Background:  Several nutritional intervention studies have shown that HIV-infected wasted children not on HAART have longer recovery times, lower rates of recovery (59% vs 83%), and higher mortality (30.4% vs 8.4%]), then those HIV-uninfected. The purpose of this study was to assess nutritional recovery, survival, and, outcomes 6 months post-discharge among HIV-infected wasted children in the era of HAART.

Methods:  Retrospective cohort analysis of clinical records of children admitted to OTP (Outpatient Therapeutic Program) at the Baylor Clinic in Lilongwe, Malawi from February 2007 to February 2008. Data from 176 children 6 to 60 months of age with uncomplicated acute moderate or severe malnutrition treated with RUTF (ready-to-use therapeutic food) as outpatients were analyzed. HAART was initiated based on WHO guidelines. Severely and moderately malnourished were followed weekly and biweekly respectively. Cure (discharge from OTP) was ascertained once all 3 criterion were met: 85% weight-for-height, mean upper arm circumference (MUAC) >12 cm, and absence of edema. Weight, height, and MUAC measurements were converted to Z-scores using WHO 2005 reference. Descriptive statistics and paired t-test to compare baseline weight-for-height z-score (WHZ) and MUAC to discharge values were done using STATA version 9.

Results:  Over 75% were <2 years old, median age 18.2 (6 to 60) months; 52% males; nearly 80% in WHO stage III or IV; 68% with severe immunosuppression for age; and 62% were on HAART or started on HAART during OTP. On admission median WHZ was -3.07 (range -5.74 to -0.85); mean MUAC 11.1 cm (7.3 to 15.4); and 11.4% had edema. During the study, 129 patients (73%) reached cure; overall mortality was 9.7%; and default rate 7.4%. At 6-month follow-up post-discharge 80.6% were alive; 2.3% relapsed; 1.5% died; 7.7% transferred out; 7.7% had unknown outcomes. Of the 105 patients with baseline and 6 month WHZ values, there was marked improvement in mean WHZ from -3.15 to -0.03 (P <0.0001]. Additionally, of the 92 patients with baseline and 6-month follow-up MUAC measurements, mean MUAC improved from 11.3 to 14.5 cm [P <0.0001].

Conclusions:  Compared to rates of cure and mortality previously reported in malnourished HIV-infected children not on HAART, rates of cure in this cohort were higher, and mortality rates lower. Further studies on optimum time to start HAART in malnourished HIV-infected children are needed.