stop supplementation, but the majority adapted to RUSF. The supplement was eaten separately from meal situations and only had a little influence on household food practices. RUSF was described as food with "medicinal qualities," which meant that many social and religious conventions related to food did not apply to it. The main concerns about RUSF related to the risk of HIV disclosure and its social consequences.
HIV patients view RUSF in a context of competing livelihood needs. RUSF intake was motivated by a strong wish to get well, while the risk of HIV disclosure caused concerns. Despite the motivation for improving health, the preservation of social networks was prioritized, and nondisclosure was often a necessary strategy. Food sharing and religious fasting practices were not barriers to the acceptability of RUSF. This study highlights the importance of ensuring that supplementation strategies, like other HIV services, are compatible with the sociocultural context of patients.
Within a Medecins Sans Frontieres's nutrition programme in Kamrangirchar slum, Dhaka, Bangladesh this study was conducted to assess the acceptability of a peanut-based ready-to-use therapeutic food (RUTF) - Plumpy'nut(®) (PPN) among malnourished pregnant and lactating women (PLW). This was a cross-sectional survey using semi-structure questionnaire that included all PLW admitted in the nutrition programme, who were either malnourished or at risk of malnutrition and who had received PPN for at least 4 weeks. A total of 248 women were interviewed of whom 99.6% were at risk of malnutrition. Overall, 212 (85%) perceived a therapeutic benefit. Despite this finding, 193 (78%) women found PPN unacceptable, of whom 12 (5%) completely rejected it after 4 weeks of intake. Reasons for unacceptability included undesirable taste (60%) and unwelcome smell (43%) - more than half of the latter was due to the peanut-based smell. Overall, 39% attributed side effects to PPN intake including nausea, vomiting, diarrhoea, abdominal distension and pain. Nearly 80% of women felt a need to improve PPN - 82% desiring a change in taste and 48% desiring a change in smell. Overall, only 146 (59%) understood the illustrated instructions on the package. Despite a perceived beneficial therapeutic effect, only two in 10 women found PPN acceptable for nutritional rehabilitation. We urge nutritional agencies and manufacturers to intensify their efforts towards developing more RUTF alternatives that have improved palatability and smell for adults and that have adequate therapeutic contents for treating malnourished PLW in Bangladesh.
Peanut milk-based ready-to-use therapeutic food (P-RUTF) primarily used to treat severe acute malnutrition at community setting is expensive. We developed an alternative milk-free soybean-maize-sorghum-based RUTF (SMS-RUTF) using locally grown ingredients that have the potential to support local economy and reduce the cost of RUTF. We describe the production process and results of acceptability of the new product. Acceptability and tolerance of SMS-RUTF was compared with P-RUTF among 45 children aged 4-11 years old based on a cross-over design. Each child consumed 250 g RUTF for 10 days followed by a five-day washout period and a subsequent 10-day period on the second RUTF. The SMS-RUTF was as acceptable as the P-RUTF among normal children aged 4-11 years of age with no associated adverse effects. SMS-RUTF was stable for at least 12 months without detectable microbiological or chemical deterioration. The major challenge encountered in SMS-RUTF development was the difficulty to accurately determine key nutrient composition due to its high oil content. Use of diversified locally available ingredients to produce RUTF is feasible. The SMS-RUTF meets expected standards and is acceptable to children aged 4-11 months old. Effectiveness and cost-effectiveness of SMS-RUTF is required.
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.
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.
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).
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.
Assessment of antiretroviral treatment programmes for HIV-infected children in sub-Saharan Africa is important to enable the development of effective care and improve treatment outcomes. We review the effectiveness of paediatric antiretroviral treatment programmes in sub-Saharan Africa and discuss the implications of these findings for the care and treatment of HIV-infected children in this region. Available reports indicate that programmes in sub-Saharan Africa achieve treatment outcomes similar to those in North America and Europe. However, progress in several areas is required to improve the care of HIV-infected children in sub-Saharan Africa. The findings emphasise the need for low-cost diagnostic tests that allow for earlier identification of HIV infection in infants living in sub-Saharan Africa, improved access to antiretroviral treatment programmes, including expansion of care into rural areas, and the integration of antiretroviral treatment programmes with other health-care services, such as nutritional support.
To understand factors affecting the compliance of malnourished, HIV-positive adults with a nutritional protocol using ready-to-use therapeutic food (RUTF; Plumpy'nut®).
Qualitative study using key informant interviews, focus group discussions and direct observations.
Ministry of Health HIV/programme supported by Médecins Sans Frontièrs (MSF) in Nyanza Province, Kenya.
Adult patients (n 46) currently or previously affected by HIV-associated wasting and receiving anti-retroviral therapy, their caregivers (n 2) and MoH/MSF medical employees (n 8).
Thirty-four out of forty-six patients were receiving RUTF (8360 kJ/d) at the time of the study and nineteen of them were wasted (BMI < 17 kg/m2). Six of the thirteen wasted out-patients came to the clinic without a caregiver and were unable to carry their monthly provision (12 kg) of RUTF home because of physical frailty. Despite the patients' enthusiasm about their weight gain and rapid resumption of labour activities, the taste of the product, diet monotony and clinical conditions associated with HIV made it impossible for half of them to consume the daily prescription. Sharing the RUTF with other household members and mixing with other foods were common. Staff training did not include therapeutic dietetic counselling.
The level of reported compliance with the prescribed dose of RUTF was low. An improved approach to treating malnourished HIV-positive adults in limited resource contexts is needed and must consider strategies to support patients without a caregiver, development of therapeutic foods more suited to adult taste, specific dietetic training for health staff and the provision of liquid therapeutic foods for severely ill patients.
Among people living with HIV/AIDS, nutritional support is increasingly recognized as a critical part of the essential package of care, especially for patients in sub-Saharan Africa. The objectives of the study were to evaluate the outcomes of HIV-positive malnourished adults treated with ready-to-use therapeutic food and to identify factors associated with nutrition programme failure.
We present results from a retrospective cohort analysis of patients aged 15 years or older with a body mass index of less than 17 kg/m² enrolled in three HIV/AIDS care programmes in Africa between March 2006 and August 2008. Factors associated with nutrition programme failure (patients discharged uncured after six or more months of nutritional care, defaulting from nutritional care, remaining in nutritional care for six or more months, or dead) were investigated using multiple logistic regression.
Overall, 1340 of 8685 (15.4%) HIV-positive adults were enrolled in the nutrition programme. At admission, median body mass index was 15.8 kg/m² (IQR 14.9-16.4) and 12% received combination antiretroviral therapy (ART). After a median of four months of follow up (IQR 2.2-6.1), 524 of 1106 (47.4%) patients were considered cured. An overall total of 531 of 1106 (48.0%) patients failed nutrition therapy, 132 (11.9%) of whom died and 250 (22.6%) defaulted from care. Men (OR = 1.5, 95% CI 1.2-2.0), patients with severe malnutrition at nutrition programme enrolment (OR = 2.2, 95% CI 1.7-2.8), and those never started on ART (OR = 4.5, 95% CI 2.7-7.7 for those eligible; OR = 1.6, 95% CI 1.0-2.5 for those ineligible for ART at enrolment) were at increased risk of nutrition programme failure. Diagnosed tuberculosis at nutrition programme admission or during follow up, and presence of diarrhoeal disease or extensive candidiasis at admission, were unrelated to nutrition programme failure.
Concomitant administration of ART and ready-to-use therapeutic food increases the chances of nutritional recovery in these high-risk patients. While adequate nutrition is necessary to treat malnourished HIV patients, development of improved strategies for the management of severely malnourished patients with HIV/AIDS are urgently needed.
To provide HIV-positive mothers who opted for exclusive breastfeeding or formula feeding from birth to 6 months postpartum as a means of prevention of mother-to-child transmission (PMTCT) of HIV with a sustainable infant food support programme (FSP) from 6 to 12 months postpartum. We describe the implementation and assessment of this pilot initiative.
The FSP included a 6-month provision of locally produced infant fortified mix (IFM; 418 kJ/100 g of gruel) for non-breastfed infants coupled with infant-feeding and psychosocial counselling and support. Acceptability and feasibility were assessed in a subsample of sixty-eight mother-infant pairs.
The FSP was developed in collaboration with local partners to support participants in a PMTCT prevention study. Formula was provided for free from 0 to 6 months postpartum. Cessation by 6 months was recommended for breastfeeding mothers.
The FSP was positively received and greatly encouraged breastfeeding mothers to cease by 6 months. As recommended, most infants were given milk as an additional replacement food, mainly formula subsidised by safety networks. Among daily IFM consumers, feeding practices were satisfactory overall; however, the IFM was shared within the family by more than one-third of the mothers. Cessation of IFM consumption was observed among twenty-two infants, seventeen of whom were fed milk and five neither of these.
Without any food support most mothers would have been unable to provide appropriate replacement feeding. The food security of non-breastfed infants urgently needs to be addressed in HIV PMTCT programmes. Our findings on a simple cost-effective pioneer intervention provide an important foundation for this process.
Few studies have reported on nutritional recovery, survival and growth among severely malnourished children with HIV. This study explores nutritional recovery in HIV-infected and HIV-uninfected children during inpatient nutrition rehabilitation and 4 months of follow-up.
Prospective cohort study.
Lilongwe district, Malawi.
Weight gain, anthropometrics.
In our sample of 454 children with severe acute malnutrition (SAM), 17.4% (n = 79) of children were HIV infected. None of the children were on antiretroviral therapy upon admission. Among the HIV-infected children, 35.4% (28/79) died, compared with 10.4% (39/375) in HIV-uninfected children (p<0.001). All children who survived achieved nutritional recovery (>85% weight for height and no oedema), regardless of HIV status. HIV-infected children had similar weight gain to HIV-uninfected children (8.9 vs 8.0 g/kg/d, not significant (NS)). Mean increases in z-scores for both subscapular (2.72 vs 2.69, NS) and triceps (1.26 vs 1.48, NS) skinfolds were similar between HIV-infected and HIV-uninfected children, respectively, during nutrition rehabilitation. 362 children were followed for 4 months, at which time mean weight for height z-score was similar in HIV-infected and HIV-uninfected children (-0.85 vs -0.64, NS).
HIV-infected children with SAM have higher mortality rates than HIV-uninfected children. Among those who survive, however, nutritional recovery is similar in HIV-infected and HIV-uninfected children.
To assess the clinical outcomes of a combined approach to the treatment of severe acute malnutrition in an area of high HIV prevalence using: (i) an initial inpatient phase, based on WHO guidelines and (ii) an outpatient recovery phase using ready-to-use therapeutic food.
An operational prospective cohort study implemented in a referral hospital in Southern Malawi between May 2003 and 2004. Patient outcomes were compared with international standards and with audits carried out during the year preceding the study.
Inpatient mortality was 18% compared to 29% the previous year. Programme recovery rate was 58.1% compared to 45% the previous year. The overall programme mortality rate was 25.7%. Of the total known HIV seropositive children, 49.5% died.
Inpatient mortality and cure rates improved compared to pre-study data but the overall mortality rate did not meet international standards. Additional interventions will be needed if these standards are to be achieved.
Objectives:
We described prevalence and risk factors for wasting and stunting among HIV-infected children with a median duration of 3 years of antiretroviral therapy (ART) at the time of their enrollment in the cohort study.
Methods:
Wasting and stunting at ART initiation and at enrollment were defined as weight-for-height/body mass index-for-age z-scores < -2 and height-for-age z-scores < -2, respectively. Logistic regression was used to assess risk factors for wasting and stunting. Main predictive factors were age at enrollment, nutritional status and age (< or ≥5 years) at ART initiation, ART duration (< or ≥3 years on first-line, or ≥3 years including a switch to second-line ART).
Results:
244 children were enrolled, 2-16 years of age. Overall, wasting and stunting prevalence dropped off consistently in children 2-10 years of age, between ART initiation and enrollment, while it remained at high levels, 52% and 42%, respectively, in children 10-16 years of age. Risk factors for wasting at enrollment were ART duration of ≥3 years including a switch to second-line (adjusted odds ratio [aOR]: 3.9, 95% confidence interval [CI]: 1.7-8.9) and wasting at ART initiation (aOR 2.7, 95% CI 1.4-5.2). The risk factor for stunting at enrollment was stunting at ART initiation (aOR 11.6, 95% CI 5.4-25.0), independent of ART duration.
Conclusions:
Malnutrition at the time of ART initiation was the main predictor of malnutrition at enrollment among HIV-infected children on ART. Longer duration on ART had no overall protective effect on wasting and stunting. Growth and virologic monitoring are of utmost importance in the comprehensive care of children with HIV infection.
Weight loss and muscle wasting remain significant clinical problems, even in the era of potent antiretroviral therapy. In
patients infected with human immunodeficiency virus (HIV), wasting, particularly loss of metabolically active lean tissue,
has been associated with increased mortality, accelerated disease progression, loss of muscle protein mass, and impairment
of strength and functional status. Factors that may contribute to wasting include inadequate intake, malabsorptive disorders,
metabolic alterations, hypogonadism, and excessive cytokine production. Evidence now demonstrates that nutritional counseling
and support, appetite stimulants, progressive resistance training, and anabolic hormones can reverse weight loss and increase
lean body mass in HIV-infected patients. Despite a growing body of evidence on the importance of nutritional intervention
to prevent wasting in adults, maintain growth velocity in children, and promote restoration of weight and lean body mass in
stable, low-weight patients, no therapeutic guidelines currently exist for the management of weight loss and wasting in HIV-infected
patients. Principles and guidelines for assessment and management of weight loss and wasting in patients with HIV/AIDS are
presented.
To determine the efficacy of home-based therapy with ready-to-use food (RTUF) in producing catch-up growth in malnourished children and to compare locally produced RTUF with imported RTUF for this purpose.
After a brief inpatient stabilization, 260 children with severe malnutrition were enrolled and systematically allocated to receive home therapy with either imported, commercially produced RTUF or locally produced RTUF. Each child received 730 kJ/kg/day and was followed up fortnightly. Children completed the study when they reached a weight-for-height Z score > -0.5 (WHZ), relapsed, died, or failed to achieve WHZ > -0.5 after 16 weeks. Analyses were stratified by human immunodeficiency virus (HIV) status.
78% of all children reached WHZ > -0.5, 95% of those with HIV-negative status and 59% of those with HIV-positive status. Eighty percent of those receiving locally produced RTUF and 75% of those receiving imported RTUF reached WHZ > -0.5. The difference between recovery rates was 5% (95% confidence interval [CI], -5-15%). The rate of weight gain was 0.4 g/kg/day (95% CI, -0.6, 1.4) greater among children receiving locally produced RTUF. The prevalence of diarrhea reported by mothers was 3.7% for locally produced RTUF and 4.3% for imported RTUF. After completion of home therapy and resumption of habitual diet for 6 months, 91% of all children maintained a normal WHZ.
Home-based therapy with RTUF was successful in affecting complete catch-up growth. In this study, locally produced and imported RTUF were similar in efficacy in treating of severe childhood malnutrition.
To determine if home-based nutritional therapy will benefit a significant fraction of malnourished, HIV-infected Malawian children, and to determine if ready-to-use therapeutic food (RUTF) is more effective in home-based nutritional therapy than traditional foods.
93 HIV-positive children >1 y old discharged from the nutrition unit in Blantyre, Malawi were systematically allocated to one of three dietary regimens: RUTF, RUTF supplement or blended maize/soy flour. RUTF and maize/soy flour provided 730 kJ x kg(-1) x d(-1), while the RUTF supplement provided a fixed amount of energy, 2100 kJ/d. These children did not receive antiretroviral chemotherapy. Children were followed fortnightly. Children completed the study when they reached 100% weight-for-height, relapsed or died. Outcomes were compared using regression modeling to account for differences in the severity of malnutrition between the dietary groups.
52/93 (56%) of all children reached 100% weight-for-height. Regression modeling found that the children receiving RUTF gained weight more rapidly and were more likely to reach 100% weight-for-height than the other two dietary groups (p < 0.05).
More than half of malnourished, HIV-infected children not receiving antiretroviral chemotherapy benefit from home-based nutritional rehabilitation. Home-based therapy RUTF is associated with more rapid weight gain and a higher likelihood of reaching 100% weight-for-height.
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Ndeye Fatou Diallo and Ndeye Rama Diagne (study clinicians and coinvestigators)
- Helene Aminata Diack Mbaye
- Mbodj
Aminata Diack Mbaye, Helene
Mbodj, Ndeye Fatou Diallo and Ndeye Rama Diagne
(study clinicians and coinvestigators);
Synergie pour l'Enfance/Centre Hospitalier Roi Baudouin
- Natalia Laschina
and Natalia Laschina (psychologist). (2)
Synergie pour l'Enfance/Centre Hospitalier Roi Baudouin (Guediawaye, Senegal): Ngagne Mbaye (investigator);
Cecile Cames (study coordinator), Philippe Msellati (investigator), Lea Pascal (study analyst), Amady Ndiaye (study technician), Suzanne Izard (data manager)
- Alhadji Bassine
Alhadji Bassine Diom, Adama Ndour (social
workers); and Bigue Badiane (laboratory technician).
Supporting institutions: Agence Nationale de
Recherches sur le SIDA et les hépatites virales, France:
Brigitte Bazin (Sponsor Representative). Study Coordination: Institut de Recherche pour le Développement
(IRD), Montpellier, France: Cecile Cames (study coordinator), Philippe Msellati (investigator), Lea Pascal
(study analyst), Amady Ndiaye (study technician),
Suzanne Izard (data manager), Caroline Desclaux-Sall (doctoral fellow), Ousseynou Ndiaye and Binta
Seck (biologists), and Ibrahima Diallo (study monitor,
until June 2013).