title: Hospitalization for severe malnutrition among HIV-infected children starting antiretroviral therapy.
abstract: OBJECTIVE
  To describe early hospitalization for severe malnutrition in HIV-infected children initiating antiretroviral therapy (ART).
  
  
  METHODS
  Randomized trial of induction-maintenance and monitoring strategies in HIV-infected children.
  
  
  METHODS
  Three tertiary hospitals in Uganda and one in Zimbabwe.
  
  
  METHODS
  1207 HIV-infected children, median age 6 years (range, 3 months to 17 years).
  
  
  METHODS
  Abacavir, lamivudine and nevirapine or efavirenz were given; children in induction-maintenance arms also received zidovudine to week 36. Pre-ART inpatient/outpatient nutritional rehabilitation for children with baseline severe malnutrition.
  
  
  METHODS
  : Hospitalization for severe malnutrition and change in CD4 cell percentage by week 12 after ART. Mortality and change in weight-for-age Z-score (WAZ) by week 24 after ART.
  
  
  RESULTS
  Thirty-nine of 1207 (3.2%) children were hospitalized for severe malnutrition (20 with oedema), median 28 days [interquartile range (IQR) 14, 36] after ART for marasmus and 26 days (IQR 14, 56) after ART for kwashiorkor. Hospitalized children had lower baseline and greater 24-week rise in WAZ than nonhospitalized children (P < 0.001). Twenty-nine of 39 (74%) children admitted for severe malnutrition had underlying infections. Of 220 children with advanced disease (baseline WAZ and CD4 cell Z-scores both <-3), 7.3% [95% confidence interval (CI) 3.8, 10.7] developed kwashiorkor and 3.6% (95% CI 1.2, 6.1) developed marasmus by week 12. CD4 cell percentage rise was similar among groups (P = 0.37). Twenty-four-week mortality was 32, 20 and 1.7% among children hospitalized with marasmus, kwashiorkor and not hospitalized, respectively, (P < 0.001).
  
  
  CONCLUSIONS
  One in nine children with advanced HIV required early hospitalization for severe malnutrition after ART, with a 15-fold increase in 6-month mortality compared with nonhospitalized children. Integration of HIV/malnutrition services and further research to determine optimal ART timing, role of supplementary feeding and antimicrobial prophylaxis are urgently required.
authors.affiliation: MRC Clinical Trials Unit, 222 Euston Road, London, UK. ajp@ctu.mrc.ac.uk
authors.forename: Andrew
authors.initials: A
authors.lastname: Prendergast
authors.forename: Mutsa F
authors.initials: MF
authors.lastname: Bwakura-Dangarembizi
authors.forename: Adrian D
authors.initials: AD
authors.lastname: Cook
authors.forename: Sabrina
authors.initials: S
authors.lastname: Bakeera-Kitaka
authors.forename: Eva
authors.initials: E
authors.lastname: Natukunda
authors.forename: Patricia
authors.initials: P
authors.lastname: Nahirya Ntege
authors.forename: Kusum J
authors.initials: KJ
authors.lastname: Nathoo
authors.forename: Christine
authors.initials: C
authors.lastname: Karungi
authors.forename: Joseph
authors.initials: J
authors.lastname: Lutaakome
authors.forename: Adeodata
authors.initials: A
authors.lastname: Kekitiinwa
authors.forename: Diana M
authors.initials: DM
authors.lastname: Gibb
mesh_terms: D000293:Adolescent; D001835:Body Weight; D018791:CD4 Lymphocyte Count; D002648:Child; D002675:Child, Preschool; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy / Q000401:mortality; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D008297:Male; D044342:Malnutrition / Q000150:complications* / Q000401:mortality; D012720:Severity of Illness Index; D014454:Uganda / Q000453:epidemiology; D015030:Zimbabwe / Q000453:epidemiology