Nutritional status of persons with HIV infection, persons with HIV infection and tuberculosis, and HIV-negative individuals from southern India

Prevalence and risk factors of malnutrition in patients with pulmonary tuberculosis: a systematic review and meta-analysis

Background

Malnutrition is prevalent in patients with pulmonary tuberculosis (PTB) and is associated with a poor prognosis.

Objective

This study aims to assess the prevalence and risk factors of malnutrition in patients with PTB.

Methods

Studies related to the prevalence and risk factors of malnutrition in patients with PTB were searched through PubMed, Embase, Web of Science, and Cochrane Library databases from January 1990 to August 2022, and two researchers screened the literature, evaluated the quality, and extracted data independently. A random-effects model was used to pool the effect sizes and 95% confidence intervals. Subgroup analysis, meta-regression analysis, and sensitivity analysis were further performed to identify sources of heterogeneity and evaluate the stability of the results. Publication bias was assessed by Doi plot, Luis Furuya-Kanamori (LFK) asymmetry index, funnel plot, and Egger's tests.

Results

A total of 53 studies involving 48, 598 participants were identified in this study. The prevalence of malnutrition was 48.0% (95% CI, 40.9-55.2%). Subgroup analysis revealed that malnutrition was more common among male gender (52.3%), bacterial positivity (55.9%), family size over 4 (54.5%), drug resistance (44.1%), residing in rural areas (51.2%), HIV infection (51.5%), Asian (51.5%), and African (54.5%) background. The prevalence of mild, moderate, and severe malnutrition was 21.4%, 14.0%, and 29.4%, respectively. Bacterial positivity (OR = 2.08, 95% CI 1.26-3.41), low income (OR = 1.44, 95% CI 1.11-1.86), and residing in rural areas (OR = 1.51, 95% CI 1.20-1.89) were risk factors of malnutrition in patients with PTB. However, male (OR = 1.04, 95% CI 0.85-1.26) and drinking (OR = 1.17, 95% CI 0.81-1.69) were not risk factors for malnutrition in patients with PTB. Due to the instability of sensitivity analysis, HIV infection, age, family size, smoking, and pulmonary cavity need to be reevaluated. Meta-regression suggested that sample size was a source of heterogeneity of prevalence. The Doi plot and LFK asymmetry index (LFK = 3.87) indicated the presence of publication bias for prevalence, and the funnel plot and Egger's test showed no publication bias for risk factors.

Conclusion

This meta-analysis indicated that malnutrition was prevalent in patients with PTB, and bacterial positivity, low income, and those residing in rural areas were risk factors for malnutrition. Therefore, clinical workers should pay attention to screening the nutritional status of patients with PTB and identifying the risk factors to reduce the incidence of malnutrition and provide nutritional interventions early to improve the prognosis in patients with PTB.

Time to recovery from malnutrition and its predictors among human immunodeficiency virus positive children treated with ready-to-use therapeutic food in low resource setting area: A retrospective follow-up study

Background and Aim

Malnutrition is a serious public health issue and a frequent impact of human immunodeficiency virus (HIV) infection, which raises the risk of morbidity and mortality in affected people. Despite the World Health Organization's (WHO) support for the use of ready-to-use therapeutic foods (RUTF) to treat malnutrition, research on the length of time it takes for children with HIV infection to recover from malnutrition and the factors that predict it is lacking, particularly Ethiopia.

Methods

An institution-based retrospective follow-up study was carried out in the Amhara regional state referral hospitals in Northern Ethiopia. From 2013 to 2018, a total of 478 children who received RUTF treatments were chosen using a simple random sampling technique. To calculate the likelihood of recovery and the median recovery period, incidence and Kaplan-Meier survival analyses were performed. The Cox regression model was used to identify predictors of time to recovery from malnutrition. The multivariable model only included variables with a p value below 0.2. While factors were deemed to be substantially linked with the outcome variable if their p value was less than 0.05.

Results

The median recovery duration was 5 months (95% confidence interval [CI] = 4-5 months), and the nutritional recovery rate was 64.64% (95% CI = 60.2-68.9). Moderate acute malnutrition (adjusted hazard ratio [AHR] = 4.60, 95% [CI] = 2.85-7.43), WHO clinical stage I (AHR = 4.01, 95% CI = 1.37-11.77), absence of opportunistic infection (AHR = 1.76, 95% CI = 1.19-2.61), haemoglobin (Hgb) count above the threshold (AHR = 1.36, 95% CI = 1.01-1.85) and family size of 1-3 (AHR = 2.38, 95% CI = 2.38-5.00) were significantly linked to rapid recovery from malnutrition.

Conclusion

In comparison to the period specified by the national guideline (3 months for moderate and 6 months for severe acute malnutrition), the median time to recovery was lengthy. Acute malnutrition, clinical stage, opportunistic infection, Hgb count, and family size were statistically associated with early recovery from malnutrition.

Nutritional Supplementation Would Be Cost-Effective for Reducing Tuberculosis Incidence and Mortality in India: The Ration Optimization to Impede Tuberculosis (ROTI-TB) Model

BACKGROUND

Undernutrition is the leading cause of tuberculosis (TB) in India and is associated with increased TB mortality. Undernutrition also decreases quality of life and economic productivity.

METHODS

We assessed the cost-effectiveness of providing augmented rations to undernourished Indians through the government's Targeted Public Distribution System (TPDS). We used Markov state transition models to simulate disease progression and mortality among undernourished individuals in 3 groups: general population, household contacts (HHCs) of people living with TB, and persons living with human immunodeficiency virus (HIV). The models calculate costs and outcomes (TB cases, TB deaths, and disability-adjusted life years [DALYs]) associated with a 2600 kcal/day diet for adults with body mass index (BMI) of 16-18.4 kg/m2 until they attain a BMI of 20 kg/m2 compared to a status quo scenario wherein TPDS rations are unchanged. We employed deterministic and probabilistic sensitivity analyses to test result robustness.

RESULTS

Over 5 years, augmented rations could avert 81% of TB cases and 88% of TB deaths among currently undernourished Indians. Correspondingly, this intervention could forestall 78% and 48% of TB cases and prevent 88% and 70% of deaths among undernourished HHCs and persons with HIV, respectively. Augmented rations resulted in 10-fold higher resolution of undernutrition and were highly cost-effective with (incremental cost-effectiveness ratio [ICER] of $470/DALY averted). ICER was lower for HHCs ($360/DALY averted) and the HIV population ($250/DALY averted).

CONCLUSIONS

A robust nutritional intervention would be highly cost-effective in reducing TB incidence and mortality while reducing chronic undernutrition in India.

Relationship between phase angle, steatosis, and liver fibrosis in patients coinfected with human immunodeficiency virus/hepatitis C virus

BACKGROUND

Malnutrition, lipodystrophy, and dyslipidemia are prevalent characteristics in patients with human immunodeficiency virus (HIV) infection with or without previous treatment. Such a clinical condition can lead to the hypothesis of the presence of hepatic steatosis with possible progression to fibrosis and the risk of hepatocellular carcinoma. Notably, a low phase angle (PA), evaluated by bioelectrical impedance analysis (BIA), is an independent prognostic marker of clinical progression and survival in HIV-infected patients.

AIM

To evaluate the relationship between PA and body composition with steatosis and hepatic fibrosis in HIV/hepatitis C virus (HCV)-coinfected patients.

METHODS

A retrospective observational study by convenience sampling of coinfected HIV/HCV patients, in which all patients underwent transient elastography (Fibroscan) and BIA evaluation. Student's t test was used for group comparisons, and Spearman's or Pearson's correlation test was used when appropriate. The significance level was set at 5%, and analyses were performed using SPSS version 21.0.

RESULTS

Forty-three patients who received antiretroviral therapy met the inclusion criteria, and 23 (53.5%) were under treatment with protease inhibitors (PIs). There was no difference in PA between those who used PIs and those who did not (P = 0.635). There was no correlation between fibrosis grade and PA (P = 0.355) or lean mass (P = 0.378). There was a significant inverse correlation between the controlled attenuation parameter (CAP) and lean mass (P = 0.378), positive correlation between PA and lean mass (P = 0.378), and negative correlation between PA and fatty mass (P = 0.378), although the CAP and PA were not correlated. When evaluated by sex, no significant correlations were found.

CONCLUSION

PA determines the muscle function of HIV/HCV-coinfected patients, and the CAP values reinforce the association with lean mass, suggesting that patients require early nutritional interventions.

Metabolomics as a Tool to Investigate HIV/TB Co-Infection

The HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) and tuberculosis (TB) pandemics are perpetuated by a significant global burden of HIV/TB co-infection. The synergy between HIV and Mycobacterium tuberculosis (Mtb) during co-infection of a host is well established. While this synergy is known to be driven by immunological deterioration, the metabolic mechanisms thereof remain poorly understood. Metabolomics has been applied to study various aspects of HIV and Mtb infection separately, yielding insights into infection- and treatment-induced metabolic adaptations experienced by the host. Despite the contributions that metabolomics has made to the field, this approach has not yet been systematically applied to characterize the HIV/TB co-infected state. Considering that limited HIV/TB co-infection metabolomics studies have been published to date, this review briefly summarizes what is known regarding the HIV/TB co-infection synergism from a conventional and metabolomics perspective. It then explores metabolomics as a tool for the improved characterization of HIV/TB co-infection in the context of previously published human-related HIV infection and TB investigations, respectively as well as for addressing the gaps in existing knowledge based on the similarities and deviating trends reported in these HIV infection and TB studies.

Undernutrition and HIV Infection in Sub-Saharan Africa: Health Outcomes and Therapeutic Interventions

PURPOSE OF REVIEW

Sub-Saharan Africa (SSA) is disproportionately burdened by the twin epidemics of food insecurity and HIV infection, and protein-calorie undernutrition is common among persons with HIV (PWH) initiating antiretroviral therapy (ART) in the region. In this review, we discuss the intersection of HIV infection and undernutrition, health outcomes among undernourished PWH starting ART, and the demonstrated and potential benefits of therapeutic interventions such as micro/macronutrient supplementation and pharmacological agents.

RECENT FINDINGS

A low body mass index (BMI), used as a general indicator of poor nutrition in most studies, is associated with impaired immune recovery and increased mortality in the early ART period. The increased risk of mortality is multifactorial, and contributors include undernutrition-related immune system dysfunction, increased susceptibility to opportunistic infections, and metabolic and cardiovascular dysregulation. Clinical trials of micro/macronutrient supplementary feeding, appetite stimulants (hormones and anabolic agents), and recombinant adipokines have shown a benefit for weight gain and metabolic health, but there are few data on mortality or immune recovery. A substantial proportion of PWH in SSA are undernourished, and undernutrition contributes to an increased risk of mortality and other adverse health outcomes. To date, there have been few prospective trials of nutritional supplementation and/or pharmacologic therapy among undernourished PWH in SSA, though findings from other settings suggest a potential benefit in this population.

Lack of Weight Gain During the First 2 Months of Treatment and Human Immunodeficiency Virus Independently Predict Unsuccessful Treatment Outcomes in Tuberculosis

BACKGROUND

Weight change may inform tuberculosis treatment response, but its predictive power may be confounded by human immunodeficiency virus (HIV).

METHODS

We prospectively followed up adults with culture-confirmed, drug-susceptible, pulmonary tuberculosis receiving standard 4-drug therapy (isoniazid, rifampin, pyrazinamide, and ethambutol) in Brazil. We examined median weight change 2 months after treatment initiation by HIV status, using quantile regression, and unsuccessful tuberculosis treatment outcome (treatment failure, tuberculosis recurrence, or death) by HIV and weight change status, using Cox regression.

RESULTS

Among 547 participants, 102 (19%) were HIV positive, and 35 (6%) had an unsuccessful outcome. After adjustment for confounders, persons living with HIV (PLWH) gained a median of 1.3 kg (95% confidence interval [CI], -2.8 to .1) less than HIV-negative individuals during the first 2 months of tuberculosis treatment. PLWH were at increased risk of an unsuccessful outcome (adjusted hazard ratio, 4.8; 95% CI, 2.1-10.9). Weight change was independently associated with outcome, with risk of unsuccessful outcome decreasing by 12% (95% CI, .81%-.95%) per 1-kg increase.

CONCLUSIONS

PLWH gained less weight during the first 2 months of tuberculosis treatment, and lack of weight gain and HIV independently predicted unsuccessful tuberculosis treatment outcomes. Weight, an easily collected biomarker, may identify patients who would benefit from alternative treatment strategies.

Tuberculosis research conducted over the years at the ICMR-National Institute for Research in Tuberculosis (ICMR-NIRT)

This review article highlights some of the key research conducted at the ICMR-National Institute for Research in Tuberculosis (ICMR-NIRT) over the years since its inception in 1956 till the present. The research carried out in the field of tuberculosis at ICMR-NIRT has been a joint effort between the ICMR, NIRT, the TB control program in India with assistance from World Health Organization (WHO) and the National Institutes of Health (NIH), USA. The research carried out at ICMR-NIRT has helped to formulate the national guidelines for the control and the management of tuberculosis in India. The major highlights of the research carried out at ICMR-NIRT are provided in this manuscript.

Assessment of Prevalence of Malnutrition and Its Associated Factors among AIDS Patients from Asella, Oromia, Ethiopia

Sub-Saharan Africa remains to be the most heavily affected region by malnutrition, accounting for 23.8% share of the global burden. Undernutrition weakens the immune system, increases the susceptibility to infections, and may worsen the impact on various kinds of diseases. Our aim was to assess undernutrition and its associated factors among AIDS-infected adult patients from Asella, Oromia Region, Ethiopia. An institutional-based cross-sectional study design was employed from June to July 2018. A total number of 519 patients were selected for the proposed work. Data was entered into EpiData, checked, coded, and analyzed using SPSS version 21 software. Descriptive statistics were used to assess the prevalence of undernutrition among patients. Bivariate and multivariate regressions were used to determine the relationship between undernutrition and its associated factors among the study participants. The results of our study showed that the overall prevalence of undernutrition was 18.3%; out of which 12.7% were mildly and 5.6% were moderately to severely undernourished, respectively. Monthly income (AOR: 3.589, 95% CI (1.469-8.768)), whole grain feeding (AOR: 2.979, 95% CI (1.252-7.088)), opportunistic infections in the last six months (AOR: 3.683, 95% CI (3.075-4.411)), clinical stage (AOR: 2.998, 95% CI (1.269-7.083)), and insufficient quality of food (AOR: 3.149, 95% CI (1.339-7.406)) were found to be significantly associated with undernutrition in this study. Therefore, HIV treatment facility should be supported with nutritional assessment, supplementation, counseling, care, and support to patients that may possibly alleviate this predicament.

Magnitude of Anemia and Associated Factors among HIV-Infected Children Receiving Antiretroviral Therapy in Pastoral Community, Ethiopia: A Retrospective Cross-Sectional Study

Background

The two major comrbidities (anemia and poor nutrition) are common manifestations of HIV-infected children, which threaten their lives. In Ethiopia, there is limited information on the magnitude and factors associated with anemia among HIV-infected children. Thus, this study was aimed to determine the magnitude and factors associated with anemia among HIV-infected children receiving antiretroviral therapy in the Afar region, Ethiopia.

Methods

A cross-sectional retrospective record review was conducted on a sample size of 102 HIV-infected children aged 6 months to < 15 years in selected ART sites of the Afar region from May 1 to 25, 2018. Patient cards from 2009 to 2017 with the required information were considered. A paired sample t-test was used to assess whether there is a significant difference in the hemoglobin level before and after the HAART regimen. Multivariable logistic regression was used to determine predictors of anemia. Statistical significance was determined atp value < 0.05.

Result

At baseline, 53.9% of study participants were anemic, from which 8.7%, 36.3%, and 9.8% were mild, moderate, and severe, respectively. There was a statistically significant improvement of hemoglobin level following the one-year course of ART treatment from 10.67 ± 1.82 to 11.5 ± 1.5 (p value ≤ 0.001): an improvement of 0.83 ± 1.74. Children who were moderately and severely stunted were more than five (AOR = 5.16, 95% CI (1.71, 15.56)) and more than twelve (AOR = 12.45, 95% CI (2.62, 59.21)) times more likely to be anemic than children who were not stunted, respectively. Children whose mothers had not attended ANC follow-up were more than three (AOR = 3.68, 95% CI (1.38, 9.81)) times more likely to be anemic than children whose mothers attended ANC. Children who were in clinical stages 3 and 4 were more than five (AOR = 5.07, 95% CI (1.79, 14.37)) times more likely to be anemic than children who were in clinical stage 1 and 2.

Conclusion

The magnitude of anemia among HIV-infected children was found to be high, which is 53.9%. Nutritional status (stunting), WHO clinical stage, and history of ANC follow-up were the predictors significantly associated with childhood anemia. Thus, interventions for HIV-infected children should consider those factors.

Household food insecurity among patients with pulmonary tuberculosis and its associated factors in South India: a cross-sectional analysis

OBJECTIVES

Food insecurity is 'the limited or uncertain availability of nutritionally adequate, safe foods or inability to acquire foods in socially acceptable ways'. Majority of tuberculosis (TB) cases of resource-poor settings experience food insecurity, which impacts treatment adherence and outcomes. We aimed to determine level of household food insecurity (HFI) and its associated factors in patients with pulmonary TB.

DESIGN

This is a cross-sectional analysis of data from an ongoing cohort study.

SETTING

National Tuberculosis Programme (NTP) in three districts of South India.

PARTICIPANTS

All newly diagnosed pulmonary TB cases of the cohort enrolled in the NTP at the Designated Microscopy Centres (DMCs) and Primary Health Centres (PHCs) from October 2015 to October 2018.

PRIMARY OUTCOME MEASURES

The proportion of baseline HFI assessed using a validated HFI Access Scale was summarised as percentage with 95% CI. Possible association of sociodemographic, morbidity and behavioural characteristics with HFI was assessed using χ2 test, and unadjusted prevalence ratios with 95% CI were calculated. The characteristics with values of p<0.2 in the univariate model were included in the multivariable generalised linear model (binomial function, log link) to derive adjusted prevalence ratios (aPRs) with 95% CI.

RESULT

Of a total of 765 patients, 261 had HFI and the proportion was 34.1% (95% CI 30.8% to 37.6%). Mild, moderate and severe food insecurity was found in 17 (2.2%), 67 (8.8%) and 177 (23.1%) TB cases, respectively. Patients with TB who had monthly family income less than rupees 3000 (aPR 2.0; 95% CI 1.3 to 3.0), Karnofsky Score of 60 or less (aPR 1.5; 95% CI 1.1 to 1.9) and those who were employed (aPR 1.4; 95% CI 1.0 to 2.0) were independently associated with HFI.

CONCLUSIONS

A high level of food insecurity was seen in households with TB cases. Additional food or cash assistance for this subgroup might improve food insecurity and thereby nutritional status.

Improvement of Nutritional Status among Tuberculosis Patients by Channa striata Supplementation: A True Experimental Study in Indonesia

OBJECTIVE

To analyze the effect of Channa striata supplementation on body mass index among tuberculosis patients, in which their health status is also investigated.

METHODS

This study employed a true experiment. The study was designed randomized pretest-posttest with a control group, in which 200 respondents were enrolled. Body mass index (BMI), used as a nutritional status indicator, was measured every week for a month. Chi-square test was used to analyze the data with a significance level of 5% by STATA 13.

RESULTS

The mean BMI of all groups increases during the month, in which rapid alteration occurs in the treatment group. The mean BMI (kg/m2) in the treatment group at weeks 0-4 was reported to be 17.43, 17.65, 17.90, 18.04, and 18.22, respectively. Meanwhile, the mean BMI (kg/m2) at weeks 0-4 in the control group was reported to be 17.20, 17.36, 17.57, 17.71, and 17.96, respectively. Furthermore, the alteration from severe thinness to higher BMI level in the treatment group is the highest. Based on the statistical test, there were no differences in BMI between the treatment and control groups (p > 0.05). However, the alteration of nutritional status in the treatment group is faster than that in the control group. In addition, there is no difference in their health status between the treatment and control groups (p > 0.05), except vomiting (p < 0.05).

CONCLUSION

The BMI among tuberculosis patients with Channa striata supplementation is increasing faster than that in the control group within a month with a minimum potential negative effect.

Impact of Anemia on Outcome of HIV-Infected Pediatric Patients: A Prospective Observational Study

Introduction

Anemia has been widely reported to predict a poorer prognosis for HIV-infected patients, both in terms of progression to AIDS and in survival. This study aimed to determine the etiology of anemia and its immunological correlation in HIV-infected children.

Materials and Methods

Four hundred and eighty-nine HIV-infected children were screened, of which 86 HIV-infected children with anemia were enrolled. Standard WHO definitions were used for anemia, HIV staging, and growth parameters. Chi-square test, t-tests, and univariate and multivariate logistic regression analyses were used to analyze the data.

Results

Anemia was present in 17.58% (86/489) of HIV-infected children, including 84.6% with moderate anemia, 11.5% with severe anemia, and 2.32% with mild anemia. The mean hemoglobin (Hb) among patients with CD4 count <350 cell/mm³ was lower (7.90 g%) (standard deviation 1.48) compared to those having CD4 >350 cell/mm³ (P = 0.02). Children with severe immunological stage had a significantly lower mean Hb (adjusted estimate: -1.61, 95% confidence interval: -2.65, -0.56) compared to those who had normal immune status. No statistically significant differences in mean Hb at baseline when compared to various demographic and clinical characteristics were observed in unadjusted and adjusted regression models.

Conclusion

Hb is an easy and inexpensive tool to measure and can be used for monitoring disease progression in a resource-limited setting.

Effectiveness of macronutrient supplementation on nutritional status and HIV/AIDS progression: A systematic review and meta-analysis

BACKGROUND & AIMS

Malnutrition is common in Sub-Saharan Africa, weakening the immune function of persons living with HIV infection (PLWH). Being malnourished at the initiation of antiretroviral therapy (ART) leads to higher risk of early mortality and reduced quality of life. Thus, introduction of protein-energy-fortified macronutrient supplements at ART initiation may improve HIV treatment outcomes. This review aimed to evaluate the effectiveness of macronutrient interventions.

METHODS

This systematic review and meta-analysis included 15 studies conducted from 2000 to 2015 among Sub-Saharan African adults.

RESULTS

Six randomized controlled trials and 4 retrospective cohort studies provided data eligible for a meta-analysis. Supplementation significantly increased the overall standardized mean difference (SMD) between baseline and follow-up data in weight (SMD = 0.382, p < .001), BMI (SMD = 0.799, p < .001); fat-free mass (SMD = 0.154, p = .009); and CD4 count (SMD = 0.428, p < .001).

CONCLUSION

Protein-energy-fortified macronutrient supplementation at ART initiation may positively influence nutritional status and immunologic response in PLWH in Sub-Saharan Africa.

Food Insecurity, Nutritional Status, and Factors Associated with Malnutrition among People Living with HIV/AIDS Attending Antiretroviral Therapy at Public Health Facilities in West Shewa Zone, Central Ethiopia

BACKGROUND

In resource limited settings, HIV/AIDS patients lack access to sufficient nutritious foods, which poses challenges to the success of antiretroviral therapy. HIV/AIDS and malnutrition are still major public health problems in Ethiopia. Though measuring nutritional status is an essential part of ART program, little evidence exists on food insecurity and nutritional status of HIV/AIDS patients in Ethiopia. Hence, the study aimed to determine food insecurity and nutritional status and contextual determinants of malnutrition among HIV/AIDS patients in West Shewa Zone, Ethiopia.

METHODS

Institution-based cross-sectional study was conducted among HIV/ADIS patients who have been attending antiretroviral therapy at public health facilities in West Shewa Zone from April to May 2016, Ethiopia. The sample size was 512 and study participants were selected from each facilities using systematic random sampling method. Data were collected using pretested questionnaire by trained data collectors. Data were entered to Epi-Info 3.5.1 for Windows and analyzed using SPSS version 22. Logistic regression analyses were conducted to determine independent factors associated with malnutrition.

RESULTS

Prevalence of malnutrition was 23.6% (95% CI: 19.7%-27.4%) and prevalence of household food insecurity was 35.2% (95% CI: 31.1%-39.0%). Factors significantly associated with malnutrition among HIV/AIDS patients were unemployment (AOR = 3.4; 95% CI: 1.8-5.3), WHO clinical stages III/IV (AOR = 3.3; 95% CI: 1.8-6.5), CD4 count less than 350 cells/μl (AOR = 2.0; 95% CI: 1.8-4.2), tuberculosis (AOR = 2.3; 95% CI: 1.3-4.9), duration on antiretroviral therapy (AOR = 1.8; 95% CI: 1.2-2.9), and household food insecurity (AOR = 5.3; 95% CI: 2.5-8.3).

CONCLUSIONS

The findings revealed high prevalence of malnutrition and household food insecurity among HIV/AIDS patients attended ART. The negative interactive effects of undernutrition, inadequate food consumption, and HIV infection demand effective cross-sectorial integrated programs and effective management of opportunistic infections like tuberculosis.

Nutrition Status Among HIV-Positive and HIV-Negative Inpatients with Pulmonary Tuberculosis

BACKGROUND

The association between tuberculosis (TB) and malnutrition is well recognized. Considering the risk of mortality due to malnutrition in patients with TB, it is necessary to conduct a thorough nutrition assessment to identify individuals at nutrition risk. The study objective was to assess the nutrition status of hospitalized patients with TB, co-infected or not by human immunodeficiency virus (HIV).

METHODS

Patients with confirmed diagnosis of TB were included using a cross-sectional design. Nutrition assessment parameters included: body mass index (BMI), triceps skin-fold thickness (TSF), bioelectrical impedance analysis (BIA), mid-upper-arm circumference (MUAC), mid-arm muscle circumference (MAMC), food frequency questionnaire, Malnutrition Screening Tool (MST), Subjective Global Assessment (SGA), and serum levels of hemoglobin.

RESULTS

A total 108 patients completed the study. Forty-four patients (40.7%) were HIV positive. Considering the BMI, 36.1% of the patients met the criteria for nutrition deficiency. Body fat percentage was low in 27.8% of patients. In addition, more than half of the participants met criteria for malnutrition according to MUAC, MAMC, TSF, SGA, or MST. Malnutrition measured by MAMC was more frequent in HIV-positive patients (n=33, 75.0%) than in HIV-negative patients (n=31, 48.4%) (P = 0.010). Regarding the components of diet, selenium and vitamin C intake among HIV-positive patients was significantly lower than in HIV-negative patients.

CONCLUSIONS

We identified a high prevalence of malnutrition in hospitalized patients with pulmonary TB, regardless of the method used to assess nutrition status. In HIV-positive patients, malnutrition measured by MAMC was more frequent than in HIV-negative patients.

Pharmacokinetics and Drug-Drug Interactions of Lopinavir-Ritonavir Administered with First- and Second-Line Antituberculosis Drugs in HIV-Infected Children Treated for Multidrug-Resistant Tuberculosis

Lopinavir-ritonavir forms the backbone of current first-line antiretroviral regimens in young HIV-infected children. As multidrug-resistant (MDR) tuberculosis (TB) frequently occurs in young children in high-burden TB settings, it is important to identify potential interactions between MDR-TB treatment and lopinavir-ritonavir. We describe the pharmacokinetics of and potential drug-drug interactions between lopinavir-ritonavir and drugs routinely used for MDR-TB treatment in HIV-infected children. A combined population pharmacokinetic model was developed to jointly describe the pharmacokinetics of lopinavir and ritonavir in 32 HIV-infected children (16 with MDR-TB receiving treatment with combinations of high-dose isoniazid, pyrazinamide, ethambutol, ethionamide, terizidone, a fluoroquinolone, and amikacin and 16 without TB) who were established on a lopinavir-ritonavir-containing antiretroviral regimen. One-compartment models with first-order absorption and elimination for both lopinavir and ritonavir were combined into an integrated model. The dynamic inhibitory effect of the ritonavir concentration on lopinavir clearance was described using a maximum inhibition model. Even after adjustment for the effect of body weight with allometric scaling, a large variability in lopinavir and ritonavir exposure, together with strong correlations between the pharmacokinetic parameters of lopinavir and ritonavir, was detected. MDR-TB treatment did not have a significant effect on the bioavailability, clearance, or absorption rate constants of lopinavir or ritonavir. Most children (81% of children with MDR-TB, 88% of controls) achieved therapeutic lopinavir trough concentrations (>1 mg/liter). The coadministration of lopinavir-ritonavir with drugs routinely used for the treatment of MDR-TB was found to have no significant effect on the key pharmacokinetic parameters of lopinavir or ritonavir. These findings should be considered in the context of the large interpatient variability found in the present study and the study's modest sample size.

Food banking for improved nutrition of HIV infected orphans and vulnerable children; emerging evidence from quality improvement teams in high food insecure regions of Kiambu, Kenya

Introduction

Estimated 236,548 People Living with HIV (PLHIV) were in Central-Eastern Kenya in 2013. Kiambu County had 46,656 PLHIV with 42,400 (91%) adults and 4,200(9%) children (1-14yrs). Amref Health Africa in Kenya, supported through USAID-APHIAplus KAMILI project, initiated two food banks to respond to poor nutritional status of the HIV infected children. Quality Improvement Teams were used to facilitate food-banking initiatives. The study aimed at assessing and demonstrating roles of community food-banking in improving nutrition status of HIV-infected children in food insecure regions.

Methods

A pre and post-test study lasting 12 months (Oct 2013 to September 2014) conducted in Kiambu County, Kenya covering 103 HIV infected children. Two assessments were conducted before and after the food banking initiative and results compared. Child Status Index (CSI) and the Middle Upper Arm Circumference (MUAC) tools were used in data collection at households. Paired T-test and Wilcoxon test were applied for analysing MUAC and CSI scores respectively using the SPSS.

Results

There was a significant improvement in the children’s nutrition status from a rating of ‘bad’ in CSI Median (IQR) score 2(2-1) before food banking to a rating of ‘fair’ in CSI Median (IQR) score 3(4-3) after food banking intervention (p=<0.001) while MUAC increased from Mean (SD) of 5.6(2.6) before intervention to 7.2(2.8) after food banking (p=<0.001).

Conclusion

Food banking is a community-based nutritional intervention that can address factors of food access, affordability and availability. Food banking is a sustainable way to contribute to quality nutrition and reduced related deaths among HIV infected children.

Change in serum 25-hydroxyvitamin D with antiretroviral treatment initiation and nutritional intervention in HIV-positive adults

Low vitamin D level in HIV-positive persons has been associated with disease progression. We compared the levels of serum 25-hydroxyvitamin D (25(OH)D) in HIV-positive and HIV-negative persons, and investigated the role of nutritional supplementation and antiretroviral treatment (ART) on serum 25(OH)D levels. A randomised nutritional supplementation trial was conducted at Jimma University Specialized Hospital, Ethiopia. The trial compared 200 g/d of lipid-based nutrient supplement (LNS) with no supplementation during the first 3 months of ART. The supplement provided twice the recommended daily allowance of vitamin D (10 μg/200 g). The level of serum 25(OH)D before nutritional intervention and ART initiation was compared with serum 25(OH)D of HIV-negative individuals. A total of 348 HIV-positive and 100 HIV-negative persons were recruited. The median baseline serum 25(OH)D level was higher in HIV-positive than in HIV-negative persons (42·5 v. 35·3 nmol/l, P17 kg/m2 were randomised to either LNS supplementation (n 189) or no supplementation (n 93) during the first 3 months of ART. The supplemented group had a 4·1 (95 % CI 1·7, 6·4) nmol/l increase in serum 25(OH)D, whereas the non-supplemented group had a 10·8 (95 % CI 7·8, 13·9) nmol/l decrease in serum 25(OH)D level after 3 months of ART. Nutritional supplementation that contained vitamin D prevented a reduction in serum 25(OH)D levels in HIV-positive persons initiating ART. Vitamin D replenishment may be needed to prevent reduction in serum 25(OH)D levels during ART.

Health & nutritional status of HIV infected children in Hyderabad, India

BACKGROUND & OBJECTIVES

Information on nutritional status of HIV infected children from India is lacking and is required before taking up nutritional supplementation trials. Thus, the aim of the present study was to assess the growth and morbidity status of HIV infected children over a period of one year in a city in southern India.

METHODS

This was an observational study carried out between July 2009 and February 2011, at two orphanages in Hyderabad, India. Seventy seven HIV-positive children aged between 1 and half and 15 years, both on and not on antiretroviral therapy (ART) were included. Nutritional status was assessed longitudinally for one year by weight gain, linear growth and body composition. Serum samples were analyzed for haemoglobin, micronutrients, CD4 and CD8 counts. Dietary intakes were assessed by institutional diet survey and morbidity data were recorded every day for 12 months.

RESULTS

Mean energy intakes were less than recommended dietary allowance (RDA) in all age groups. Iron and folate intakes were less than 50 per cent of RDA; 46 (59.7%) children were stunted, 36 (46.8%) were underweight and 15 (19.5%) had low BMI for age. Anaemia was observed in 35 (45.5%) children. Micronutrient deficiencies such as vitamin D (40/77; 51.9%), vitamin A (11/77; 14.3%), folate (37/77; 48.1%), iron (38/77; 49.3%) were widely prevalent. HIV viral load was higher in children not on ART and those with morbidity. Respiratory (36.6%) and dermatological illnesses (18.8%) were the commonest presentations.

INTERPRETATION & CONCLUSIONS

Acute, chronic malnutrition and micronutrient deficiencies were common in HIV infected children, especially in those not on ART and having morbidity. With severe malnutrition being an alarming consequence of HIV, prophylactic nutritive care should be considered for integration into HIV care strategies besides initiation of ART to improve the nutritional status and quality of life of these children.

Nutritional Supplementation Is a Necessary Complement to Dietary Counseling among Tuberculosis and Tuberculosis-HIV Patients

The Brazilian Ministry of Health and the World Health Organization recommend dietary counseling for patients with malnutrition during tuberculosis treatment. Patients under tuberculosis therapy (infected and not infected with HIV) were followed-up to evaluate the effectiveness of dietary counseling.

OBJECTIVE

describe the nutritional status of patients with tuberculosis.

METHODS

an observational follow-up study over a 180-day period of tuberculosis therapy in adults was conducted. Subjects were assessed for body composition (using BMI, TSF and MUAC parameters), serum biomarkers and offered dietary counseling. The data obtained at each visit (D15, D30, D60, D90, D120, D150, and D180) were analyzed, showing trajectories over time and central tendencies each time.

RESULTS

at baseline, the mean age was 41.1 (± 13.4) years; they were predominantly male, with income lower than a local minimum wage and at least six years of schooling. Patients showed predominantly pulmonary tuberculosis. At baseline, all patients suffered from malnutrition. The overall energy malnutrition prevalence was of 70.6%. Anemia at baseline was observed in both groups (63.2%), however, it was significantly more pronounced in the HIV+. At the end, energy malnutrition was reduced to 57.1% (42.9% of HIV- and 71.4% of the HIV+). Micronutrients malnutrition was evident in 71.4% of the HIV- patients and 85.7% of HIV+ patients at the end of tuberculosis therapy. Using BMI (≤ 18.5 kg/m2cutoff) as an index of malnutrition, it was detected in 23.9% of the HIV- and 27.3% of the HIV+ patients at baseline, with no evident improvement over time; using TSF (≤ 11.4mm as cutoff) or MUAC (≤ 28.5cm as cutoff), malnutrition was detected in 70.1% and 85.3% of all patients, respectively. Nevertheless, combining all biomarkers, at the end of follow-up, all patients suffered from malnutrition.

CONCLUSION

Although with a limited number of patients, the evidence does not support that dietary counseling is effective to recover from malnutrition in our population.

The effect of standard dose multivitamin supplementation on disease progression in HIV-infected adults initiating HAART: a randomized double blind placebo-controlled trial in Uganda

BACKGROUND

Efficacy trials investigating the effect of multivitamin (MV) supplementations among patients on Highly Active Antiretroviral Therapy (HAART) have so far been inconclusive. We conducted a randomized, double blind, placebo controlled trial to determine the effect of one recommended daily allowance (RDA) of MV supplementation on disease progression in patients initiating HAART.

METHODS

Eligible subjects were randomized to receive placebo or MV supplementation including vitamins B-complex, C and E. Participants were followed for up to 18 months. Primary endpoints were: change in CD4 cell count, weight and quality of life (QoL). Secondary endpoints were: i) development of a new or recurrent HIV disease progression event, including all-cause mortality; ii) switching from first- to second-line antiretroviral therapy (ART); and iii) occurrence of an adverse event. Intent-to-treat analysis, using linear regression mixed effects models were used to compare changes over time in the primary endpoints between the study arms. Kaplan-Meier time-to-event analysis and the log-rank test was used to compare HIV disease progression events and all-cause mortality.

RESULTS

Four hundred participants were randomized, 200 onto MV and 200 onto placebo. By month 18, the average change in CD4 cell count in the MV arm was 141 cells/uL compared to 147 cells/uL in the placebo arm, a mean difference of -6 · 17 [95 % CI -29 · 3, 16 · 9]. The average change in weight in the MV arm was 3 · 9 kg compared to 3 · 3 kg in the placebo arm, a mean difference of 0 · 54 [95 % CI -0 · 40, 1 · 48]; whereas average change in QoL scores in the MV arm was 6 · 8 compared to 8 · 8 in the placebo arm, a mean difference of -2.16 [95 % CI -4 · 59,0 · 27]. No significant differences were observed in these primary endpoints, or in occurrence of adverse events between the trial arms.

CONCLUSIONS

One RDA of MV supplementation was safe but did not have an effect on indicators of disease progression among HIV infected adults initiating HAART.

TRIAL REGISTRATION

Clinical trials NCT01228578 , registered on 15th October 2010.

Food Insecurity and Its Relation to Psychological Well-Being Among South Indian People Living with HIV

Food insecurity (FI) and its link with depression and quality of life (QOL) among people living with HIV (PLHIV) in India are not well-documented. We analyzed cohort data from 243 male and 129 female PLHIV from Bengaluru, and found 19 % of men and 26 % of women reported moderate or severe FI over a 6-month period. Women reported higher mean depression than men, and lower mean QOL. In multivariate analyses adjusting for HIV stigma and demographic covariates, both male and female PLHIV with moderate to severe FI showed lower mean QOL than those reporting mild to no FI. Male but not female food insecure participants also had higher depression scores in adjusted regression analyses. As ART has improved the physical health of PLHIV, more effort is being invested in improving their psychological well-being. Our results suggest such interventions could benefit from including nutritional support to reduce FI among PLHIV.

Tuberculosis incidence rate and risk factors among HIV-infected adults with access to antiretroviral therapy

OBJECTIVE

The objective of this study is to determine the incidence rate and risk factors of tuberculosis (TB) among HIV-infected adults accessing antiretroviral therapy (ART) in Tanzania.

DESIGN

A prospective observational study among HIV-infected adults attending HIV clinics in Dar es Salaam.

METHODS

We estimated TB incidence rates among HIV-infected patients prior to and after ART initiation. We used Cox proportional hazard regressions to determine the predictors of incident TB among HIV-infected adults enrolled in the HIV care and treatment programme.

RESULTS

We assessed 67 686 patients for a median follow-up period of 24 (interquartile range: 8-49) months; 7602 patients were diagnosed with active TB. The TB incidence rate was 7.9 [95% confidence interval (95% CI), 7.6-8.2] per 100 person-years prior to ART initiation, and 4.4 (95% CI, 4.2-4.4) per 100 person-years for patients receiving ART. In multivariate analyses, patients on ART in the first 3 months had a 57% higher risk of TB (hazard ratio: 1.57, 95% CI, 1.47-1.68) than those not on ART, but the risk significantly decreased with increasing duration of ART. Risk factors for incident TB included being male, having low BMI or middle upper arm circumference, lower CD4 cell count and advanced WHO disease stage. There was seasonal variation for incident TB, with higher risk observed following the rainy seasons (May, June and November).

CONCLUSION

In TB endemic regions, HIV-infected patients initiating ART, particularly men and those with poor nutritional status, should be closely monitored for active TB at ART initiation. In addition to increasing the access to ART, interventions should be considered to improve nutritional status among HIV-infected patients.

Distinct gender differences in anthropometric profiles of a peri-urban South African HIV population: a cross sectional study

Background

Highly active antiretroviral therapy (HAART) has extended life expectancy and enhanced the well-being of HIV-positive individuals. Since there are concerns regarding HAART-mediated onset of cardio-metabolic diseases in the long-term, we evaluated the anthropometric profile of black HIV-infected individuals in a peri-urban setting (Western Cape, South Africa).

Methods

A cross sectional study design was followed to describe the gender differences in different HAART treatment groups. HIV-positive patients (n = 44 males, n = 102 females; 20–40 years) were recruited for three groups: 1) control (HIV-positive, HAART-naïve), 2) HIV-positive (<3 years HAART), and 3) HIV-positive (>3 years HAART).

Results

All participants underwent comprehensive anthropometric and bio-electrical impedance analyses. No significant differences were observed in the male treatment groups. HAART-naïve females are mostly overweight (73.90 ± 2.79). This is followed by a period of muscle wasting seen in the triceps skinfold (29.30 ± 2.19 vs 20.63 ± 1.83; p < 0.01), muscle mass (22.23 ± 0.46 vs 19.82 ± 0.54; p < 0.01), and fat free mass (49.40 ± 1.08 vs 44.16 ± 1.21; p < 0.01) upon HAART initiation (<3 years HAART). Thereafter all parameters measured had levels similar to that seen for the female HAART-naïve group. Females on <3 years HAART exhibited significantly decreased body cell mass (p < 0.01), protein mass (p < 0.01), muscle mass (p < 0.01), fat free mass (p < 0.01), and fat mass (p < 0.001) versus matched HAART-naïve controls. The W:H ratio for the female treatment groups placed the females overall at a higher risk for developing cardiovascular disease compared to the males.

Conclusions

This study found striking gender-based anthropometric differences in black South African HIV-positive individuals on HAART. We also conclude from this observational study that no significant differences were found in the different male treatment groups. All female body composition parameters initially showed lower values (<3 years HAART). The female treatment group (>3 years HAART) displayed values similar to that seen in the HAART-naïve group. Higher W:H ratios in females receiving longer-term HAART potentially increases their risk for the future onset of cardio-metabolic complications.

Association between chronic hepatitis C virus infection and low muscle mass in US adults

Given that low muscle mass can lead to worse health outcomes in patients with chronic infections, we assessed whether chronic hepatitis C virus (HCV) infection was associated with low muscle mass among US adults. We performed a cross-sectional study of the National Health Examination and Nutrition Study (1999-2010). Chronic HCV-infected patients had detectable HCV RNA. Low muscle mass was defined as <10th percentile for mid-upper arm circumference (MUAC). Multivariable logistic regression was used to determine adjusted odds ratios (aORs) with 95% confidence intervals (CIs) of low muscle mass associated with chronic HCV. Among 18 513 adults, chronic HCV-infected patients (n = 303) had a higher prevalence of low muscle mass than uninfected persons (13.8% vs 6.7%; aOR, 2.22; 95% CI, 1.39-3.56), and this association remained when analyses were repeated among persons without significant liver fibrosis (aOR, 2.12; 95% CI, 1.30-3.47). This study demonstrates that chronic HCV infection is associated with low muscle mass, as assessed by MUAC measurements, even in the absence of advanced liver disease.

Prevalence of Plasmodium falciparum Parasitaemia and Its Correlation with Haematological Parameters among HIV-Positive Individuals in Nigeria

Malaria and HIV are the two most important health challenges of our time. Haematologic abnormalities are features in Plasmodium falciparum infection, and anaemia is a well-known outcome. The prevalence and haematological impact of P. falciparum parasitaemia were determined among HIV-infected individuals in Nigeria. Parasite detection was carried out using microscopy and Polymerase Chain Reaction (PCR). Haemoglobin concentration was determined using an automated machine while CD4+ T-cells count was analyzed using flow cytometer. Thirty-seven (18.5%) out of the 200 HIV individuals enrolled had malaria parasites detected in their blood. All the positive cases were detected by PCR while only 20 (10%) were detected by thick blood microscopy. The mean haemoglobin concentration and packed cell volume (PCV) of HIV individuals with malaria parasitaemia were lower compared to those without malaria parasitaemia but the difference was not statistically significant. Also no significant difference was observed in malaria positivity in respect to sex and mean CD4+ cell count. The study highlights the effects of P. falciparum parasitaemia on the haematologic and immune components of HIV individuals.

[Study of anemia in HIV positive children naive to antiretroviral treatment in Lubumbashi, Democratic Republic of Congo]

Introduction

Beaucoup d'enfants infectés par le VIH arrivent à la consultation dans un état d'anémie. Notre objectif était d’évaluer la prévalence et le typage de l'anémie chez ces enfants.

Méthodes

C'est une étude transversale réalisée dans 3 centres de prise en charge des Personnes Vivant avec le VIH à Lubumbashi de Mai 2010 à Mai 2011. La population d’étude était de 152 enfants, âgés de 6 à 180 mois, naïfs au traitement antirétroviral. Les statistiques descriptives usuelles ont été utilisées.

Résultats

La prévalence globale de l'anémie (définie comme l'hémoglobine < 11g/dl) était de 69,1% (n=105) et 11,4% avaient une anémie sévère (Hg < 7,0 g/dl). Parmi eux, 16% ont été transfusés au moins 1 fois. L'anémie sévère était positivement associée au stade clinique de la maladie (p=0,02). L'anémie microcytaire était majoritaire dans les deux tranches d’âge. Elle était plus hypochrome chez les enfants en âge préscolaire soit 9,5% et plus normochrome en âge scolaire soit 15,2%. L'anémie normocytaire était plus normochrome dans les deux tranches d’âge soit 12,4% en âge préscolaire et 6,7% en âge scolaire. L'anémie macrocytaire était rare.

Conclusion

Environ sept enfants sur dix, âgés de moins de 15 ans infectés par le VIH naïfs au traitement antirétroviral dans notre milieu sont anémiques. L'anémie est corrélée à la sévérité de la maladie. Il est important d'associer une prise en charge nutritionnelle et corriger l'anémie avant une trithérapie antirétrovirale.

Vitamin D status among pulmonary TB patients and non-TB controls: a cross-sectional study from Mwanza, Tanzania

BACKGROUND

Little is known about vitamin D status in low-income populations burdened with infectious diseases. Hence, there is a need for data on correlates of serum 25-hydroxy vitamin D (S-25(OH)D) and its validity during infections.

OBJECTIVE

To assess the role of pulmonary TB (PTB) and HIV as correlates of S-25(OH)D.

DESIGN

Age-sex-matched cross-sectional study among PTB patients and non-TB controls.

METHODS

PTB patients were categorized as sputum negative (PTB-) and positive (PTB+) by culture. Non-TB controls were randomly selected among age-sex-matched neighbours to PTB+ patients. Height, weight, arm circumference and triceps skinfold were measured, and body mass index (BMI), arm fat (AFA) and muscle area (AMA) computed. HIV status, and S-25(OH)D, C-reactive protein (S-CRP) and α1-acid glycoprotein (S-AGP) were determined. Linear regression analysis with controls and PTB patients combined was used to identify correlates of S-25(OH)D.

RESULTS

S-25(OH)D data were available on 97.8% (1570) of 1605 participants. Mean (SD) S-25(OH)D was 84.4 (25.6) nmol/L with 39.6% <75 nmol/L among 347 non-TB controls. Time of recruitment, sex, PTB and HIV, and elevated S-AGP were correlates of S-25(OH)D. S-25(OH)D was 24.8 (95% CI 18.6;30.9) nmol/L higher in PTB compared to controls among females, but only 9.8 (95% CI:4.5;15.2) nmol/L among males (interaction p<0.0001). Females had 13.8 (95% CI:8.2;21.9) nmol/L lower S-25(OH)D than males, and HIV infected individuals had 8.5 (95% CI:4.9;12.1) higher S-25(OH)D compared to uninfected. Elevated S-AGP was a positive correlate of S-25(OH)D. Low BMI was associated with S-25(OH)D, but not with infections or S-AGP in the model.

CONCLUSION

While S-25(OH)D may decline transiently during a mild acute phase response, it may increase if the acute phase response leads to loss of fat. The validity of S-25(OH)D as a marker of vitamin D status may be affected by infections.

Nutritional status of adult patients with pulmonary tuberculosis in rural central India and its association with mortality

Under-nutrition is a known risk factor for TB and can adversely affect treatment outcomes. However, data from India are sparse, despite the high burden of TB as well as malnutrition in India. We assessed the nutritional status at the time of diagnosis and completion of therapy, and its association with deaths during TB treatment, in a consecutive cohort of 1695 adult patients with pulmonary tuberculosis in rural India during 2004 - 2009.Multivariable logistic regression was used to obtain adjusted estimates of the association of nutritional status with deaths during treatment. At the time of diagnosis, median BMI and body weights were 16.0 kg/m²and 42.1 kg in men, and 15.0 kg/m²and 34.1 kg in women, indicating that 80% of women and 67% of men had moderate to severe under-nutrition (BMI<17.0 kg/m²). Fifty two percent of the patients (57% of men and 48% of women) had stunting indicating chronic under-nutrition. Half of women and one third of men remained moderately to severely underweight at the end of treatment. 60 deaths occurred in 1179 patients (5%) in whom treatment was initiated. Severe under-nutrition at diagnosis was associated with a 2 fold higher risk of death. Overall, a majority of patients had evidence of chronic severe under-nutrition at diagnosis, which persisted even after successful treatment in a significant proportion of them. These findings suggest the need for nutritional support during treatment of pulmonary TB in this rural population.

Carnitine deficiency and its possible risk factors in TB patients: first report

AIM

To assess carnitine serum levels and possible risk factors of its deficiency in patients with TB.

PATIENTS & METHODS

All newly diagnosed TB patients admitted to an infectious diseases ward were recruited. Demographic, clinical and paraclinical characteristics of the patients were collected. Total carnitine serum concentrations were measured. To investigate factors that can predict carnitine deficiency, logistic regression analysis with odds ratio and 95% CI was performed.

RESULTS

The mean ± standard deviation of carnitine serum levels of patients was 43.77 ± 32.92 µmol/l. Carnitine deficiency was detected in 47.7% of the study population. According to the final model of multivariate logistic regression analysis, increased serum triglyceride levels and hypoalbuminemia were identified as predictive factors of carnitine deficiency in TB patients aged over 35 years old.

CONCLUSION

Nearly half of Iranian patients with TB were carnitine-deficient. Increased serum triglyceride levels and hypoalbuminemia were identified as independent risk factors of carnitine deficiency in patients aged over 35 years. Considering malnutrition as a major risk factor of TB and the safety of carnitine supplementation, use of carnitine as an adjunctive modality instead of other standard interventions may show beneficial effects in patients with TB.

Impact of nutritional supplementation on immune response, body mass index and bioelectrical impedance in HIV-positive patients starting antiretroviral therapy

Background

Challenges to HIV care in resource limited settings (RLS) include malnutrition. Limited evidence supports the benefit of nutritional supplementation when starting antiretroviral therapy (ART) in RLS.

Methods

Randomized controlled pilot study. HIV-positive ART-naive adults with self-reported weight loss were randomized to receive ART plus FutureLife porridge® nutritional supplement (NS) (388 kcal/day) or ART alone (Controls) for 6 months. Patients returned for monthly assessments and blood was drawn at enrolment and 6 months on ART. Differences in body composition, biochemical and laboratory parameters were estimated at 6 months on treatment.

Results

Of the 36 randomized patients, 26 completed the 6 month follow-up (11 NS vs 15 Controls). At enrolment, groups were similar in terms of age, gender, body mass index (BMI) and bioelectrical impedance. NS patients had a lower median CD4 count (60 cells/mm³ [IQR 12–105 vs 107 cells/mm³ [IQR 63–165]; p = 0.149) and hemoglobin (10.3 g/dL [IQR 9.0-11.3] vs 13.1 g/dL [IQR 11.1-14.7]; p = 0.001).

At 6 months, NS patients increased their median CD4 count by 151 cells/mm³ [IQR 120–174) vs 77 cells/mm³ [IQR 33–145] in the Controls. NS patients had higher mean percentage change in body weight (12.7% vs 4.9%; p = 0.047), BMI (7.8% vs 5.5%; p = 0.007), absolute CD4 count (83.0% vs 46.4%, p = 0.002) and hemoglobin (9.5% vs 1.0%; p = 0.026). Patients in the NS arm had a higher mean percentage fat-free mass (16.7% vs −3.5%, p = 0.036), total body water (13.0% vs −1.9%, p = 0.026), intracellular water (16.1% vs −4.1%, p = 0.010) and basal metabolic rate (5.3% vs −0.2%, p = 0.014) compared to Controls. Patients in the NS arm also showed an improvement in physical activity at 6 months post-ART initiation compared to Controls (p = 0.037).

Conclusion

Preliminary results are encouraging and suggest that NS taken concurrently with ART can promote weight gain, improve immune response and improve physical activity in HIV-positive patients that present at ART initiation with weight loss.

Increased risk of mortality and loss to follow-up among HIV-positive patients with oropharyngeal candidiasis and malnutrition before antiretroviral therapy initiation: a retrospective analysis from a large urban cohort in Johannesburg, South Africa

OBJECTIVE

We investigated the effect of oropharyngeal candidiasis (OC) and body mass index (BMI) before antiretroviral therapy (ART) initiation on treatment outcomes of human immunodeficiency virus (HIV)-positive patients.

STUDY DESIGN

Treatment outcomes included failure to increase CD4 count by ≥50 or ≥100 cells/μL or failure to suppress viral load (<400 copies/mL) at 6 or 12 months in addition to loss to follow-up (LTFU) and mortality by 12 months. Risk and hazard ratios (HRs) were estimated with the use of log-binomial regression and Cox proportional hazards models, respectively.

RESULTS

Baseline CD4 <100 cells/μL, low BMI (<18.5 kg/m(2)), low hemoglobin, and elevated aspartate transaminase were associated with OC at ART initiation. Patients with low BMI with and without, respectively, OC were at risk of mortality (HR 2.42, 95% CI 1.88-3.12; HR 1.87, 95% CI 1.54-2.28) and LTFU (HR 1.36, 95% CI 1.02-1.82; HR 1.55, 95% CI 1.30-1.85).

CONCLUSIONS

Low BMI (with/without OC) at ART initiation was associated with poor treatment outcomes. Conversely, normal BMI with OC was associated with adequate CD4 response and reduced LTFU compared with without OC.

Low nutrient intake among adult women and patients with severe tuberculosis disease in Uganda: a cross-sectional study

BACKGROUND

Information regarding dietary nutrient intake during tuberculosis disease is lacking. We established the relationship between disease severity or wasting during pulmonary tuberculosis and nutrient intake.

METHODS

In a cross-sectional study of 131 adults with or without pulmonary tuberculosis were screened for human immune-deficiency virus (HIV), wasting, disease severity using 13 item validated clinical TBscore, and 24-hour dietary intake recall.

RESULTS

Of the 131 participants, 61 were males and 70 females. Overall men and women had similar age. In average 24-hour nutrient intake, the following nutrients: energy, protein, total fat, carbohydrate, calcium, vitamin A, and folate were low among patients with severe tuberculosis disease. Patients with moderate-to-severe clinical TBscore had lower average energy intake than patients with mild TBscores (6.11 vs. 9.27 MJ, respectively) (p<0.05). The average 24-hour nutrient intakes between wasted and non-wasted tuberculosis patients were comparable. Nutrient intake among men was higher when compared to women regardless of wasting and severity of tuberculosis. Among those with wasting, men had higher average energy intake than women (8.87 vs. 5.81 MJ, respectively) (p<0.05). Among patients with mild disease, men had higher average energy intake than women with mild disease (12.83 vs. 7.49 kcal, respectively) (p<0.001).

CONCLUSIONS

Findings suggest that severity of pulmonary tuberculosis and female gender had reduced nutrient intake. Early tuberculosis diagnosis and nutritional support may be important in management of tuberculosis patients.

Predictors of change in nutritional and hemoglobin status among adults treated for tuberculosis in Tanzania

BACKGROUND

Patients with tuberculosis (TB) often suffer from profound malnutrition.

OBJECTIVE

To examine the patterns and predictors of change in nutritional and hemoglobin status during and after TB treatment.

METHODS

A total of 471 human immunodeficiency virus (HIV) positive and 416 HIV-negative adults with pulmonary TB were prospectively followed in Dar es Salaam, Tanzania. All patients received 8 months' TB treatment following enrollment.

RESULTS

About 40% of HIV-positive and 47% of HIV-negative TB patients had body mass index (BMI) < 18.5 kg/m 2 at baseline, while about 94% of HIV-positive and 84% of HIV-negative participants were anemic at baseline. Both HIV-positive and HIV-negative patients experienced increases in BMI and hemoglobin concentrations over the course of TB treatment. Among HIV- positive patients, older age, low CD4 cell counts, and high viral load were independently associated with a smaller increase in BMI from baseline to 8 months. Fe- male sex, older age, low CD4 cell counts, previous TB infection and less money spent on food were independently associated with a smaller improvement in hemoglobin levels among HIV-positive patients during treatment.

CONCLUSION

HIV-positive TB patients, especially those with low CD4 cell counts, showed poor nutritional recovery during TB treatment. Adequate nutritional support should be considered during TB treatment.

Nutritional status and its response to treatment of children, with and without HIV infection, hospitalized for the management of tuberculosis

BACKGROUND

The association of childhood tuberculosis (TB) and malnutrition is known, but treatment response, the influence of the acute-phase response (APR) and concomitant HIV infection are not well documented.

AIM

To evaluate the nutritional response and APR in HIV-infected and uninfected children hospitalised for the treatment of TB and receiving standard anti-tuberculosis chemotherapy.

METHODS

During a study of the pharmacokinetics of standard anti-tuberculosis agents, anthropometric parameters were measured and blood concentrations of nutrients and C-reactive protein (CRP) determined at 1 and 4 months after initiation of chemotherapy.

RESULTS

24 HIV-infected and 34 HIV-uninfected children were studied. On enrollment, 31.6% of HIV-infected and 2.9% of HIV-uninfected children were underweight, and 31.6% and 14.7%, respectively, were stunted. Mean values of weight, height/length, head circumference and mid-upper-arm circumference on enrollment and at 4-month assessment in HIV-infected and uninfected children did not differ. Mean triceps skinfold (TSF) (8.17 and 9.73 cm) and subscapular skinfold (SSF) thicknesses (5.75 and 7.5 cm) on enrollment differed significantly (P = 0.03 and P = 0.003); by 4 months, TSF had declined to 5.97 cm (P<0.001) and 8.87 cm (P = 0.05), respectively, and SSF to 5.57 cm (P = 0.79) and 6.73 cm (P = 0.04); the arm muscle area (AMA) was low in a majority of children on enrollment and remained so at the second assessment. CRP was raised in 66.6% and 53.3% of HIV-infected and -uninfected children on enrollment, but at 4-month assessment was raised in 63.2% and 15.2%, respectively. Other micronutrient and haematological findings probably reflect an APR, but no children had sub-normal zinc or magnesium values; most selenium and vitamin C and E values were normal. An elevated platelet count (> 420 × 10(9)/L) was significantly more common in HIV-uninfected children, and was still raised in 39% at 4 months.

CONCLUSION

A majority of HIV-infected and uninfected children had an APR but it had resolved by 4 months in most HIV-uninfected children. In both groups, low and declining skinfolds and a persistently low AMA indicate a persistent disturbance of fat and protein metabolism, despite successful chemotherapy.

Anemia in adults with tuberculosis is associated with HIV and anthropometric status in Dar es Salaam, Tanzania

SETTING

Tuberculosis (TB) infected adults attending out-patient TB clinics in Dar es Salaam, Tanzania.

OBJECTIVE

To examine the association of anemia with human immunodeficiency virus (HIV) co-infection, indicators of socio-economic status (SES) and anthropometric status in TB-infected adults.

DESIGN

Cross-sectional data collection during screening for a clinical trial.

RESULTS

Overall, 750 females and 1693 males participated in this study, of whom respectively 49% and 24% were co-infected with HIV-1. Hemoglobin levels were significantly lower in females than in males and in HIV-positive than in HIV-negative participants. HIV co-infection in this antiretroviral-naïve population was also associated with severe anemia (hemoglobin < 85 g/l) in both women (prevalence ratio [PR] = 2.07, 95%CI 1.65-2.59) and men (PR 3.45, 95%CI 2.66-4.47). Although severe anemia was negatively associated with indicators of SES, especially in males, adjustment for SES indicators only marginally changed its association with HIV co-infection. In both sexes, anemia was inversely associated with anthropometric status, independently of HIV infection and SES.

CONCLUSION

Among TB-infected adults, anemia is strongly associated with HIV co-infection and anthropometric status, independently of SES indicators. As anemia is a risk factor for morbidity and mortality in both infections, the management of anemia in TB-HIV co-infected patients warrants special attention.

Malnutrition in a population of HIV-positive and HIV-negative drug users living in Chennai, South India

BACKGROUND

Malnutrition is a strong predictor of poor outcomes in people living with HIV (PLHIV). Drug users are at increased risk of malnutrition regardless of whether or not they are infected with HIV. Little data exists on the nutritional status of drug users (with or without HIV infection) in India.

METHODS

We describe and compare the nutrition and metabolic status of 107 HIV-positive and 193 HIV-negative male clients of a community-based drop-in center for injection drug users in Chennai, India. Measures of nutrition and metabolic status include body composition, dietary intake, food insecurity, and serum lipid levels.

RESULTS

We found poor overall nutritional status in both the HIV-positive and HIV-negative clients, with HIV-positive men faring worse on some parameters. Both groups had extremely low percent body fat, but levels in HIV-positive participants were significantly lower (6.5% versus 7.9%, p=.01). HIV-positive men also had significantly lower total caloric and fat intakes compared to HIV-negative men. A considerable proportion (70%) of both HIV-positive and HIV-negative drug users were food insecure. HDL cholesterol levels were significantly lower and below normal range in the HIV-positive compared to HIV-negative men.

CONCLUSIONS

The high levels of food insecurity and poor nutritional status in this population, regardless of HIV status, indicates critical need for intervention. Improving nutritional status in those who are infected with HIV prior to initiation of antiretroviral treatment may help patients to reap the full benefits of therapy.

The effect of energy–protein supplementation on weight, body composition and handgrip strength among pulmonary tuberculosis HIV-co-infected patients: randomised controlled trial in Mwanza, Tanzania

Undernutrition is common among smear-positive pulmonary tuberculosis (PTB+) patients. Micronutrient supplementation may improve treatment outcomes, but it is unclear whether additional energy–protein would be beneficial. The present study aimed to assess the effect of energy–protein supplementation on weight, body composition and handgrip strength against a background of high micronutrient intake during tuberculosis (TB) treatment. A total of 377 PTB+ patients co-infected with HIV were randomly allocated one or six biscuits daily for 60 d during TB treatment. Weight, arm fat area, arm muscle area and handgrip strength were assessed at baseline and 2 and 5 months. There were no effects on any outcome at 2 months, but energy–protein supplementation was associated with a 1·3 (95 % CI − 0·1, 2·8) kg marginally significant gain in handgrip strength at 5 months. However, after 2 months, energy–protein supplementation led to a weight gain of 1·9 (95 % CI 0·1, 3·7) kg among patients with cluster of differentiation 4 (CD4) counts ≥ 350 cells/μl, but not among patients with low CD4 counts ( − 0·2 kg; 95 % CI − 1·3, 0·8, Pinteraction = 0·03). Similarly, at 5 months, energy–protein supplementation led to a 2·3 (95 % CI 0·6, 4·1) kg higher handgrip strength gain among patients with CD4 counts < 350 cells/μl, but not in those with high CD4 counts (Pinteraction = 0·04). In conclusion, energy–protein supplementation to PTB+ HIV-co-infected patients had no overall effects on weight and body composition, but was associated with marginally significant gain in handgrip strength. More research is needed to develop an effective supplement, before it is recommended to TB programmes.

Pilot randomized trial of nutritional supplementation in patients with tuberculosis and HIV-tuberculosis coinfection receiving directly observed short-course chemotherapy for tuberculosis

OBJECTIVE

To investigate the effects of nutritional supplementation on the outcome and nutritional status of south Indian patients with tuberculosis (TB) with and without human immunodeficiency virus (HIV) coinfection on anti-tuberculous therapy.

METHOD

Randomized controlled trial on the effect of a locally prepared cereal-lentil mixture providing 930 kcal and a multivitamin micronutrient supplement during anti-tuberculous therapy in 81 newly diagnosed TB alone and 22 TB-HIV-coinfected patients, among whom 51 received and 52 did not receive the supplement. The primary outcome evaluated at completion of TB therapy was outcome of TB treatment, as classified by the national programme. Secondary outcomes were body composition, compliance and condition on follow-up 1 year after cessation of TB therapy and supplementation.

RESULTS

There was no significant difference in TB outcomes at the end of treatment, but HIV-TB coinfected individuals had four times greater odds of poor outcome than those with TB alone. Among patients with TB, 1/35 (2.9%) supplemented and 5/42(12%) of those not supplemented had poor outcomes, while among TB-HIV-coinfected individuals, 4/13 (31%) supplemented and 3/7 (42.8%) non-supplemented patients had poor outcomes at the end of treatment, and the differences were more marked after 1 year of follow-up. Although there was some trend of benefit for both TB alone and TB-HIV coinfection, the results were not statistically significant at the end of TB treatment, possibly because of limited sample size.

CONCLUSION

Nutritional supplements in patients are a potentially feasible, low-cost intervention, which could impact patients with TB and TB-HIV. The public health importance of these diseases in resource-limited settings suggests the need for large, multi-centre randomized control trials on nutritional supplementation.

Weight variation over time and its association with tuberculosis treatment outcome: a longitudinal analysis

OBJECTIVE

Weight variation during therapy has been described as a useful marker to predict TB treatment outcome. No previous study has used longitudinal analysis to corroborate this finding. The goal of this study was to evaluate change and trends of patients' bodyweight over time depending on TB treatment outcome.

METHODS AND FINDINGS

A retrospective cohort study with all TB cases diagnosed from 2000 to 2006 was carried out. Information from 5 public tuberculosis treatment facilities at Pampas de San Juan de Miraflores, Lima, Peru was analyzed. Poor outcome was defined as failure or death during TB therapy, and compared to good outcome defined as cured. Longitudinal analysis with a pre-specified marginal model was fitted using Generalized Estimating Equations to compare weight trends for patients with good and poor outcome adjusting for potential confounders. A total of 460 patients (55.4% males, mean age: 31.6 years) were included in the analysis: 42 (9.1%) had a poor outcome (17 failed and 25 died). Weight at baseline was not different comparing outcome groups (p = 0.17). After adjusting for age, gender, type of TB, scheme of treatment, HIV status and sputum variation during follow-up, after the first month of treatment, patients with good outcome gained, on average, almost 1 kg compared to their baseline weight (p<0.001), whereas those with poor outcome lost 1 kg (p = 0.003). Similarly, after 4 months, a patient with good outcome increased 3 kg on average (p<0.001), while those with poor outcome only gained 0.2 kg (p = 0.02).

CONCLUSIONS

Weight variation during tuberculosis therapy follow-up can predict treatment outcome. Patients losing weight during TB treatment, especially in the first month, should be more closely followed as they are at risk of failure or death.

Addressing Tuberculosis in the Context of Malnutrition and HIV Coinfection

Background

Tuberculosis is the second leading cause of infectious disease mortality (1.8 million/year), after HIV/AIDS. There are more than 9 million new cases each year. One-third of the world's population, and 50% of adults in sub-Saharan Africa, South Asia, and South-East Asia, are infected, representing an enormous pool of individuals at risk for developing the disease. The situation is complicated by the HIV/AIDS pandemic, widespread undernutrition, smoking, diabetes, increased mobility, and emergence of multi- and extensively drug-resistant tuberculosis.

Objective

To review the scientific evidence about the interactions among tuberculosis, nutrition, and HIV coinfection.

Results

HIV infection and malnutrition lower immunity, increasing the risk of reactivation tuberculosis and primary progressive disease. Having either tuberculosis or HIV infection causes weight loss. Malnutrition markedly increases mortality among both tuberculosis and HIV/AIDS patients and should be treated concurrently with treatment of the infections. Tuberculosis treatment is a prerequisite for nutritional recovery, in addition to intake of nutrients required for rebuilding tissues, which is constrained in food-insecure households. Additional pharmaceutical treatment to reduce the catabolic impact of inflammation or promote growth may be needed. Specific nutrients can contribute to faster sputum smear clearance, which is important for reducing transmission, as well as faster weight gain when combined with an adequate diet. Adequate nutrition and weight gain in undernourished populations might reduce the incidence of tuberculosis.

Conclusions

The many risk factors for the development of tuberculosis need to be addressed simultaneously, especially HIV/AIDS and food insecurity and undernutrition. For stronger evidence-based guidelines, existing recommendations and clinical applications need to be more widely applied and evaluated.

Body composition among HIV-seropositive and HIV-seronegative adult patients with pulmonary tuberculosis in Uganda

PURPOSE

We determined whether human immunodeficiency virus (HIV) infection affects body cell mass and fat mass wasting among adults with pulmonary tuberculosis (PTB).

METHODS

We screened 967 Ugandan adults for PTB and HIV infection in a cross-sectional study. We compared anthropometric and bioelectric impedance analysis (BIA) body composition parameters among HIV-seropositive and HIV-seronegative men and women with or without PTB by using a non-parametric test.

RESULTS

We found that poor nutritional status associated with TB differed among men and women. Anthropometric and BIA body composition did not differ between HIV-seropositive and HIV-seronegative patients regardless of gender. Average weight group difference in men consisted of body cell mass and fat mass in equal proportions of 43%. In women, average weight group difference consisted predominantly of fat mass of 73% and body cell mass of 13%. Compared to individuals without TB, patients with TB had lower body mass index, weight, body cell mass, and fat mass regardless of gender and HIV status.

CONCLUSIONS

Gender, but not HIV status, was associated with body composition changes in TB. TB appears to be the dominant factor driving the wasting process among co-infected patients.

Nutritional aspects of HIV-associated wasting in sub-Saharan Africa

The twin global epidemics of HIV infection and food scarcity disproportionately affect sub-Saharan Africa, and a significant proportion of patients who require antiretroviral therapy (ART) are malnourished because of a combination of HIV-associated wasting and inadequate nutrient intake. Protein-calorie malnutrition, the most common form of adult malnutrition in the region, is associated with significant morbidity and compounds the immunosuppressive effects of HIV. A low body mass index (BMI), a sign of advanced malnutrition, is an independent predictor of early mortality (<6 mo) after ART initiation in several analyses, and recent studies show an association between early weight gain when receiving ART and improved treatment outcomes. The cause of the observed increase in mortality is uncertain, but it is likely due in part to malnutrition-induced immune system dysfunction, a higher burden of opportunistic infections, and metabolic derangements. In this article, we describe the epidemiology of HIV infection and malnutrition in sub-Saharan Africa, potential causes of increased mortality after ART initiation among patients with a low BMI, recent studies on post-ART weight gain and treatment outcome, and trials of macronutrient supplementation from the region. We close by highlighting priority areas for future research.

Anemia and growth failure among HIV-infected children in India: a retrospective analysis

Background

Anemia and poor nutrition have been previously described as independent risk factors for death among HIV-infected children. We sought to describe nutritional status, anemia burden and HIV disease correlates among infected children in India.

Methods

We analyzed retrospective data from 248 HIV-infected children aged 1–12 years attending three outpatient clinics in South India (2004–2006). Standard WHO definitions were used for anemia, HIV staging and growth parameters. Statistical analysis included chi square, t tests, univariate and multivariate logistic regression analyses.

Results

The overall prevalence of anemia (defined as hemoglobin < 11 gm/dL) was 66%, and 8% had severe anemia (Hb < 7 gm/dL). The proportion of underweight and stunted children in the population was 55% and 46% respectively. Independent risk factors of anemia by multivariate analysis included the pre-school age group (age younger than 6 years) (OR: 2.87; 95% CI: 1.45, 5.70; p < 0.01), rural residence (OR: 12.04; 95% CI: 5.64, 26.00; p < 0.01), advanced HIV disease stage (OR: 6.95; 95% CI: 3.06, 15.79; p < 0.01) and presence of stunting (Height-for-age Z Score < -2) (OR: 3.24; 95% CI: 1.65, 6.35; p < 0.01). Use of iron/multivitamin supplementation was protective against risk of anemia (OR: 0.44; 95% CI: 0.22, 0.90; p = 0.03). Pulmonary tuberculosis was an independent risk factor in multivariate analysis (OR: 3.36; 95% CI: 1.43, 7.89; p < 0.01) when correlated variables such as HIV disease stage and severe immunodeficiency, and nutritional supplement use were not included. Use of antiretroviral therapy (ART) was associated with a reduced risk of anemia (OR: 0.29; 95% CI: 0.16, 0.53; p < 0.01). No significant association was found between anemia and gender, cotrimoxazole, or ART type (zidovudine versus stavudine).

Conclusion

The high prevalence and strong interrelationship of anemia and poor nutrition among HIV-infected children in India, particularly those living in rural areas underscores the need for incorporating targeted nutritional interventions during national scale up of care, support and treatment among HIV-infected children.