The impact of HIV on the management of severe malnutrition in Malawi

Summary of published paper

There has been remarkably little published on the implications of HIV infection for emergency nutrition interventions.

HIV infection is common among children admitted for nutritional rehabilitation in non-emergency settings. Surveys of children admitted to malnutrition units have found an HIV seroprevalence ranging from 14% in Rwanda in 1989 to 49% in Zimbabwe in 1993/4 reflecting the increasing prevalence and burden of childhood HIV infection.

The findings of a recent study¹ in Malawi suggest that there may be important issues to be addressed regarding the treatment and management of HIV positive severely malnourished children. Many of these issues may have even greater relevance to emergency settings.

The study was undertaken in a central nutritional rehabilitation unit (NRU) in southern Malawi to assess the impact of HIV infection on clinical presentation and case fatality rates. HIV seroprevalence in 250 severely malnourished children over one year of age was 34.4% and overall mortality was 28%. A significantly higher proportion of children with marasmus (62.2%)were HIV positive than children with kwashiorkor(21.7%).

Breastfed children presenting with severe malnutrition were more likely to be HIVseropositive. Clinical features were generally not helpful in distinguishing HIV sero-positive from HIV sero-negative children. The case fatality rate was significantly higher for HIV seropositive children. Immunosuppression arising from HIV infection increases the risk of sepsis, already a common cause of death in malnourished children. Less direct effects were through an impact on the management of children, e.g. increased demands on limited nursing staff and food supplies, the added risk of certain types of infection in overcrowded units, and the sense of hopelessness that undermines staff morale and performance when faced with large numbers of children with poor prognosis.

Many staff felt that HIV infected malnourished children should be managed at home. Furthermore, in the general wards and outpatient clinics many marasmic children were seen who were not admitted to the NRU and once admitted were only kept in for short periods. Also, absence of HIV testing meant that an unknown number of marasmic children (failing to thrive owing to maternal sickness or TB) who were not infected with HIV were labelled clinically as HIV infected and managed from the perspective of having a poor prognosis.

The authors of the article conclude by discussing the increasing difficulties of managing the growing impact of HIV infection on severely malnourished children in Malawi in the context of reduced support for NRUs.

¹The impact of the human immunodeficiency virus type 1 on the management of severe malnutrition in Malawi: Kessler.L et al: Annals of Tropical Paediatrics (2000) 20, pp 50-56