The use of anthropometric indices as an alternative guide to initiating antiretroviral therapy (ART) in children at the Mildmay Centre in Uganda
Thesis (MNutr (Interdisciplinary Health Sciences. Human Nutrition))--Stellenbosch University, 2008.
Introduction: More than half a million children worldwide die from the Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) each year. In Uganda, HIV/AIDS is a major cause of infant and childhood mortality. Although the government of Uganda, through various strategies, has increased access to antiretroviral drugs (ARVs), resulting in national scaling up of accessibility to antiretroviral therapy (ART), initiation of ART in resource-limited areas remains a challenge due to constraints such as the absence of or limited number of CD4 machines and related laboratory constraints. Further scaling up of ART for children would be greatly strengthened by increased access to laboratory services for CD4 counts or the introduction of alternative indicators or guidelines for the initiation of ART. Aim: This study therefore set out to investigate, through the analysis of retrospectively collected data, whether anthropometric indices (wasting - weight for height; underweight - weight for age; and stunting - height for age) could provide a useful alternative guide when deciding about initiation of ART in children aged 2-12 years in the absence of sophisticated clinical and laboratory support. Methods: The study was conducted at the Mildmay Centre, an HIV/AIDS specialist centre located in Kampala, Uganda. Parameters such as the age at which children had been initiated onto ART, duration on ART, World Health Organisation (WHO) and Centre for Disease Control (CDC) disease stages at time of initiation, anthropometry at time of initiation, CD4% staging at time of initiation, support received from food aid programmes, referral to other health centres as a result of malnutrition and care-giver nutrition education/counselling were all determined retrospectively from clinical records. Results: It was found, based on CDC (2000) growth reference charts, that of the total number of children who took part in this study (N=125), 98.4% were mildly wasted, 52.8% mildly underweight and 75.2% mildly stunted when they were initiated onto ART. Of the children, who had WHO disease staging documented - 40% (N=50), the majority - 86% (N=43) were in WHO disease staging II and III during initiation of ART. and 96% (N=48) were mildly wasted. However, the relationship between WHO disease staging and wasting, underweight, and stunting at initiation of ART in children at the Mildmay centre was not significant. The relationship between CD4% and underweight or stunted children was also not significant. It was established however, that in the absence of CD4 laboratory parameters (since CD4% is vital in the initiation of ART in children) as is the case in resource limited areas, anthropometric indices (moderate to severe wasting, weight for height -W/H) could be used concurrently with CDC and WHO disease staging to initiate ART in children. However, it is important to note that anthropometric indices on their own cannot be used as a guide for initiating ART in children. Conclusion: Anthropometric status alone cannot be used to accurately determine when to initiate ART in children 2-12 years.