Research<strong>Nutrition</strong>al Status ofHIV+ Pre-SchoolChildren inSouth AfricaSummary of unpublished researchNursing health professional doing clinicalinvestigation at Livningstone HospitalBy Liana Steenkamp, Dr Jill von derMarwitz, and Charlene GiovanelliLiana Steenkamp is a nutritionist currently basedat the HIV/AIDS Centre, University of PortElizabeth and since 2001, has been involved in HIVrelated research and training. She previously spent10 years working in various nutrition sectors of theDepartment of Health.Dr Jill von der Marwitz is Co-ordinator at theHIV/AIDS Centre, Faculty of Health Sciences,University of Port Elizabeth, Port Elizabeth, SouthAfrica.Charlene Giovanelli is a dietitian currently based atLivingstone hospital, Port Elizabeth.The contribution of M Minnaar, Sr Oliphant and DrMAI Khan in carrying out this study is gratefullyacknowledged.Sr Oliphant, South Africa, 2003In paediatric AIDS, nutritional status seems tobe of greater prognostic value than any particularopportunistic infection 1 . A number ofstudies conducted amongst HIV infected childrenin South Africa have found underweightprevalence figures of 25-30%, and figures of 55-60% for stunting 2,3 . These are much higher than theaverage percentages in a national survey conductedon children below 6 years of age, which indicatedthat 10% were underweight and 23% stunted4 .In the Eastern Cape, where the prevalence ofpoverty, TB and HIV is amongst the highest inSouth Africa, a recent study set out to determinethe impact of risk factors on the prevalence ofmalnutrition amongst HIV infected children. Itwas hoped that such information would assistdecision makers in the formulation of optimalnutrition strategies to limit the impact ofHIV/AIDS on the health of children.The study took place at the immunology(outpatient) clinic at Livingstone Hospital, in theEastern Cape, South Africa, between June andAugust 2003. One hundred and two HIV infected 5children, between the ages of 18 and 72 months,were included in the study. The children were ona standard regimen, receiving antibiotic (co-trimoxazole)prophylaxis, treatment of opportunisticinfections, therapeutic dosages of Vitamin A everyfour to six months and a daily multivitaminsupplement. None of the children received antiretroviraltreatment, as such treatment did not formpart of the government’s protocol for treatment atthe time of the study. The study was undertakenwith the informed and written consent from eachsubject’s parent/caretaker.Socio-demographic and nutritional data werecollected by trained, registered dietitians, assistedby a translator when necessary. This includedanthropometric measurements of height andweight, mid upper arm circumference (MUAC)and triceps skinfold thickness.Clinical assessment data, to determine the indicesof morbidity, were collated with the assistanceof registered health care professionals, whichincluded a paediatrician and a registered nurse.Findings<strong>Nutrition</strong>al statusThe children in the sample (mean age 40.7months) had a mean weight-for-age Z-score(WAZ) of –1.96 (SD=1.57), a mean height-for-ageZ-score (HAZ) of – 2.48 (SD=1.6) and a meanweight-for-height Z-score (WHZ) of –0.66(SD=1.53). Although half (50.9%) of the childrenwere underweight (WAZ < -2) and 58.8% werestunted (HAZ < -2), only 21.5% had a WHZ below–2. Eight children (7.8%) were severely malnourished(WHZ
Liana Steenkamp, S AfricaTaking forward research onadult malnutritionSummary of ongoing researchBy Laura Wyness, Researcher,University of Aberdeen, UKPRENResearchSkin lesions in a HIV positive child withmalnutritionSkin lesions in a HIV positive childwithout malnutritionstatus is acceptable. A large group which isvulnerable with low WAZ scores, but relativelygood WHZ scores, may therefore bemissed. The study indicates that in theabsence of comprehensive nutrition assessment,simple markers, like the presence ofchronic diarrhoea and loss of appetite, canbe used to refer these patients for a moredetailed nutritional screening to determinewhether they qualify for nutrition interventionin the form of supplementation.Education forms the cornerstone ofpreventative therapy and it is vitally importantthat parents/caretakers receivecomprehensive and accurate information.Patients seen by the health care providersmust be given health education at antenatalclinics regarding infant feeding and thedangers of early mixed feeding, especially ifinfants are HIV positive. Alternative remediesare currently aggressively beingpromoted in the popular media in preferenceto sound nutrition practices, which iscontributing to a great deal of uncertaintyamongst health care workers about alternativecomplementary therapies. This studyindicated no nutritional benefits are derivedfrom such practices. <strong>Nutrition</strong>al managementof disease complications, in particulardiarrhoea and anorexia need to be addressed,as these variables indicated a significantrelationship with malnutrition andwasting.For further information, contact: LianaSteenkamp, HIV/AIDS Centre, Faculty ofHealth Sciences, University of PortElizabeth, PO Box 1600, Port Elizabeth,6000, South Africa.Email: lianast@iafrica.com1Sun WY, Sangweni B. Rationale for <strong>Nutrition</strong>Support of Children with HIV/AIDS fromSocioeconomically Disadvantaged Families.Journal of Applied <strong>Nutrition</strong>. 1997; 49: 88 – 93.2Hussey, G and Eley, B. <strong>Nutrition</strong>al managementof Measles and HIV infection in children,1126 – 1136, Encyclopaedia of Human <strong>Nutrition</strong>,1998, Academic Press, London.3Eley B, Sive A, Abelse L et al. Growth andmicronutrient disturbances in stable, HIV-infectedchildren in Cape Town. Annals of TropicalPaediatrics 2002; 22: 19 – 23.4South African Vitamin A Consultative Group(SAVACG). Anthropometric, vitamin A, iron andimmunization coverage status in children aged6 – 71 months in South Africa, 1994. SouthAfrican Medical Journal. 1996; 86: 354 – 357.5As confirmed by Enzyme-linkedimmunosorbent assays.Liana Steenkamp, S AfricaAdult malnutrition was initially put on theagenda of the United Nations StandingCommittee on <strong>Nutrition</strong> (UNSCN)Working Group on <strong>Nutrition</strong> inEmergencies meeting in April 1999. The current positionof research in this area is that there is no consensuson standards or indices to assess malnutrition inadults in complex emergencies. At the UNSCNmeeting in 2001, research priorities, identifying stepsto improve the assessment of adult malnutrition,were agreed. Since then, the thematic group on adultmalnutrition within the working group has becomingincreasingly active. Work is now being taken forwardthrough a unique academic – NGO (non-governmentalorganisation) partnership, inter-linked by PREN(Partners for Research in <strong>Emergency</strong> <strong>Nutrition</strong>), arecently established collaborative research group atthe University of Aberdeen, (figure 1).Working in partnership with NGOs, bilateral andglobal organisations, PREN aims to carry out muchneeded epidemiological and evidence-based practiceresearch, driven by questions from the field, withinthe area of malnutrition in complex emergencies. AMemorandum of Understanding (MoU) has beendeveloped to provide assurance to all members involvedin the project on issues such as data ownership,publication, confidentiality and management of thearrangement.Figure 1: Project Partnership Working.HumanitarianScientific AdvisoryGroup (HSAG)HSAG is a neutral research platform and includes:• UNSCN <strong>Nutrition</strong> in Emergencies AdultTheme Group.•<strong>Emergency</strong> <strong>Nutrition</strong> Network (ENN)• Epicentre• Centre for Disease Control (CDC)NGOs Project Support Group includes membersof the participating NGOsPREN, University of Aberdeen.Questions atPopulationSurvey LevelQuestions atFeedingCentrePopulationLevelPRENNGOs(Project SupportGroup)Table 1AimsThe aims and objectives of the project were definedover several months through discussions betweenPREN and the HSAG. The main aims of the projectare first, to carry out a robust, standardisedSystematic Critical Literature Review (SCLR), toexplore the indicators of nutritional status availableto assess severe adult malnutrition. Secondly, to developtechniques for assessing routine, retrospectivefield data on severe adult malnutrition that has beencollected by different NGOs. This form of data isbeing used, as it will include a broad range ofcontexts and populations. This work will help achievethe third aim to develop a model to aid the assessmentof severe malnutrition in adults during complexemergencies.LiteratureThe SCLR will search for, quality assess andsummarise the evidence identified in the publishedand unpublished literature on methods currentlyused, and methods that could be used, to assess thenutritional status of adults during a complex emergency.The methods of nutritional assessment mayinclude anthropometric and functional indications,clinical signs, and contextual or situation indicators.Initial SurveyIn the initial stages of this project, a survey wasconducted to investigate the type of data collected byNGOs, the problems experienced when collecting thisdata and the format of the data. A total of 27 NGOswere contacted and asked to complete a questionnaire(response rate 60%). The findings from this surveywere used to inform the planning of the project.The current stage of the project is to request routineretrospective field data on severe adult malnutritionfrom NGOs. To facilitate the preparation of thedata for analysis, data from a few NGOs will beinitially requested, with other NGOs being contactedas required. The data initially requested will consistof databases of Therapeutic Feeding Programmes(TFPs) and nutritional surveys (on database andhardcopy, if available). Context variables will besought from Food Security Reports and Head ofMission Reports.Data AnalysisDescriptive statistics of each NGO’s dataset will becarried out and findings reported back to that particularNGO. Analysis of the data will be carried out attwo levels. The specific questions that the data willbe used to address are shown in table 1.Why do you find significant numbers of severely malnourished adults in some crises andnot in other crises?Do context factors give a direction of risk of severe malnutrition in an adult population,taking different levels of anthropometric measures as the dependent variable?Can context factors inform/help interpret and generalise findings from specific surveysdone in specific contexts?On a descriptive basis, analysis will be carried out on two levels, i) Acute and ii) Acute-onchronicemergency situations. Each level will aim to take into account the prevalence ofco-morbidities (e.g. HIV/TB).Are the associations found at the population survey level also seen at the TFP populationlevel, (i.e. what context factors characterise the situation in a TFP with significant numbersof severely malnourished adults)?How are context factors associated with different levels of anthropometric measures?This exciting partnership work hasenabled research on severe adult malnutritionto be actively taken forward.Completion of this project is planned aroundthe end of 2005. The project group willensure regular dissemination between fieldand academic areas.Project Research QuestionsFor further information contact: Laura Wyness,PREN Researcher (l.wyness@abdn.ac.uk) andDr Jane Knight, PREN Project Leader, (PREN@abdn.ac.uk)University of Aberdeen, Department of Public Health,Medical School, Polwarth Building, Foresterhill,Aberdeen AB25 2ZD, Scotland UK.Tel: +44 (0)1224 551883 Fax: +44(0)1224 55092511
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