Early assessment of weight velocity can support frontline health workers in predicting malnutrition in HIV-exposed infants: preliminary results from a DREAM cohort in Malawi.

BACKGROUND: Children born to HIV-positive mothers are particularly susceptible to malnutrition. Currently, monitoring programs rely on punctual anthropometric measurements to assess child growth. Growth velocities could be an additional tool in identifying critical time windows for prevention and implementation of early intervention for malnutrition. METHODS: A retrospective analysis was conducted using data from 817 HIV exposed but uninfected children extracted from DREAM program database. By using the WHO reference for growth standards, patterns of weight velocity for different intervals of assessment from one to 18 months of age were explored. Odds ratios and multinomial logistic regressions between selected weight velocity Z-scores thresholds and successive malnutrition indices (at 6, 12, 18 months of age) were calculated. RESULTS: Weight velocity was above the standard mean in the first 3 months, then progressively declined over time. In children with normal nutritional status, significant risks of becoming malnourished (mild malnutrition - underweight [OR 10.8; 95% CI: 4.5-26], chronic malnutrition - stunting [OR 8.3; 95% CI: 2-34.9] and acute malnutrition - wasting [OR 11.7; 95% CI: 1.5-90.5]) started when weight velocity Z-scores <0, at all interval ages. Multinomial regression showed that in the first 6 months, the weight velocity decrements strongly impacted on underweight (OR 17.9; 95% CI: 4-80.7), while the risk of Stunting occurred later at 18 months (OR 8.7; 95% CI: 4.3-17.6), with highest impact at the lowest thresholds. CONCLUSIONS: The assessment of weight velocity Z-scores, coupled with the already validated malnutrition indices, can support frontline health workers in early prediction of child malnutrition and performing nutritional counselling in the context of HIV/AIDS and food insecurity.

Malnutrition decreases the odds of attaining motor milestones in HIV exposed children: results from a paediatric DREAM cohort.

OBJECTIVE: HIV and malnutrition are the two major causes of infant mortality in Sub-Saharan Africa. The study describes the impact of malnutrition on motor milestone development in HIV-exposed children. DESIGN: Randomized community intervention trial (SMAC, Safe Milk for African Children). SETTING AND PARTICIPANTS: Growth, motor development, and malnutrition were assessed in a sample of 76 HIV-exposed children, aged 0-24 months, at the Blantyre Dream Centre in Malawi. MAIN OUTCOME MEASURES: We assessed growth and selected motor milestone achievement in agreement with WHO/UNICEF criteria. Odds ratios and 95%confidence intervals were calculated according to motor milestones and malnutrition indices. Multivariable logistic regression was performed with 18 months data. RESULTS: High rates of malnutrition were observed. Underweight increased by 6.7/9.2 and 3.2/5.5 the odds of not standing alone and not walking alone at 15 and 18 months. Stunting increased by 9.7 the odds of not standing alone at 11 months and by 6.1 the odds of not walking alone at 18 months. Wasting increased by 5.5/10.3 the odds for not walking with assistance at 12 and 18 months. Low weight for age was associated with delay in walking at 18 months (HR=2.9). CONCLUSION: Malnutrition in HIV-exposed children decreases the likelihood of adequate development.

Hematologic alterations and early mortality in a cohort of HIV positive African patients.

INTRODUCTION: Infection with Human Immunodeficiency Virus (HIV) is highly prevalent worldwide, especially in Sub-Saharan Africa, where anaemia is also widespread. HIV infection is known to be associated with anaemia and various other haematologic alterations, but little data on correlation with immunological and virologic conditions in treatment-naïve patients and impact on mortality are available. Our study aims to investigate hematologic features in HIV-infected individuals in Malawi and Mozambique and assesses possible correlations with early morality. MATERIAL AND METHODS: We conducted a retrospective analysis of baseline data (general details, nutritional status, full blood count and HIV infection progress data) and 12 months follow-up status for HIV+ adult patients in 22 health facilities in Malawi (11 sites) and Mozambique (11 sites) run by DREAM program. Anagraphic details, anthropometric characteristics, full blood count, CD4+ count and Viral Load data were collected from electronical medical records (EMR) for all the HIV-positive, treatment-naïve patients starting care in the sites in the period January 2007 -December 2016. Follow-up status after one year since enrolment in care was also considered. All the data extracted from the EMR were included in a dataset and then analysed. Univariate and multivariate analysis were conducted through logistical regression to investigate associations, and survival analysis analysed in a Cox regression model. RESULTS: On the whole, 22.657 patients were included; severe and moderate anaemia were observed in 1.174 (8,2%) and 4.703 (21,9%) patients respectively. Gender, nutritional status, CD4+ count, and viral load (VL) were associated with anaemia, leukopenia, and thrombocytopenia. Among 21.166 fully evaluable patients, 8.494 (40,1%) had at least one cytopenia. Any cytopenia was present in 1/3 of patients with normal nutritional status and less advanced HIV infection, and it wouldn't be diagnosed in a basic HIV care setting. During the first year of treatment, 1.725 subjects (7,6% of the entire sample) died. Anaemia, lower Red blood cells and platelets counts correlated with mortality in the first year of care, independently by body mass index, haemoglobin, CD4+ count and VL. CONCLUSIONS: Notwithstanding anaemia is known to be associated with HIV infection at diagnosis, full blood count is not routinely performed in many African countries. Our results emphasize that including the study of a broader set of parameters in the routine HIV care services in Sub-Saharan Africa would provide significant clinical information able to predict other alterations and poor outcomes.

Nutritional rehabilitation of HIV-exposed infants in Malawi: results from the drug resources enhancement against AIDS and malnutrition program.

Infant malnutrition in sub-Saharan Africa is a public health priority and a challenge in high HIV prevalence areas. The Drug Resources Enhancement Against AIDS and Malnutrition program, with multiple medical centers in Sub-Saharan Africa, developed an innovative intervention for the surveillance and control of malnutrition. In a pilot initiative, 36 HIV-exposed children were evaluated at baseline upon presentation for malnutrition and at six months post- treatment. Parameters included HIV-free survival, nutritional status and change in diet. Food diary data was entered and processed using the Nutrisurvey (WHO) software. At 6 months post-intervention, a significant improvement in anthropometric parameters was noted. Slowing of linear growth was observed in patients with malaria with a mean gain in centimetres of 4.4 ± 1.7 as compared to 5.6 ± 1.7 in children with no malaria, p < 0.048 (CL 95%: -2.32, -0.01). Dietary diversity scores increased from 5.3 ± 1.9 to 6.5 ± 1.3, p < 0.01 at 6 months. A significant increase (+25%, p < 0.02) in the number of children eating fish meals was noted. Our pilot data describes positive outcomes from a rehabilitative nutritional approach based on use of local foods, peer education, anthropometric and clinical monitoring in areas of high food insecurity. The relationship between malaria and linear growth retardation requires further investigation.