Severe Acute Malnutrition and HIV in African Children

HIV is a significant cause of severe acute malnutrition (SAM) in Africa, which radically alters its epidemiology and clinical presentation. Clinical diagnosis of HIV is difficult: marasmus, oral candidiasis and persistent diarrhea are associated with HIV, but are also commonly observed in SAM. The same pathogens have been identified in HIV-infected and -uninfected children with SAM, but the former respond less well to treatment. HIV also affects children’s nutrition through food insecurity and infant feeding practice. A threefold greater mortality (30%) occurs in children living with HIV during nutrition program admission and continues after discharge. Nutrition interventions alone are able to achieve a nutritional cure in most HIV-infected children, including those with severe immunodeficiency, although weight gain is slower. Nonresponse to nutritional therapy is a defining WHO clinical criteria for initiating antiretroviral treatment, and malnutrition is the strongest predictor of death after starting antiretrovirals. Few studies have addressed whether initial management of SAM in HIV infection should be modified from the standard protocol for HIV-uninfected SAM, but the high excess mortality suggests important differences in pathophysiology. Prophylactic cotrimoxazole reduces mortality, but for most HIV-infected children antiretrovirals are needed to achieve long-term survival. It remains unclear when antiretroviral treatment should be initiated. Pharmacokinetic and safety data are limited in SAM and immune reconstitution inflammatory syndromes may occur early during treatment. A better implementation of, and linkage between, nutrition, HIV counseling and testing, prevention of mother–child transmission, cotrimoxazole and antiretroviral services will be critical to improving the outcome in those children living with HIV and their families.