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Indian Pediatr 2011;48: 333-334 |
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Persistence of Stunting After Highly Active
Antiretroviral Therapy in HIV-Infected Children in South India |
N Poorana Ganga Devi, K Chandrasekaran, PK Bhavani, C Thiruvalluvan and
Soumya Swaminathan
Tuberculosis Research Centre (ICMR), Chennai, India.
Email: [email protected]
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After one year of antiretroviral treatment in 49 HIV-infected children
compared to 53 children without, weight for age improved significantly
and was highly correlated with baseline immune status and CD4% increase
but height for age did not change. Stunting is a common feature of
pediatric HIV, both on and off HAART.
Key words: Anti-retroviral treatment, Children, HIV,
Stunting, Undernutrition.
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Growth failure is a common feature of children with HIV-1 infection [1,2],
and the only effective treatment is to treat the infection [3]. We
investigated the effect of highly active antiretroviral treatment (HAART)
on growth and immunologic parameters in HIV-infected children over a
period of one year. We also examined the impact of baseline immune status
on post-HAART improvement in under-weight, stunting and wasting.
A cohort of HIV-infected children was followed at the
Tuberculosis Research Centre clinic, Madurai, every three months with
clinical monitoring and every 6 months with laboratory investigations
including complete blood counts and CD4, CD8 counts. Nutritional
counseling, iron, folic acid and multivitamin supplements and
cotrimoxazole prophylaxis were provided to all children. Children were
referred to the nearest government antiretro-viral treatment centre, where
they were initiated on treatment as per NACO guidelines [4]. The study was
approved by the TRC Institutional Ethics committee.
Of 102 children, 49 were started on treatment (HAART
group) after assessment at the ART centre while 53 were considered not to
require ART (non HAART group). The median age of the entire group was 74
months (>60% between 5-10 years). The prevalence of underweight (WAZ <-2)
and wasting (WHZ<-2) at baseline in the HAART group (81% and 56%) was
significantly higher than in the non-HAART group (59% and 29%) while rates
of stunting (HAZ<-2) were not different (52% and 50%, respectively). ART
eligible children had lower baseline median CD4% and CD4 counts indicating
their worse immune status.
The change in nutritional status at one year was
compared using proportions and median values (Table I).
While WAZ, WHZ and BMI improved significantly in the children on HAART,
rates or degree of stunting did not change. Children who were initiated on
HAART at CD4>15% had less severe stunting after one year than those at CD4
<15%. WAZ and BMI worsened in the group not started on HAART. The
correlation coefficient between increase in CD4% and percent increase in
weight at one year was 0.35, P<0.02.
TABLE I
Nutritional Status at Baseline and the End of 1 Year in Children on HAART and Those Not Eligible
Growth parameter |
HAART (n = 49) |
Non-HAART (n = 53) |
|
Baseline |
1 year |
Baseline |
1 year |
Weight for age ‘Z’ score |
Median (IQR) |
-2.84 (-3.25, -2.21) |
-2.18* (-2.80, -1.72) |
-1.85 (-2.82, -1.28) |
-2.12 (-2.48, -1.68) |
< -2 SD (%) |
82 |
57* |
43 |
57** |
Height for age ‘Z’ score |
Median (IQR) |
-2.02 (-3.38, -0.68) |
-2.27 (-3.35,-1.16) |
-1.76 (-3.18, -1.10) |
1.80 (-2.84,-1.22) |
< -2 SD (%) |
50 |
62 |
46 |
46 |
Weight for height ‘Z’ score |
Median (IQR) |
-2.41 (-3.12, -1.63) |
-1.08 (-1.75, -0.26) |
-1.08 (-1.50, -0.07) |
-1.32 (-1.78, -0.92) |
< -2 SD (%) |
59 |
12* |
17 |
17 |
BMI ‘Z’ score |
Median (IQR) |
-3.04 (-5.24, -2.24) |
-1.50* (-3.14, -1.50) |
-1.15 (-2.13, -0.37) |
-1.73 (-2.54, -0.98) |
< -2 SD (%) |
79 |
42* |
27 |
42** |
CD4 cell% |
Median (IQR) |
14 (8.0, 18.0) |
30* (25.0, 36.0) |
23 (18.5, 30.5) |
25** (21.0, 33.5) |
CD4 cell count |
Median (IQR) |
408 (195, 896) |
1138* (726, 1506) |
946 (591.5, 1315.0) |
863 (542.5, 1253.0) |
Hemoglobin |
Median (IQR) |
10.0 (8.85, 11.35) |
11.7* (10.10, 12.40) |
11.2 (9.8, 11.8) |
11.5* (10.92, 12.2) |
* P<0.01
and ** P<0.05; median values compared using Wilcoxon Signed Rank
Test, proportions compared using chi square test. |
While we found an overall beneficial effect of HAART on
growth and immunologic parameters, a substantial proportion of children
were under-nourished even at the end of one year and stunting persisted.
It is possible that height takes longer to show catch-up growth and that a
longer follow-up would show improvement. However, we showed earlier that
stunting and undernutrition occur early in the course of HIV [5], and the
negative impact of chronic infection and malnutrition on height may be
irreversible.
Most children in this cohort were over 5 years of age
and belonged to the lower socioeconomic strata. However, we believe that
our results are generalizable to the population of HIV-infected children
currently accessing care through the government ART centers in India as
well as in other resource-poor countries, because of the similar high
prevalence of malnutrition described in other cohorts [6-9]. Strategies to
prevent irreversible stunting such as earlier initiation of HAART and/or
nutritional supplementation must be explored.
Acknowledgments: Dr C Padmapriyadarsini and Dr
Sheik Iliayas for their valuable contributions at various stages of the
study.
References
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