Effect of Age at Antiretroviral Therapy Initiation on Catch-up Growth Within the First 24 Months Among HIV-infected Children in the IeDEA West African Pediatric Cohort

Abstract

Background We described malnutrition and the effect of age at antiretroviral therapy (ART) initiation on catch-up growth over 24 months among HIV-infected children enrolled in the IeDEA West African paediatric cohort (pWADA). Methods Malnutrition was defined at ART initiation (baseline) by a Z-score <-2 SD, according to three anthropometric indicators: Weight-for-age (WAZ) for underweight, Height-for-age (HAZ) for stunting, and Weight-for-Height/BMI-for-age (WHZ/BAZ) for wasting. Kaplan-Meier estimates for catch-up growth (Z-score ≥-2 SD) on ART, adjusted for gender, immunodeficiency and malnutrition at ART initiation, ART regimen, time period and country, were compared by age at ART initiation. Cox proportional hazards regression models determined predictors of catch-up growth on ART over 24 months. Results Between 2001 and 2012, 2004 HIV-infected children < 10 years of age were included. At ART initiation, 51% were underweight, 48% were stunted and 33% were wasted. The 24-month adjusted estimates for catch-up growth were 69% (95% confidence interval [CI]: 57;80), 61% (95%CI: 47;70), and 90% (95%CI: 76;95) for WAZ, HAZ, and WHZ/BAZ, respectively. Adjusted catch-up growth was more likely for children <5 years of age at ART initiation compared to children ≥5 years for WAZ, HAZ (P<0.001), and for WHZ/BAZ (P = 0.026). Conclusions Malnutrition among these children is an additional burden that has to be urgently managed. Despite a significant growth improvement after 24 months on ART, especially in children <5 years, a substantial proportion of children still never achieved catch-up growth. Nutritional care should be part of the global healthcare of HIV-infected children in sub-Saharan Africa.

Stunting and growth velocity of adolescents with perinatally acquired HIV: differential evolution for males and females. A multiregional analysis from the IeDEA global paediatric collaboration

“…In our cohort, late age at ART initiation was strongly associated with stunting and poor HAZ evolution. This finding has been observed in many other studies, but mostly among children younger than age 10 years . Children who spend their first years of life with HIV without ART may have chronic inflammation due to uncontrolled HIV, which can affect growth.…”

Challenges of malnutrition care among HIV-infected children on antiretroviral treatment in Africa

“…Finally, even if all HIV-infected children presented a nutritional recovery with ART, with a significant gain in weight and height, the nutritional status was not completely restored for a significant number of children who remained malnourished, even after 1 to 2 years of treatment [24,31,33,34,38,41,47,51]. Thus, ART alone is not sufficient and specific interventions are needed to improve the nutritional care of HIV-infected children.…”

“…Finally, the age at which ART is initiated in a child may influence the nutritional response. Many authors focusing on this issue have reported that the earlier the treatment was initiated in children, the better was the nutritional response in weight [32,33,37,38,41,42,47] and height [38,42,47,48]. However, some authors reported no effect of age on the nutritional response to treatment [31,45] or even a lower growth in younger children [32].…”

Growth in HIV‐infected children on long‐term antiretroviral therapy

“…Previous studies consistently describe improved weight outcomes for younger children , possibly related to less severe gastrointestinal impairment and shorter duration of chronic immune activation . Reports on the impact of age on height differ between studies, with improved height outcomes with younger age in some studies , while others reported no difference or worse height outcomes for younger children . HIV‐infected children are increasingly reaching adulthood due to the availability of ART; therefore, studies to evaluate the impact of age at ART initiation on the timing and magnitude of the pubertal growth spurt and final adult height are needed.…”