Background:  Malnutrition is common in HIV-infected children in Africa, but there are no data for African children on how long it takes to normalize their nutritional status. We examined anthropometric status and response to ART in children treated at a large public-sector clinic in Malawi.

Methods:  Since 2001, a total of 1,021 HIV-1 infected children aged <15 years had at least one visit at the Lighthouse clinic in Lilongwe. All children who started ART between January 2001 and December 2006 were included and followed until March 2008. Weight and height were measured at regular intervals from 1 year before to 2 years after the start of ART. Sex- and age-standardized z scores were calculated for weight-for age (WAZ) and height-for-age (HAZ). Predictors of growth were analyzed in multivariable mixed-effect models.

Results: A total of 497 children started ART and were followed for 966 person-years. Among the 524 children who did not start ART, 487 (92.9%) were lost to follow up, 35 (6.7%) were still followed and 2 (0.4%) had been transferred out. Median age (interquartile range; IQR) was 8 years (4 to 11 years). Most children were underweight (52%), stunted (70%), in advanced clinical stages (94% in WHO stages 3/4) and had severe immunodeficiency (77%). During the year before starting ART, WAZ, and HAZ were stable, with median (IQR) scores at ART initiation of -1.78 (-2.47 to -0.87) and -1.82 (-2.69 to -1.07), respectively. After starting ART median (IQR) WAZ increased to 0.44 (-0.70 to 1.65) and median (IQR) HAZ to 0.76 (-0.19 to 1.82) at 24 months (P <0.001 for both indicators). While normal median values for WAZ and HAZ were reached after 18 months on ART for the group as a whole, in children with WAZ and HAZ <-3 at ART start, medians had not normalized by 24 months on treatment. In multivariable models, baseline WAZ or HAZ were the most important determinants of subsequent z-score trajectories. The Figure shows observed medians (IQR) and predicted WAZ and HAZ by baseline category. Conclusions:  These data demonstrate a sustained growth response on ART, but children remain on trajectories defined by the nutritional status when they started therapy, and in most children it takes 1 to 2 years for indicators to normalize. Interventions leading to earlier HIV diagnosis and initiation of ART could prevent mortality, loss to follow up, underweight and stunting, and improve growth and other outcomes in HIV-infected children.