5th Francophone Conference on HIV/AIDS: report back on sessions
Maternal health and responding to HIV: same struggle!
Measuring malnutrition in a cohort of HIV-exposed newborns fed infant formula in West Africa
Cartoon bubble and slogan contest results
Growing Up Info is published by
Développement and Sol En Si.
This issue’s contributors are:
Dr David Masson:
Many thanks to the GROWING Up technical committee for their advice and editing.
The 5th Francophone Conference on HIV/AIDS held in Casablanca from March 28 to 31, 2010 dedicated several sessions to the critical issues in the management of pediatric HIV.
Safer breastfeeding with ARVs
Taking ARVs while breastfeeding was underscored once again as an effective method of preventing HIV transmission from mother to child: this WHO-recommended policy is becoming the most appropriate one for resource-limited countries given the difficulties in implementing replacement feeding. However, this strategy requires that protagonists pay renewed attention to following up mothers and children. Efforts to improve the availability and feasibility of feeding infants formula should continue and staff should receive help and support to overcome the practical obstacles they face as they try to implement safer breastfeeding.
Early treatment for HIV-infected newborns: WHO guidelines difficult to implement
The WHO recommends that all infants under the age of 12 months should be started on ARVs once an HIV diagnosis has been made regardless of clinical stage and immune status. In the absence of an early diagnosis through PCR it is recommended that infants under 12 months presenting with symptoms of HIV infection should be started on HAART. But implementation of this policy is difficult especially because ARVs in pediatric formulations are not appropriate; one study already showed the difficulties in implementing this strategy. Early results of the PEDIACAM study, currently underway in Cameroon involving infants under 7 months old reveal a relatively high proportion of precocious mortality despite treatment. These preliminary results deserve to be closely watched!
Teenagers living with HIV and the transition from pediatric to adult services
Pediatric care and treatment services in the global South are seeing more and more teenagers in their patient flow, including young adults, and this is because of improvements in care and treatment (better availability of ARVs, better medical and laboratory follow up). Over the years, these teenagers have developed trusting relationships with healthcare staff; they can feel worried or anxious about making the transition to adult infectious disease services. This transition can have both psychological and medical consequences including fear of abandonment, feelings of aggression, depression, not showing up for appointments, or even going so far as to not take their medicines on schedule or to stop taking them altogether. Delays in growth observed in some teenagers in Southern countries can cause physical complexes that do not facilitate the transition of a young person with a « child’s body » into adult services. This resistance has also been seen in parents and healthcare staff because they feel that these strong bonds with staff enable better monitoring of their children.
A solution—transition counseling sessions: to facilitate this transition, the Saint-Pierre University Hospital in Brussels created transition counseling within its adult services wing. Taking into consideration the specific needs of young people, the program includes designated counselors, flexible schedules and greater availability.
A study published in April’s issue of The Lancet gave an overview of maternal mortality in 181 countries. Every year 340,000 women die during pregnancy, while giving birth or shortly thereafter. However, this figure is globally decreasing. The rate of maternal mortality is decreasing in several Southern countries. Unfortunately, little to no progress has been made over the last ten years in most countries in subsaharan Africa.
According to the study’s authors, HIV infection is one of the root causes of this high rate of maternal mortality especially in South Africa. Without HIV, 60,000 maternal deaths would be avoided each year. The fight against AIDS and the fight for access to prenatal, obstetric and postnatal quality care are two battles to be fought simultaneously for women health.
With this in mind Sidaction and ID support the “Non-assistance to endangered mothers” campaign launched by Oxfam France, Doctors of the World, Action for Global Health and Lawyers for World Health. Illustrated by the maternal health issue, this citizen’s mobilizations initiative is asking for an increase in aid to developing healthcare systems, with an emphasis on reinforcing health personnel in the South as well as supporting policies of free access to care for the most vulnerable, particularly women and children. We invite you to sign the petition at: santepourtoutes.org !
To find out more:
The study in The Lancet on maternal mortality: http://www.thelancet.com/
« Non-assistance to endangered mothers»: http://www.santepourtoutes.org/
Growing Up program studied weight progression in children enrolled in nutritional support programs that are funded by Growing Up to evaluate these programs’ impact. The study’s goal was to determine the prevalence of malnutrition in a cohort of 88 newborns under a year old that were being fed infant formula from 0 to 12 months of age and receiving fortified flour from 7 to 12 months (the infant formula and fortified flour were donated by the Growing UP program). These babies were monitored at a community HIV health center and the study was conducted in real life conditions with monitoring data collected by caregivers between March 1, 2007 and December 5, 2008 (this was neither operational research nor a planned study with a protocol designed in advance)
The overall analysis was based on WHO’s weight for age index. The longitudinal index of W/A of three sub-groups of children— infants enrolled in the program during their first weeks of life, infants enrolled during weaning and babies suffering from malnutrition at enrollment were also observed.
We analyzed a total of 473 of W/A measurements corresponding to 520 food distributions. Each measurement was compared to the 2006 WHO standards. A cohort was created in the WHO Anthro software and completed with Excel.
The main results of the study are:
Infants’ conditions when they were enrolled in the study according to age category
0-3 month old infants
23 infants in their first trimester of life were enrolled 21 were weighed before being receiving nutritional support: 7 (33%) had a W/A <-3 DS which corresponded to acute malnutrition or delay in intra uterine growth (Intra Uterin Growth Retardation-IUGR) or prematurity; 3 (14%) had a W/A between -3 and -2 DS, or 47% who presented a W/A ratio indicating pathology.
3-6 month old infants
29 infants were enrolled during their 2nd trimester of life, 27 were weighed before receiving nutritional support: 2 (7%) had a W/A of <-3 DS (and even <-4 DS); 6 (22%) had a W/A between -3 and -2 DS, or 30% who presented a W/A indicating pathology. However, severe malnutrition was clearly less prevalent.
6 to 9 month old infants
32 infants were enrolled during their 3rd trimester of life, 31 were weighed before receiving nutritional support: 5 (16%) had a W/A <-3 DS; 5 (16%) had a W/A <-2 DS, or 32% who presented with a W/A indicating pathology.
Babies over 9 months of age
4 babies were enrolled between 9 and 10 months of age ½. 3 presented with a pathological W/A.
Progession of an average W/A for the most severely malnutritioned infants
14 babies presented with a W/A of < -3 DS when they were enrolled. The average W/A index of this group improved from -4,0 DS at enrollment to -2,6 DS after 4 months of care. Still, 3 babies’ conditions in this sub-group (over 20%) continued to deteriorate despite nutritional support.
Progression of W/A for babies enrolled before they have reached two months
We can observe an improvement in the average W/A during the first two months after which it stagnates. The average W/A indicators of this sub-group are ½ DS below the average of the total of the cohort. There are also large interindividual variations with more than 40% of the babies’ W/A decreasing after two months of care.
Progression of W/A around the weaning period
Infants enrolled in the program between 5 and 7 months, had an overall W/A that was better than that of infants enrolled in the program during their first weeks of life. The many variations are due to staff inadequacies. When we look at the overall results, we can see an improvement that is stable after 8 months of life.
Progression of the mean W/A
For the entire cohort, for the 83 infants who were initially weighed, the mean W/A is around -1,5 DS at enrollment. After an initial improvement in the overall nutritional state of the cohort for the first 2 months there seems to be a stagnation between -1,2 et -1,3 DS.
While these results should be carefully interpreted, 30% infants with a W/A < -2DS at the time of enrollment shows the importance of nutritional support in caring for HIV-exposed children.
It is probable that newborns and very young infants with a delay in growth (the most severely malnutritioned and the most frequently seen in this cohort), regardless of the cause, would benefit from being monitored more closely so as to adapt the quantity and quality of their food to their weight gain.
Moderate failure to gain weight (16%) or severe failure to gain weight (16%) in infants enrolled during weaning seems to confirm that a non negligeable proportion of breastfed infants develop a failure to gain weight during the first six months of life, in the absence of specific nutritional monitoring.
After enrolling in this program we observe in the entire cohort an improvement during 2 months followed by a flattening out of the weight curve at between -1,2 et -1,3 DS, as if the nutritional supplements were suboptimal. In fact there is a very large dispersion in the distribution of indices and it seems that age, nutritional status at entry and other factors such as immune status influence weight change. In particular, severe malnutrition occurring in newborns or very young infants persists for several months before gradual recovery.
This brief analysis which highlights the importance of malnutrition among children exposed to HIV, can help identify certain trends and issues that should be explored.
The nutritional supplements that this program distributes provide sufficient quantities based on theoretical caloric intake. These products improve the overall nutritional status of the cohort of children enrolled in the program. However, individual results are poor in infants where malnutrition is present at inclusion and combining medical and nutritional care is appropriate in these cases. This implies that children should be weighed, but also that their growth must be analyzed before products are distributed to help children who are behind in their growth or whose growth curves have flattened out to follow up with a nutrition specialist (CREN or pediatric consultation).
Further studies are needed to more rigorously determine the prevalence of acute malnutrition (weight for height) and retarded growth (size / age) among children exposed to HIV. The optimal nutritional strategies remain problematic, especially when malnutrition occurs before the age of introduction of complementary feeding among breastfed children. Finally, recommendations on combining medical care and nutritional support should be developed and disseminated.
To find out more:
Results tables as well as the complete study will soon be available on the GROWING UP website www.grandir.sidaction.org
In the context of the “fathers getting tested for HIV” campaign that we would like to support for our partners in Africa we held a cartoon bubble and slogan contest among our readers. Thank you for your participation! None of the ideas that were sent in completely matched the poster’s intent-- to create awareness among men about the importance in general of getting tested for HIV and the particular importance of testing during the pregnancy of their partner—so we created messages based on all of your contributions (see below).
This poster will be distributed to the partner associations of GROWING UP.