Antiretroviral Therapy in Severely Malnourished, HIV-Infected Children in Asia.
Information on antiretroviral therapy (ART) use in HIV-infected children with severe malnutrition (SM) is lacking. We investigated long-term ART outcomes in this population.
Children enrolled in the TREAT Asia Pediatric HIV Observational Database who had SM (weight-for-height or BMI-for-age z-score <-3) at ART initiation were analyzed. Generalized estimating equations were used to investigate poor weight recovery (weight-for-age z-score <-3) and poor CD4% recovery (CD4% <25), and competing risk regression was used to analyze mortality and toxicity-associated treatment modification.
Three hundred fifty five (11.9%) of 2993 children starting ART had SM. Their median weight-for-age z-score increased from -5.6 at ART initiation to -2.3 after 36 months. Not using cotrimoxazole prophylaxis at baseline was associated with poor weight recovery (OR 2.49 vs. using, 95%CI 1.66-3.74, p<0.001). Median CD4% increased from 3.0 at ART initiation to 27.2 after 36 months, and 56 (15.3%) children died during follow-up. More profound SM was associated with poor CD4% recovery (OR 1.78 for z-score <-4.5 vs. -3.5 to <-3.0, 95%CI 1.08-2.92, p=0.023) and mortality (HR 2.57 for z-score <-4.5 vs. -3.5 to <-3.0, 95%CI 1.24-5.33, p=0.011). Twenty two toxicity-associated ART modifications occurred at a rate of 2.4 per 100 patient-years and rates did not differ by malnutrition severity.
Cotrimoxazole prophylaxis is important for the recovery of weight-for-age in severely malnourished children starting ART. The extent of SM does not impede weight-for-age recovery or antiretroviral tolerability but CD4% response is compromised in children with a very low weight-for-height/BMI-for-age z-score which may contribute to their high rate of mortality.
Boettiger DC, Aurpibul L, Hudaya DM, Fong SM, Lumbiganon P, Saphonn V, Truong KH, Hansudewechakul R, Nguyen LV, Do VC, et al. Antiretroviral Therapy in Severely Malnourished, HIV-Infected Children in Asia. Pediatr Infect Dis J. 2016 Feb 1. [Epub ahead of print] PubMed PMID: 26835972.