The benefit of supplementary feeding for wasted Malawian adults initiating ART

Abstract

Food insecurity is considered to be an important contributor to HIV associated wasting in sub-Saharan Africa. Low body mass index (BMI) is a strong risk factor for early mortality during antiretroviral therapy (ART). Nutritional supplementation has become standard of care in wasted patients starting ART in many countries in the region, but there is no unequivocal evidence base for this intervention. Against this background, we performed a retrospective study to compare food supplementation versus no nutritional intervention in wasted adults starting ART in Blantyre, Malawi. All patients received free nevirapine, lamivudine, and stavudine. Participants in an effectiveness trial of two food supplements received either corn-soy blend (CSB) or ready-to-use food spread (RUFS) during the first 14 weeks of ART. Results were compared with a historical control group receiving no food supplement that was part of an observational cohort study of outcomes of the same ART regimen. Characteristics on initiation of ART were similar in the three groups, except the use of cotrimoxazole prophylaxis which was more frequent in the food-supplemented groups. Linear regression analysis showed that increase in BMI was greatest in the RUFS group and better in the CSB group than in those receiving no food supplementation at 14 weeks. These differences were no longer significant at 26 weeks. Lower BMI, CD4 count and hemoglobin, WHO clinical stage IV, male gender, and not receiving cotrimoxazole prophylaxis were independent risk factors for mortality at 14 and 26 weeks in the logistic regression analysis. Supplementary food use was not directly associated with improved survival.

Effect of cotrimoxazole on mortality in HIV-infected adults on antiretroviral therapy: a systematic review and meta-analysis

“…Of the nine, seven reported an estimate for the effect of cotrimoxazole on mortality, [28][29][30][31][32][33][34] whereas three reported an estimate for the effect on morbidity. 28,35,36 Two studies also reported the preventive effect on malaria.…”

“…28,35,36 Two studies also reported the preventive effect on malaria. 28,36 Assessment of publication bias indicated that three studies [28][29][30] were of high methodological quality, while the other six [31][32][33][34][35][36] were of moderate methodological quality (Table 4, available at: http://www.who. int/bulletin/volumes/90/2/11-093260).…”

“…The summary estimate of the effect of cotrimoxazole on the incidence rate of death derived using a random-effects model was 0.42 (95% confidence interval, CI: 0.29-0.61). Survival was increased by either continuing cotrimoxazole at ART initiation, 29,[33][34][35] initiating cotrimoxazole at the same time as ART 29,34 or initiating cotrimoxazole when the patient was stable on ART.…”

Food Security and Nutrition Interventions in Response to the Aids Epidemic: Assessing Global Action and Evidence

“…Another randomized supplementary feeding trial in Malawi compared the impact on BMI and fat-free body mass of wasted HIV patients starting ART who were supplemented with specialized, energy dense, ready-to-use, fortified (RUF) spread versus the more commonly used corn-soy blend (CSB) for a short duration of 14 weeks and a historical control group [40,41]. Supplementary feeding with the RUF resulted in a greater increase in BMI and lean body mass than feeding with CSB, but there were no significant observed differences in markers of disease progression, quality of life, or adherence to ART between RUF and CSB groups.…”

Food supplementation among HIV-infected adults in Sub-Saharan Africa: impact on treatment adherence and weight gain

“…In two studies the effect of WFP food rations were examined (42,45) . In these studies both study populations were ART naive, which may account for the small-to-modest increases in BMI observed (0·6 and 0·49 kg/m 2 , respectively).…”