To the Editor:
Protein-energy malnutrition (PEM) and late HIV disease, both common features in sub-Saharan Africa, have similar features.1-4 Consequently, distinguishing the 2 conditions clinically is difficult.5 Several studies have shown that HIV is common in malnourished children, especially children with marasmus and marasmic-kwashiorkor.4,6 The World Health Organization (WHO) recommends that severely malnourished children should not be tested routinely for HIV on the premise that knowledge of HIV status does not play any role in the management of the child, except to diagnose interstitial lymphocytic pneumonia, and that a positive test result might cause the nursing staff to neglect the child.7 Some reports have indicated that mortality among malnourished HIV-positive children was significantly higher than for malnourished HIV-negative children,4,8 although other studies have not found a similar significant difference between HIV-positive and HIV-negative malnourished children.6,9,10 In a study,9 HIV-positive malnourished children had nearly twice the odds of dying as HIV-negative malnourished children. It has been suggested that early identification in HIV disease may present a critical window of opportunity to intervene effectively.2,11 In the years after the WHO recommendation on routine HIV testing of malnourished children, management of HIV in resource-poor settings has improved and HIV awareness has increased dramatically. This recommendation not to routinely screen for HIV in malnourished children therefore might require some modifications to fit the present context.
In the absence of routine screening of malnourished children for HIV, the level of suspicion of the health care staff becomes important in identifying children who might be at higher risk of HIV. In high HIV prevalence areas, because of the high index of suspicion for HIV, there is an increased chance of picking up HIV infection coexisting with PEM. In low HIV prevalence settings, the index of suspicion is low, increasing the chances that HIV might not be considered in the diagnostic workup. This is even more likely in areas in which resources are limited and infrastructure is lacking. In such settings, a delayed or missed diagnosis of HIV-PEM comorbidity could increase mortality from malnutrition.4 All available information on HIV-PEM interaction comes from high-prevalence settings. Similar information from low HIV prevalence resource-poor settings is scarce.
We carried out a retrospective case-control study as a preliminary assessment to investigate the effect of HIV on clinical outcome in children managed at a nutritional supplementation center in a low HIV prevalence setting in rural Gambia to provide information that should guide further research in this area. Routine screening for HIV is not carried out at the center; screening is conducted when there is poor response to management, diagnosis of tuberculosis (TB), and confirmed HIV in 1 or both parents. We compared the clinical outcome in malnourished children with confirmed HIV with that in malnourished children of negative or unknown serostatus. For each case, 4 gender- and age-matched controls were chosen. The outcome measures were duration of hospitalization and mortality.
There were 286 admissions, with an HIV prevalence of 2.10%. Table 1 describes the baseline characteristics of the cases and controls. All the anthropometric indices (weight-for-height z score [WHZ], weight-for-age z score [WAZ], height-for age z score [HAZ], and body mass index [BMI]) were significantly poorer in the HIV-positive group than in the controls. The HIV-positive group stayed longer on admission than the HIV-negative controls (P < 0.001). The association remained strong after controlling for baseline anthropometric indices (WHZ, WAZ, HAZ, and BMI; β-coefficient = 5.59 days; P = 0.002). Two deaths occurred in the HIV-positive group and none in the controls (Fisher exact P value = 0.034). Among the HIV-positive group, the average duration from admission to when a decision to screen for HIV was made was 20.8 days (range: 7 to 40 days, SD = 15.4 days). Children who were screened earlier (within 2 weeks) had a shorter stay at the center compared with children who were screened later (after 2 weeks) (duration of stay: 5.6 weeks vs. 11.2 weeks; t = 2.63; P = 0.078). The 2 deaths occurred among those in whom the decision to screen for HIV was made later in their management.
The results from this preliminary study suggest that in low HIV prevalence settings, delayed diagnosis of HIV in malnourished children is associated with a poorer outcome. This is similar to the finding by other workers from high HIV prevalence settings with larger population samples.4,12 We have previously shown that comorbidities were common among children seen in primary health care settings, many of whom present with overlapping symptoms and signs such that it becomes difficult to define their relative contributions to childhood morbidity and mortality properly (CVN, West African College of Physicians [WACP] thesis, 2007). The presence of multiple comorbidities therefore might account for the difference between these findings and those that reported no significant difference.
Although our small numbers of HIV-positive children makes extrapolating our results to other low HIV prevalence settings difficult, the study suggests that delayed diagnosis of HIV infection in severely malnourished children is associated with poor clinical outcome. In low-prevalence resource-poor settings in which such diagnosis is likely to be missed, clinical guidelines outlining the indications for HIV screening in malnourished children might improve clinical outcome.
Chidi Victor Nweneka, MBBS, MSc
Medical Research Council Laboratories Keneba Field Station Banjul, The Gambia
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