Nutritional Cure Among Children with HIV and Severe Acute Malnutrition Attending an Outpatient Therapeutic Care Program in Kampala, Uganda

Background: HIV and severe acute malnutrition (SAM) remain significant causes of morbidity and mortality among children in sub-Saharan Africa. Despite this, contemporary research on SAM outcomes among children with HIV, especially children over 5 years of age and those on antiretroviral therapy (ART), is lacking. The Sphere Handbook 2018 has set a target for acceptable cure rate for outpatient therapeutic care (OTC) programs of greater than 75%. We aimed to assess the proportion of HIV positive pediatric patients on ART with SAM achieving cure and the factors associated with cure, as well as time to cure in an OTC program providing ready-to-use therapeutic food.

Methods: This was a retrospective observational study of patients with HIV, age 6 months to 15 years at time of enrollment into OTC for SAM diagnosis, from January 2015 - December 2017 at a pediatric HIV clinic in Kampala, Uganda. Diagnosis of SAM determined per World Health Organization guidelines as BMI for age z-score (BMZ) or weight for height z-score (WHZ) <-3, red MUAC or bilateral edema and cure is BMZ/WHZ >-2 or green MUAC and no edema for two weeks by 120 days after enrollment.

Results: Data from 166 patients were analyzed: 42.8% were female, mean age 5.4 years (SD 4.7), 88.0% had a red MUAC, mean BMZ/WHZ -2.7 (SD 1.3), height for age z-score -3.2 (SD 1.4), and weight for age z-score -3.8 (SD 1.3) at admission. At discharge, 36.1 % (60/166) achieved cure, 15.6% (26/166) were lost to follow up, 2.4 % (4/166) died, and 45.8% (76/166) failed. The average time to cure was 59.9 days (SD 27.8). Febrile patients at admission were 45% less likely to achieve cure (p= 0.06, 95% CI: 0.03 – 1.03). Patients with CD4 count less than or equal to 200 at admission were 54% less likely to achieve cure (p= 0.04, 95% CI: 0.22 – 0.96). Patients 5 years or older were 67% less likely to achieve cure (p= <0.001, 95% CI: 0.18 - 0.58).

Conclusion: We observed poor rates of cure from SAM among our pediatric HIV positive cohort despite treatment with ART. The cure rate in this population is far below the international target of 75% suggesting that standard management of SAM may not adequately address the needs of this specific population. Moreover, patients with fever, low CD4, or those 5 years and older at diagnosis of SAM may require more intense therapy or closer monitoring than their counterparts.