Community-based therapeutic care in HIV-affected populations

Retention and Treatment Outcomes of an Undernutrition Program for HIV patients involving Ready-to-Use Therapeutic Food at Gondar University Hospital, Ethiopia: A Cross-Sectional Study

INTRODUCTION

Despite global efforts to eradicate poverty and hunger, under-nutrition is still a major health problem, especially in Sub-Saharan Africa, where HIV/AIDS prevalence is also a serious burden.

AIM

To assess the retention and outcomes of under-nutrition treatment program in Gondar University Hospital, Ethiopia.

SETTINGS AND DESIGN

A cross-sectional study was conducted in HIV positive children and adults participating in the Ready-to-use Therapeutic Food (RUTF) treatment program at Gondar University Hospital ART clinic for one year from November 2012 to November 2013.

MATERIALS AND METHODS

Six hundred and thirty six patient records were followed-up for one year. Outcome variables were Mid-Upper Arm Circumference (MUAC) values measured as severe, moderate acute malnutrition, normal after treatment, non-respondent, relapsed and lost to follow-up using the hospital records of HIV positive children and adults eligible for the program.

STATISTICAL ANALYSIS

Univariate and multivariate analysis were performed to compute Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR). Statistical significance was set at p-value<0.05.

RESULTS

Among 636 clients, 44.2% achieved MUAC measures ≥ 125 mm for children and ≥ 21 cm for adults at 4 and 6 months. 70.1% of those were children while 29.9% of the 281 were adults. Moreover, a more positive initial response to ready-to-use therapeutic food was found among children as there was significant increase (p<0.05) in MUAC value after the second month of initiating treatment while adults achieved a significant (p<0.05, p<0.01) in MUAC at the 4(th) and 6(th) month respectively. There was a significant association between age, nutrition status and treatment outcome, while sex, HIV status, education and residency were not associated with treatment outcome.

CONCLUSION

Recovery and weight gain rates were below 50%. Defaulter rates were higher than the Sphere standards and recovery was better in children than adults. Integrated RUTF and HIV program and strict follow-up and education or counselling of HIV positive patients should be strengthened.

Improving survival of children with severe acute malnutrition in HIV-prevalent settings

The care of severely malnourished children in sub-Saharan Africa is challenging, especially in HIV-prevalent settings. Recent improvements to facility-based individual case management, and increased community-based management focusing on early identification and high programme coverage have led to reductions in mortality. Further interventions are urgently needed to address resistant mortality, mostly attributable to HIV. This paper explores strategies in three main areas to improve survival for children with severe acute malnutrition (SAM): identifying HIV and improving case management for HIV-infected children; strengthening existing strategies to improve outcomes for all children with SAM, regardless of HIV status; and improving early identification and increasing programme coverage. Although interventions to further improve survival among children with SAM in sub-Saharan Africa must firstly ensure best care for all children, HIV-infected children are at particular risks for mortality. Integration of specific interventions for HIV testing and treatment into SAM care is essential. International guidelines should reflect best evidence, and are in urgent need of updating and adapting to local country context. Effective interventions already exist that can improve survival in children with SAM in HIV-prevalent settings. The challenge is to implement what we know and to research what we do not.

Rationale and design of a study using a standardized locally procured macronutrient supplement as adjunctive therapy to HIV treatment in Kenya

Poor nutritional status at initiation of antiretroviral therapy (ART) is predictive of mortality. Decreased dietary intake is a major determinant of weight loss in HIV. Despite a biological rationale to treat undernutrition in adults receiving ART, few studies have provided data on feasibility, safety, effectiveness, and sustainability of specific macronutrient supplements with HIV treatment in adults, especially supplements such as a food basket, a supplement approach seldom evaluated in spite of its wide use. We present the rationale and design for a study of a locally procured macronutrient supplement given to HIV-infected patients initiating ART with a body mass index (BMI) ≤20.0 kg/m(2). The objective was to determine feasibility of procurement, distribution, safety and to obtain preliminary effectiveness data for a locally procured supplement. The design was a comparative study for 200 adult participants at two Kenya government-supported clinics. The primary outcome was BMI at 24 weeks. Supplement duration was 24 weeks, total follow-up was 48 weeks, and the study included a comparison site. Novel aspects of this study include use of a standardized macronutrient supplement to protect the participant against household food sharing, and a complementary micronutrient supplement. Comprehensive data collected included dietary intake, HIV-related quality-of-life, food security, neuropsychiatric assessments, laboratory studies, and household geomapping. Assessments were made at baseline, at 24 weeks, and at 48 weeks post-ART initiation. Challenges included establishing a partnership with local millers, distribution from the HIV clinic, food safety, and tracking of participants. These findings will help inform nutrition support programming in Kenya and similar settings, and provide needed data regarding use of macronutrient supplements as an adjunctive intervention with ART.

HIV/AIDS, undernutrition, and food insecurity

Despite tremendous advances in care for human immunodeficiency virus (HIV) infection and increased funding for treatment, morbidity and mortality due to HIV/AIDS in developing countries remains unacceptably high. A major contributing factor is that >800 million people remain chronically undernourished globally, and the HIV epidemic largely overlaps with populations already experiencing low diet quality and quantity. Here, we present an updated review of the relationship between HIV infection, nutritional deficiencies, and food insecurity and consider efforts to interrupt this cycle at a programmatic level. As HIV infection progresses, it causes a catabolic state and increased susceptibility to other infections, which are compounded by a lack of caloric and other nutrient intake, leading to progressive worsening of malnutrition. Despite calls from national and international organizations to integrate HIV and nutritional programs, data are lacking on how such programs can be effectively implemented in resource-poor settings, on the optimum content and duration of nutritional support, and on ideal target recipients.

HIV prevalence and mortality among children undergoing treatment for severe acute malnutrition in sub-Saharan Africa: a systematic review and meta-analysis

This systematic review and meta-analysis explored HIV prevalence and mortality in children undergoing treatment for severe acute malnutrition (SAM) in sub-Saharan Africa. It included all studies reporting on HIV infection within a sample of children with SAM where HIV status was assessed using a blood test and SAM was defined using the WHO, Gomez, Wellcome or Waterlow definitions. Children from 17 studies were included in the analysis (n=4891), of whom 29.2% were HIV-infected. HIV-infected children were significantly more likely to die than HIV-uninfected children (30.4% vs. 8.4%; P<0.001; relative risk=2.81, 95% CI 2.04-3.87). HIV-negative children treated within community-based therapeutic care (CTC) programmes had lower mortality (4.3%) than those treated within an inpatient nutrition rehabilitation unit (NRU) (15.1%). There was no significant difference in mortality for HIV-infected children with SAM treated in the CTC (30.0%) or NRU (31.3%) settings. HIV prevalence is high in children with SAM in sub-Saharan Africa, and HIV-infected children are at significantly increased risk of mortality. There is an urgent need to integrate HIV testing and treatment into care for children with SAM in regions of high HIV prevalence.

Factors associated with religious congregation members' support to people living with HIV/AIDS in Kumasi, Ghana

Physical, social and economic constraints often limit the ability of people living with HIV/AIDS to meet their basic needs. Community members are a valuable source of support for people living with HIV/AIDS, although little is known about the types of support they provide or how to mobilize this support. To examine this issue, a survey of 1200 members of 6 religious congregations was conducted in Kumasi, Ghana. A fifth of congregation members reported providing some support to people with HIV/AIDS in the last 6 months, mostly through prayer, financial support, and counseling. Factors associated with providing support include having heard a congregation or tribal chief speaking about HIV/AIDS, collective efficacy related to HIV/AIDS, and perceived risk of becoming infected with HIV. To enhance support to people with HIV/AIDS, programs should involve community leaders and encourage dialogue on ways to address the epidemic.