healthmedicinet

Characteristics of the population

Between September and December 2011, 2027 children were seen in the 12 participating
centres of the Growing up Programme, representing more than 90 % of the active files. Among them, 1407 (69 %) had a confirmed
diagnosis of HIV-infection. Of these children, 22 % were excluded for age criteria
and 35 % for missing data. Finally, 1350 HIV-infected children were included in our
study (Fig. 1). Their median age was 10 years (interquartile range [IQR]?=?7]–13]), 49 % were girls, 60 % were orphans for one or both parents, 77 % were on cotrimoxazole
prophylaxis and 80 % were on ART for a median duration of 36 months (IQR?=?[18–61]).
Of these children, 22 % had reached WHO clinical stage III or IV of HIV disease and
17 % were severely immunodeficient. Among the 237 children not on ART at the time
of the study, 13 % were eligible (stage 3 or 4, or severely immunodeficient). More
than 55 % of the included children did not receive any nutritional support at the
time of the study or in the past 6 months (Table 1). Among the 45 % of children receiving nutritional support at inclusion, less than
2 % had received RUTF; and solid or semi-solid foods were the most frequently used
(80 %).

Fig. 1. Selection of the population and prevalence of acute, chronic and mixed malnutrition
(95 % Confidence Interval [CI])

Table 1. Characteristics of the 1350 HIV-infected children of the study population according
to age groups

Except for gender, all children characteristics differed significantly according to
age groups (Table 1). More than half of the children between 2 and 5 years had missing CD4 data. The
2–5 and 5–10 years groups were at a more advanced clinical stage of HIV disease than
the 10–19 years group (25 % vs 19 % at clinical stage III or IV, p?=?0.002). Compared
with the 5–10 and 10–19 years groups, the 2–5 years group had received more important nutritional support prior to the
study (19 % vs 12–13 % with at least 3 supports, p??0.001) and also during the study
(11 % vs 5 % with 3 supports, p??0.001). The youngest children were also less often
orphans compared with older children (71 % of 2–5 years no orphans vs 51 % of 5–10
years vs 23 % of 10–19 years, p??0.001) (Table 1).

Prevalence of malnutrition

In the overall study population, 42 % of children were malnourished with 123 children
(9 %, 95% CI?=?6]–12]) suffering from acute malnutrition, 344 (26 %, 95% CI?=?23]–28]) from chronic malnutrition, and 100 (7 %, 95% CI?=?5]–10]) from mixed malnutrition (Fig. 1). In other words, 16 % of children were wasted and 33 % were stunted with, in both
cases, 36 % of them severely malnourished.

The prevalence of malnutrition differed significantly by age. Among children aged
2–5 years, half were malnourished, and we observed the highest rate of chronic malnutrition
among this age group reaching 37 % (compared to 24 % in both 5–10 and 10–19 year old
groups). Children aged 5–10 years were malnourished in 36 % of cases, and children
aged 10 to 19 years in 44 % (Table 2).

Table 2. Prevalence of malnutrition among the 1350 HIV-infected children of the study population
according to age groups

Among the non-malnourished children, 45 % received at least one nutritional support
before or during the study. Among the malnourished children at the time of the survey,
whatever the type of malnutrition, 53 % received at least one nutritional support
before or during the study. This nutritional support was more frequent for children
between 2 and 5 years of age with no malnutrition, acute or chronic malnutrition,
compared with older children (p??0.001, p?=?0.001 and p?=?0.005 respectively). Children
with mixed malnutrition and aged between 5 and 10 had more frequently a nutritional
support compared with the other age groups (p?=?0.025). Also, among children who had
a nutritional support, most of them were supported both before and during the study,
whatever the malnutrition degree (Table 3).

Table 3. Nutritional supplementation practices according to the type of malnutrition and age
groups. N?=?1350

Factors associated with acute malnutrition

More than half of children suffering from acute malnutrition were aged??10 years;
63 % were boys, 37 % were known to be either moderately or severely immunodeficient
and 27 % were reported to be at a WHO clinical stage III or IV, although unexplained
moderate or severe malnutrition are criteria for classifying an HIV-infected child
at these stages. Furthermore, 63 % of children presenting acute malnutrition didn’t
receive any nutritional support during the study. Moreover, 66 % were initiated on
ART for more than 6 months and 20 % were not yet receiving ART (Table 4).

Table 4. Baseline characteristics of the study population according to the type of malnutrition.
N?=?1350

In univariate analysis, acute malnutrition was significantly twice as high in boys
as in girls, and in children with severe immunodeficiency compared to those not (OR?=?2.13,
95% CI?=?[1.44–3.16] and OR?=?2.27, 95% CI?=?[1.43–3.62] respectively) (Table 5).

Table 5. Factors associated with malnutrition (acute, chronic and mixed), univariate and multivariate
multinomial logistic regressions. N?=?1350

In the adjusted analysis for age group, sex, country, immunodeficiency, malnutrition
history, duration on ART and orphan status, boys were twice more likely malnourished
than girls (aOR?=?2.27, 95% CI?=?[1.52–3.41]), as well severely immunodeficient children
compared to non-immunodeficient children (aOR?=?2.07, 95% CI?=?[1.25–3.42]), and non-ART-treated
children compared with those on ART for more than 6 months (aOR?=?1.70, 95% CI?=?[1.01–2.84])
(Table 5).

Factors associated with chronic malnutrition

Among children suffering from chronic malnutrition, 47 % were aged 10 years, 55 %
were boys, 30 % were moderately or severely immunodeficient and 28 % were reported
to be at and advanced clinical stage (III or IV). Among these children, 43 % hadn’t
received any nutritional support during the 6 months prior to the study, 9 % were
recently initiated on ART and 18 % were not receiving ART (Table 4).

In univariate analysis, chronic malnutrition was significantly twice as low in children
older than 5 years of age as in younger children ([5–10[ vs. [2–5[ : OR?=?0.51, 95%
CI?=?[0.34–0.75], [10–19[ vs. [2–5[: OR?=?0.57, 95% CI?=?[0.39–0.84]), higher in boys
compared to girls (OR?=?1.50, 95% CI?=?[1.16–1.94]), in children with missing immunological
data (OR?=?1.76, 95% CI?=?[1.17–2.65]), in children ART-initiated for less than 6 months
compared to children on ART since more than 6 months (OR?=?1.74, 95% CI?=?[1.06–2.85]),
and in those who had an history of malnutrition (OR?=?1.73, 95% CI?=?[1.34–2.23])
(Table 5).

In the adjusted analysis for age group, sex, country, immunodeficiency, malnutrition
history, duration on ART and orphan status, the risk of chronic malnutrition was reduced
in children aged 5–10 years compared to those aged 2–5 years (aOR?=?0.61, 95% CI?=?[0.38–0.99]).
On the other hand, chronic malnutrition was more likely among boys compared to girls
(aOR?=?1.56, 95% CI?=?[1.20–2.03]). Children who had received nutritional support
within the 6 months prior to the study were more likely malnourished compared to those
not receiving any support (aOR?=?1.99, 95% CI?=?[1.43–2.77]) (Table 5).

Factors associated with mixed malnutrition

Among children suffering from mixed malnutrition, 87 % were aged more than 10 years.
There were 67 % of boys, 45 % were moderately or severely immunodeficient and 32 %
were at an advanced clinical stage. Furthermore, 54 % hadn’t received any nutritional
support during the study and 51 % hadn’t received any during the 6 months prior to
the study. Moreover, 12 % were recently initiated on ART and 12 % were not receiving
ART (Table 4).

In univariate analysis, mixed malnutrition was significantly twice as low in children
aged 5 to 10 years of age as in younger children (OR?=?0.32, 95% CI?=?[0.15–0.69]),
higher in boys compared to girls (OR?=?2.50, 95% CI?=?[1.61–3.88]), as well as in
children with severe immunodeficiency (OR?=?3.22, 95% CI?=?[2.01–5.51]), and in children
ART-initiated for less than 6 months compared to children on ART for more than 6 months
(OR?=?2.40, 95% CI?=?[1.21–4.78]) (Table 5).

In the adjusted analysis for age group, sex, country, immunodeficiency, malnutrition
history, duration on ART and orphan status, we observed lower risks of mixed malnutrition
in children aged 5–10 years compared to 2–5 years (aOR?=?0.34, 95% CI?=?[0.14–0.84]).
Risks of mixed malnutrition were higher among boys compared to girls (aOR?=?2.60,
95% CI?=?[1.64–4.10]) and among severely immunodeficient children compared to non
immunodeficient children (aOR?=?2.43, 95% CI?=?[1.40–4.23]) and in those on ART for
less than 6 months compared to children on ART for more than 6 months (aOR?=?2.54,
95% CI?=?[1.17–5.55]) (Table 5).