THE EFFECT OF WASTING ON VIRAL SUPPRESSION AND MORTALITY OF HIV POSITIVE CHILDREN FOLLOWING INITIATION OF ANTIRETROVIRAL THERAPY AT BAYLOR-UGANDA
SSEGUJJA, BONIFACE JOSEPH
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Background: Under-nutrition/malnutrition has frequently been reported in HIV infected children with significantly high rates of the severe and moderate variant. Some reports indicate that over half of all children with HIV/AIDS (CLHIV) may also be suffering from severe undernutrition. It is clear that malnutrition negatively affects the immune system, making malnourished children vulnerable to infections and in those already HIV infected, quickening progression to AIDS. Initiation of Antiretroviral therapy (ART) in children with malnutrition is believed to improve their short term and long term outcome although the response in those without malnutrition is more optimal. It is possible that malnutrition may impair the immune response to ART, prolonging the period during which patients are at risk of opportunistic infection and directly or indirectly increasing the risk of death. Despite the presence of the comprehensive guidelines for care of malnutrition in People living with HIV (PLHIV), and the recent advance in the care of CLHIV, there has been limited study in the recent time to evaluate the effect of wasting on HIV viral suppression and mortality of HIV-positive children following initiation of ART at Mulago Hospital/Baylor College of Medicine Bristol Myers Squibb Children’s Clinical center of excellence (Baylor-Uganda). Objectives: This study sought to determine the prevalence of wasting in HIV positive children at the time of initiation of ART and its relationship with viral suppression and mortality following initiation of ART. Methodology: A retrospective cohort and cross-sectional study was conducted among 543 HIVpositive children initiated on ART from 1st January 2016 to 31st December 2017 in Baylor-Uganda at Mulago Hospital. Data was extracted from an electronic database and entered into excel and analysis was done using STATA Version 14. Continuous variables were summarized using means and standard deviations while categorical variables were summarized using frequencies and percentages. Bivariate analysis was performed to evaluate the association between wasting with viral suppression and mortality. The relationship between wasting and mortality was examined using Cox proportional hazards model. The Kaplan-Meier survival curve was used to estimate time to death in strata of child wasting status. Results: The mean (SD) age of the participants was 4.44(4.13) years;52.7% were male. Of the 543 participants, 155(28.5%) had wasting. Of those with wasting, 100/155 (65.5%) were severely xii wasted. Having severe wasting (Weight-for-Height Z-score (WHZ)/BMI-for-age Z-score (BAZ) ≤-3 SD) at ART initiation was associated with 2.11 times higher risk of having unsuppressed viral load by 6th months’ follow-up [OR 2.11 (95% CI 1.12-3.96)]. Overall mortality in the study was 61 out of 543 (11.2%). Children with moderate wasting (-3< WHZ/BAZ ≤-2 SD) had 3.25 times higher risk of death [HR 3.25 (95% CI 1.55-6.83)] and children with severe wasting (WHZ/BAZ ≤-3SD) had 5.47 times higher risk of death [HR 5.47 (95% CI 3.15-9.51)]. Conclusions and Recommendations: One in four children with HIV were wasted at ART initiation at Baylor-Uganda. Having severe wasting increased the risk of having unsuppressed viral load by 6th and 12th months’ follow-up. Wasting at the time of ART initiation was associated with increased risk of death, especially during the first 6 months after ART initiation. We recommend clinicians to be keen on assessment of nutritional status in HIV infected children initiating ART, so that those with severe wasting are closely monitored including assessment of viral loads. This is particularly important in the first 6 months of ART where majority of the deaths occur.