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Hospitalization for severe malnutrition among HIV-infected children starting antiretroviral therapy

Prendergast, Andrewa; Bwakura-Dangarembizi, Mutsa Fb; Cook, Adrian Da; Bakeera-Kitaka, Sabrinac; Natukunda, Evad; Nahirya Ntege, Patriciae; Nathoo, Kusum Jb; Karungi, Christined; Lutaakome, Josephe; Kekitiinwa, Adeodatac; Gibb, Diana Ma

doi: 10.1097/QAD.0b013e328345e56b
Clinical Science: Concise Communication

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.

aMRC Clinical Trials Unit, London, UK

bUniversity of Zimbabwe, Harare, Zimbabwe

cBaylor-Uganda Paediatric Infectious Disease Centre, Mulago Hospital, Uganda

dJoint Clinical Research Centre, Kampala, Uganda

eMRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda.

Received 23 September, 2010

Revised 2 February, 2011

Accepted 17 February, 2011

Correspondence to Dr Andrew Prendergast, MRC Clinical Trials Unit, 222 Euston Road, London, NW1 2DA, UK. Tel: +44 207 670 4814; fax: +44 207 670 4775; e-mail:

© 2011 Lippincott Williams & Wilkins, Inc.