|Year : 2018 | Volume
| Issue : 1 | Page : 1-6
Nutritional status of perinatally HIV-infected children on antiretroviral therapy from a resource-poor rural South African community
Antonio George Lentoor
Department of Clinical Psychology, School of Medicine, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria, South Africa
|Date of Web Publication||2-Jul-2018|
Antonio George Lentoor
Department of Clinical Psychology, School of Medicine, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria
Source of Support: None, Conflict of Interest: None
Objective: In Sub-Saharan Africa, millions of children are suffering from HIV and coexisting child undernutrition. Despite efforts to curb the spread of HIV through the availability of treatment and various nutritional programmes, it has been argued that undernutrition remains highly prevalent in rural areas. The objective of this study was to describe the prevalence and psychosocial factors influencing the nutritional status in the sample of rural-based HIV-infected children on antiretroviral therapy. Materials and Methods: Anthropometric and home environment data were collected from 152 perinatally HIV-infected children on antiretroviral therapy who lived with their primary caregivers in a rural Eastern Cape community. Results: More than half of the sample of children had inadequate nutritional status. The prevalence of stunting particularly was high (36.2%), while 12% were underweight and only 2.7% presented with wasting. Coexisting poor quality home-environment (P < 0.01) added to this burden. Younger age children who lived with a younger biological caregiver were found to present more with stunting than older age children (χ2 [n = 152] = 14.79, P = 0.005), but no significant differences were observed for underweight or wasting. Conclusion: It is important in a context such as South Africa, with the double burden of HIV infection and poverty, that all efforts be directed at alleviating undernutrition. Early pediatric HIV management should not only focus on the provision of treatment but should also prioritize the quality of care of HIV-positive children in the home to improve on their nutritional health.
Keywords: HIV/AIDS, nutritional status, pediatrics, resource-poor setting, stunting, underweight, wasting
|How to cite this article:|
Lentoor AG. Nutritional status of perinatally HIV-infected children on antiretroviral therapy from a resource-poor rural South African community. Afr J Med Health Sci 2018;17:1-6
|How to cite this URL:|
Lentoor AG. Nutritional status of perinatally HIV-infected children on antiretroviral therapy from a resource-poor rural South African community. Afr J Med Health Sci [serial online] 2018 [cited 2018 Nov 20];17:1-6. Available from: http://www.ajmhs.org/text.asp?2018/17/1/1/235741
| Introduction|| |
Children from low-income families are particularly vulnerable to nutritional deprivation and are at increased risk of various medical and developmental deficits. The recent UNICEF, World Health Organization (WHO), World Bank global, and regional child malnutrition estimates from 1990 to 2017 revealed that developing countries, Africa and Asia, carry the greatest burden of all forms of nutritional disorders. The report estimates that globally, more than 150 million children under the age of 5 years suffer from stunting, while nearly 52 million are wasted and more than 40 million struggling with overweight and obesity. Undernutrition not only affects the physical health (i.e., immunological resistance creating vulnerability for disease and illness) of children but also jeopardises neurodevelopment through its adverse effects on brain development.
Globally, nutritional status is used as an appropriate measurement for gauging the well-being of children, and in particular, to identify those children who are at risk of disease vulnerability and developmental deficits. Childhood undernutrition can be classified clinically based on three nutritional indicators: low height for age (stunting), low weight for height (wasting), and low weight for age (underweight).
In low-income sub-Saharan countries where there is the burden of an already super-imposed medical condition such as HIV/AIDS, the vulnerability to adverse nutritional outcomes worsens; more so, due to the associated adverse effects of poverty. Children living with HIV are at greater risk for malnutrition. Stunting is reported to be the most common nutritional disorder affecting South African children's physical growth and cognitive development and is considered the strongest predictor of mortality in HIV-infected children below 5 years of age. Stunting is associated with chronic undernutrition, which has been found to create a physical vulnerability that weakens the immunity in children; impairing their ability to fight off opportunistic infections caused by HIV/AIDS, adding to an increased risk for premature death and vulnerability to other health-related challenges. Despite the observed pattern of change in child mortality and the efforts to bring about improvements with regard to the health and nutritional status of South African children over the years, through the availability of treatment and various nutritional programmes, the challenge of undernutrition remains constant for HIV-infected children with adverse health implications and premature mortality. It is against this backdrop that the researcher undertook this study to describe the patterns of nutritional status in the sample of rural-based HIV-positive children on antiretroviral treatment; and second, to describe some of the psychosocial factors influencing nutritional status among an already vulnerable group of HIV-positive children.
| Materials and Methods|| |
The research was conducted in a rural subdistrict of Eastern Cape province, South Africa. The Eastern Cape is one of the poorest provinces in South Africa, with high levels of under development and an unemployment rate of about 24.3%. A sample of 152 child/caregiver dyads were recruited through an invitation to both biological and nonbiological caregivers of children infected with HIV perinatally and treated on combination antiretroviral therapy (cART) in the pediatric department from one of the two local tertiary hospitals in the rural district.
Participants of the study were recruited through convenience sampling from the pediatric department of the respective pediatric HIV outpatient clinic (PHOC); they attended after the Head of the Department granted formal access. The research assistant addressed all caregivers in the general waiting area of the PHOC. Caregivers who showed interest in the study were directed to a private consulting room with the research assistant. The research was explained to the caregivers in English and isiXhosa (depending on the caregivers preferred use of language) by the researcher (clinical psychologist) and an isiXhosa speaking research assistant (clinical social worker) who both had prior experience of working with HIV/AIDS-infected children and parents. Each caregiver was informed that their participation or refusal in the study would not affect their child's treatment or quality of care at the health facility. All caregivers were provided with a consent form in both languages. Written informed consent was obtained from the caregivers once comprehended the nature of the study. Caregivers were informed of the availability of counseling and social-welfare services should the need for these arise.
All child measures were administered to the child in the presence of the caregiver. Caregivers completed a sociodemographic interview and home screening questionnaire (HSQ) in the privacy of their home, in the absence of the children to avoid distraction. To ensure the confidentiality of the participants, the names, locations, and any other identifying data were not reported. Ethical approval for the study was obtained from the University of KwaZulu Natal's Biomedical Research Ethics Committee (Protocol Number: BE252/11) and the Ethics Committee of the Hospital.
Sociodemographic information, as informed through a literature search of commonly associated socioeconomic factors that influence nutritional status of children from similar context, was collected.
The weight and height of the HIV-positive children were obtained in accordance with the WHO child growth standard procedures. Each child's weight was measured in kilograms (kg) to one decimal, using a Salter mechanical bathroom scale with an accurate 1 kg precision up to 120 kg capacity. The height of each child was then collected by measuring their length with an inelastic tape measure in a vertical position by having them stand barefoot on a flat surface against a wall, with the child's heel, buttock, and occiput making contact with the wall while standing. Their birth dates were taken from their hospital folders and were confirmed by asking caregivers the age of their child. Finally, their nutritional status (using the indicators stunting (height-for-age Z-scores [HAZ]), underweight (weight-for-age Z-scores [WAZ]), and wasting (weight-for-height Z-scores [WHZ]) were expressed as Z-scores of <−2 or more, standard deviations below the norm respectively, using the World Health Organization (WHO) child growth standards 2006 and WHO Reference 2007 Anthro software.
Home screening questionnaire
The HSQ was used to assess the overall quality of the home environment in which the children were reared. The 34-item questionnaire taps into home-environmental characteristics such as family activities, organization, discipline, and resources available for physical stimulation in the home. The HSQ has been widely used as a tool that identifies home environments likely to be suboptimal for child development in South Africa  and other developing countries. The HSQ demonstrated an acceptable reliability in this study sample of HIV-positive children, with a Cronbach's internal consistency reliability coefficient of 0.61.
The statistical package IBM SPSS Statistics for Windows, Version 21.0. was used to describe the mean HAZ, WAZ, and WHZ as well as the prevalence of stunting, underweight, and wasting. Pearson's (r) correlation was performed to determine the associations between the nutritional status, home environment, and sociodemographic factors. Group comparisons between biological and nonbiological caregiver, age of the caregiver, and gender of the child were conducted using independent sample t-tests. Differences between groups (biological vs. nonbiological caregiver) and child's age groups (3-level age groups 3–4, 5–6, and 6> years) were assessed using the one-way analysis of variance test. All tests conducted were two-tailed and held statistical significance at P < 0.05.
| Results|| |
Of all 152 HIV-positive children on ARV treatment in the study, over half (57.2%, n = 87) were girls with an age range of 31.38–92.78 months (mean age = 63.13) [Table 1]. The majority (63%, n = 96) of the HIV-positive children were living under the care of a single nonbiological adult relative caregiver such as grandmother. The average age of the caregiver was 45 years (65% were 36 years and above), with just over 60% having secondary education but being unemployed (89%) and only the government child social support grant as their main source of income (88.8%), while living in dense and overcrowded conditions (68%).
Nutritional status of the HIV-positive children
Of the 152 HIV-positive children on antiretroviral therapy studied in this research, 36.2% were stunted (n = 55), 12% were underweight 2.7% (n = 4) had wasting [Figure 1].
|Figure 1: Nutritional status of HIV-positive children in the study (n = 152)|
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Quality of home-environment
All of the HIV-positive children in the study lived in unfavorable home environments (n = 152, mean = 14.69, standard deviation [SD] = 3.22), with scores falling below 42 on the HSQ.
Psychosocial factors influencing the nutritional status of HIV+ children
A suboptimal home environment, child's age, caregiver type, and age was positively associated with children's nutritional status; weight for age (underweight) (r = 0.24, P < 0.01) and height for age (stunting) (r = 0.18, P < 0.05). This positive correlation was significantly stronger (t(150) = 2.88, P < 0.01 two-tailed) when raised by younger age (18–35 years) biological caregiver (r = 0.42, P < 0.01), in a dense and overcrowded (r = 0.19, P < 0.05) home environment lacking in optimal stimulation (P< 0.05). Besides caregiver and socioeconomic variables, younger age (3–4 years = [43.4%] children were found to present more with stunting than older (6 years-and above = [35%]) age children (χ2[n = 152] = 14.79, P = 0.005) but no significant differences were observed for underweight (χ2[n = 152] = 6.39, P = 0.171) or wasting (χ2[n = 152] =1.49, P = 0.475). Gender differences between boys (mean = 18.74, SD = 6.18) and girls (mean = 19.59, SD = 5.77) were not found to be significant for the children (χ2 [n = 150] =0.379, P > 0.05, two tailed) [Table 2].
|Table 2: Factors influencing nutritional status of HIV + children (n=152)|
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| Discussion|| |
In this study, the prevalence and the associated psychosocial factors that influence undernutrition of children infected with HIV were described. Consistent with other studies in developing countries, the finding revealed a high prevalence of undernutrition. The high prevalence of nutritional deficit in this sample is supported in other rural community-based studies among HIV-infected children on ARVs and treatment-naïve groups., In a previous study conducted in South Africa, HIV was associated with a significantly greater impact on stunting than on underweight and wasting. Similarly, a study in Tanzania among 213 HIV-positive and 203 HIV-negative children (age range 6–60 months) found 36.6% HIV-positive children had growth failure, while 22.1% were underweight, and only 13.6% were wasted. The study reported that HIV directly affects the immune system which can contribute to micronutrient deficiencies, increasing the risk for malnutrition in HIV-positive children. Growth failure has been found to be a risk factor for rapid HIV disease progression that impacts on childhood HIV-related morbidity and mortality. More so, it is associated with long-term adverse neurodevelopmental outcomes in children such as poor cognitive development and academic performance.
A higher prevalence of growth failure was associated with the HIV-positive children despite having adequate access to antiretroviral treatment, a finding supported elsewhere. Poor nutritional outcomes have been linked to food insecurity that was prevalent in over half of the ART-treated HIV-positive children's households living in dar es Salaam, Tanzania  and unhygienic environments with poor water and sanitation in South African HIV-positive children on cART. While some studies have argued that ART can mitigate the negative effects of HIV on child nutritional status, others have concluded that antiretroviral therapy treatment alone is not sufficient to safeguard HIV-positive children against malnutrition, especially because it coexists with socioenvironment, economic, and health-related risk factors. Thus, in the presence of contextual risk factors, HIV can directly exaggerate the impact of malnutrition in children. Perhaps, this could explain the high prevalence of nutritional deficits observed in the current sample despite the children having access to cART.
The finding from this study showed that the nutritional status of the HIV-positive children living in this rural community is influenced by multiple interrelated factors that can be categorized into child, caregiver, and socioenvironmental level factors. Younger age children had a greater risk for undernutrition than older age HIV-positive children. They had a greater vulnerability to growth retardation. Child age has also been documented in other studies as an important risk factor, with the greatest impact of HIV infection being on stunting rather than on underweight and wasting. Some research argues that the higher prevalence of stunting among younger age children than older age children may be linked to low birth weight, followed by catch-up growth in older years. Being a younger biological caregiver was implicated as a risk factor for undernutrition among HIV-positive children in this study. This is due to the indirect effects of maternal HIV. HIV-positive mothers were found to be at greater risk for opportunistic infections during pregnancy, which put them at greater risk of fetal growth retardation resulting in higher low birth weight deliveries compared to HIV-negative mothers. Some research concluded, in addition to biological characteristics such as maternal age (younger age), small maternal size and maternal infection, increased risk of child malnutrition is also linked to inexperience and inadequate childcare practices (for example, unhygienic and poor feeding practices). Maternal physical health and caregiving practices are important determinants of childhood health and development outcomes.
In this study, density and overcrowding were found to have a negative influence on nutritional status with HIV-positive children from larger households (>7 people) having a higher risk of being stunted and underweight than those from smaller households (<6 people). This is in agreement with other studies that found malnutrition was prevalent among children from large households with limited resources. In addition, coexisting poor quality home-environments, poor infrastructure, and limited financial resources added to the burden of undernutrition (P< 0.01) in the present study. From the finding, the conclusion can be drawn that the HIV-positive children were living in home environments that deprived them of optimal stimulation, which was associated with an increased risk of stunting and underweight, especially if they were young and living with their biological caregivers. Previous research shows that South African rural communities lack basic infrastructure and services, including clean water, sanitation, electricity and health-care support services relative to urban communities, which added to children's vulnerability for poor growth and long-term developmental dysfunction. It can be argued that the impact of HIV on children in poor-resource settings is compounded by the reality that many children are raised in conditions coexisting with poverty, poor infrastructure, and limited access to basic services that already disadvantage them.
Limitations entrenched in the present study need to be considered when interpreting the results. First, the data are cross-sectional, correlational, and descriptive in nature; therefore, they preclude drawing any conclusion based on causality and directionality. Second, given that this study was a convenience sample, the ability to generalize beyond the population is limited; as such, the finding may not be assumed for the entire rural population of children living with HIV/AIDS across South Africa. However, the large sample size of children with HIV infection and caregivers' adds to the strength of the study. The current findings suggest that additional research is necessary to fully understand the complex association between childhood HIV, socioecological vulnerabilities, and nutritional outcomes of children from communities with coexisting high levels of poverty.
| Conclusion|| |
This study highlights that malnutrition remains an important public health concern in poor-resource settings and every effort should be directed at finding interventions to mitigate against its adverse outcomes. Early pediatric HIV management, in addition to ART, should prioritize the quality of care of HIV-positive children in the home to improve their nutritional health. Nutritional support, better support to caregivers in the form of psychosocial counseling and nutritional education, infrastructure support, especially to rural communities, and home-based stimulation intervention should become part of the package of childcare.
The author would like to thank the study participants for their contribution to the research. The assistance of Ms Yvone Nte in collecting the data and Ms Martha for assisting with the editing of the manuscript is gratefully acknowledged.
Financial support and sponsorship
Partial financial support was received from the National Research Foundation. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Conflicts of interest
There are no conflicts of interest.
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