Prevalence of HIV Infection among Under 5 Children with Protein Energy Malnutrition presenting at Usmanu Danfodiyo University Teaching Hospital Sokoto Nigeria

Niger J Paed 2014; 41 (4): 341 - 344

ORIGINAL

Yusuf T

Prevalence of HIV-infection among

Jiya NM

Ahmed H

under-5 children with protein

Baba J

energy malnutrition presenting at

Haruna AS

Usmanu Danfodiyo University

Teaching Hospital, Sokoto, Nigeria

DOI:http://dx.doi.org/10.4314/njp.v41i4,10

Accepted: 9th June 2014

Abstract Background : HIV infec-

aged 12.0-23.9 months. Twenty-

tion is a major health problem

seven of the 100 children with

Yusuf T

(

)

worldwide. It is associated with

PEM had HIV-infection giving a

Jiya NM , Ahmed H, Baba J

Protein-Energy

Malnutrition

prevalence rate of 27%: 59.3% in

Department of Paediatrics,

(PEM) among under-5 children

males and 40.7% in females.

with attendant high morbidity and

Among the HIV-infected children,

Haruna AS

the 24.0 – 35.9 months age group

Department of Medical Microbiology

mortality.

Usmanu Danfodiyo University

Objective:

determine

the

was the most affected (53.8%).

Teaching Hospital,

prevalence

HIV-infection

Infected and non-infected children

Sokoto State, Nigeria.

among children presenting with-

were comparable in terms of age

( χ =7.35,

Email: dimei74@gmail.com

various subtypes of PEM.

p=0.12),

gender

( χ =0.36,

Methodology: Children suffering

p=0.55)

and

socio-

economic ( χ =3.01, p=0.25). The

from PEM aged below 5 years

admitted into the Paediatric units

mode of transmission was mater-

of UDUTH, Sokoto between Oc-

nal to child transmission in all

tober 1 , 2010 and April 30 ,

cases. The highest prevalence of

2011 were tested for HIV infec-

HIV infection was found among

tion using ELISA tests and HIV-

marasmus

subgroup

(65%).

DNA PCR. Nutritional status was

Twenty-two (81.5%) of the 27

determined using the modified

cases were discharged home, while

Wellcome Classification and so-

five patients died giving a case

cioeconomic classification was by

fatality rate of 18.5%.

the

scheme

developed

Conclusion: HIV infection is com-

Oyedeji’s. Data were analyzed

mon among under-5 children with

using SPSS 17.0 statistical pack-

PEM with no age, gender or socio-

age. P-value ≤ 0.05 was consid-

economic predilection. The clini-

ered significant.

cal type of PEM most often af-

Results:

One-hundred

under-5

fected is marasmus.

children (64 males, 36 females)

with PEM were studied. The

Key words: Protein-energy mal-

mean (±SD) age was 19.8± 9.2

nutrition, HIV-infection, Under-5

months and the majority were

Introduction

Human Immunodeficiency Virus infection is also a ma-

jor health problem facing the world today. As at the end

Protein-energy malnutrition (PEM) is a prevalent health

of 2010, about 34m people were living with HIV world-

condition among under-5 children in developing coun-

wide. This includes 3.0 – 3.8 million children aged ≤ 15

years, about 68% of whom live in sub-Saharan Africa .

tries, contributes directly or indirectly to almost half of

under-five mortalities globally . PEM is estimated to

HIV infection has a complex and intimate relationship

with PEM . The triad of weight loss, chronic diarrhoea

affect every fourth child in the developing world with

the regional prevalence range for the mild-moderate and

and prolonged fever are the major criteria for the diag-

severe forms of 20-40% and 1-10% respectively . Ac-

nosis of symptomatic HIV infection especially in

cording to the 2008 Nigerian Demographic and Health

resource-poor settings where laboratory diagnosis of

Survey , it was estimated that 41% of the under five

HIV is not always possible. Clinically, unexplained se-

children are undernourished in Nigeria with majority

vere wasting or severe malnutrition not responding to

seen in the Northwestern part of the country.

standard therapy is classified as Stage IV in paediatrics

342

HIV/AIDS clinical staging. Both severe malnutrition

North of the Equator. It shares borders with Niger Re-

and HIV have a deleterious effect on the immune system

public to the north, Kebbi State to southwest and Zam-

fara State to the east . Approval was sought and ob-

and their clinical presentations overlap with many simi-

larities. Studies have suggested that certain clinical fea-

tained from the Ethics Committee of the hospital and

tures and co-morbidities may be more predictive of HIV

written consent was also obtained from the parents/

infection in severe PEM

8-11

. These clinical features in-

guardians of the patients. The information obtained was

clude lymphadenopathy, oral candidiasis, skin disorders,

treated with confidentiality.

hepatomegaly, persistent diarrhoea, chronic discharging

The age, sex, weight of the subjects, the presence of

ears and prolonged fever.

oedema, the occupation and the educational level at-

HIV infection and its complications have been associ-

tained by the parents/guardians were documented. The

ated with nutritional disorders. Several studies both in

nutritional status and the socioeconomic class were clas-

sified using modified Wellcome Classification and the

Nigeria and other parts of Africa have shown that under-

Oyedeji’s socio-economic classification respectively.

nutrition (wasting) is a common presentation of HIV/

. Jiya and coworkers

AIDS in children

11-15

in 2010

The HIV status was confirmed using ELISA tests and

reported that 87.8% of the children admitted with HIV

HIV-DNA PCR (for those aged <18 months) after ob-

infection in Usmanu Danfodiyo University Teaching

taining parental/caregiver’s consent. The parents of the

Hospital, Sokoto had protein-energy malnutrition and

infected children were referred to the HIV Counseling

majority (58%) of them had marasmus. The cause of

and Testing Unit of the hospital for confirmation of their

undernutrition may be multifactorial including poor in-

HIV status. The results of the HIV test for the parents

take, GI malabsorption of nutrients, increased nutritional

were also documented and those who were positive were

requirement from high basal metabolic rate and psycho-

referred to Antiretroviral Treatment (ART) Clinic.

social problems such as poverty, and illness in biologi-

The data were entered and analyzed using SPSS 17.0

cal family members .

statistical package. Comparisons were made using chi-

square tests and a p-value of less than 0.05 was regarded

HIV infection among inpatients and children admitted

as statistically significant.

into nutrition rehabilitation units (NRUs) in sub-Saharan

Africa had been reported to be between 8.6-54%

8-11

However, Adeleke and his colleagues

reported HIV

infection in 22.6% of children admitted with PEM in

Results

Kano, Nigeria. The co-existence of PEM and HIV infec-

tion especially among under-5 children increases the

A total of one-hundred under-5 children with PEM were

morbidity and mortality among this age group, therefore

studied during the seven month study period. There

early detection of HIV infection will enhance reduction

were 64 (64%) males and 36 (36%) females giving a

of morbidity and mortality in both the children and their

male: female ratio of 1.8:1. The mean (±SD) age was

families. The current study was conducted to determine

19.8± 9.2 months with majority aged 12.0 – 23.9 months

the prevalence of HIV-infection among children present-

as shown in Table 1.

ing with PEM, its relationship with the clinical types of

Fifty-two of the 100 children had their HIV status con-

PEM at presentation and its outcome.

firmed with HIV-DNA Polymerase Chain Reaction

(HIV-DNA PCR) while that of the remaining 48 was

with ELISA test. Twenty-seven (27%) of the 100 chil-

dren with PEM were positive for HIV-infection. Among

Subjects and Methods

the 27 HIV-infected children, there were 16 males and

11 females with an M: F ratio of 1.45:1 ( χ =0.36,

The cross-sectional study was conducted among under-5

p=0.55) as in Table 1. The age group with the highest

children with protein-energy malnutrition who were

prevalence of HIV infection was 24.0 – 35.9 months

seen at the Emergency Paediatric Unit (EPU), Paediatric

(53.8%). All the HIV-infected under-5 children with

Outpatient Clinic and Paediatric Medical Ward of Us-

PEM were aged below three years as shown in Table 2.

manu Danfodiyo University Teaching Hospital, Sokoto

HIV infection was confirmed positive in all the mother

between October 1 , 2010 and April 30 , 2011. The

of the HIV infected children.

subjects were recruited consecutively till sample size

was achieved and all clinical types of PEM were equally

Table 1: Age distribution of children with Protein-Energy

represented. Thus, by design, the first 20 patients pre-

Malnutrition in relation to HIV study

senting with each form of malnutrition (underweight,

Age Group

HIV Status

marasmus, underweight-kwashiorkor, kwashiorkor and

months

HIV-Positive

HIV-Negative

Total

marasmic-kwashiorkor) were recruited into the study.

6.0 – 11.9

6 (33.3)

12 (66.7)

12.0 – 23.9

14 (21.2)

52(78.8)

The hospital is a tertiary health facility that serves as a

24.0 – 35.9

7 (58.3)

5 (41.7)

referral centre for people of Sokoto, Zamfara, and Kebbi

36.0 – 47.9

2 (100)

states; and the neighbouring Niger and Benin Republics

48.0 – 59.9

2 (100)

in the West African sub-region. Sokoto state is located

All

27(27)

73(73)

100

at the extreme part of North-western Nigeria between

Figures in brackets are percentages of total.

longitude 3 and 7° East and between latitude 10 and 14

χ =7.35, p= 0.12.

343

Table 2: Gender distribution and HIV Status of Under-5

Discussion

Children with PEM in UDUTH, Sokoto

3,19

HIV Status

Gender

HIV infection is a predisposing factor to PEM

. The

Female

Male

Total

co-existence of the two conditions increases the morbid-

ity and mortality in under-5 children . In the present

HIV-Positive

11(40.7)

16(59.3)

HIV-Negative

25(34.2)

48(65.8)

study, the prevalence of HIV infection among the mal-

All

36(36)

64(64)

100

nourished under-5 children was found to be 27%. This

Figures in brackets are percentages of total.

prevalence is comparable to 26.2% reported earlier by

χ 2 =0.36, p=0.55

Adeleke and colleagues

among children with PEM in

Kano, Nigeria and 29.2% overall prevalence reported by

Table 3 shows the socioeconomic status (SEC) of the

Fergusson et al in a meta-analysis of seventeen African

study subjects. About three-quarter of the malnourished

studies. However, the figure is lower compared to that

were low SEC, one quarter who infected with HIV. The

reported by Bachou and his colleagues

who reported

prevalence rates among the malnourished children of the

40% among Ugandan children with severe PEM. The

upper and middle SEC were 18.2% and 46.2% respec-

difference in the prevalence may be related to the differ-

tively. This differences in prevalence rates of HIV infec-

ence in the HIV prevalence in the general population in

tion according to SEC were not statistically significant

these areas. As at the end of 2012, 7.2% and 3.7% of the

( χ =3.01, p=0.25) as depicted on Table 3

population were living with HIV in Uganda and Nigeria

All the HIV-infected children with PEM presented with

respectively . There was no significant difference in the

prolonged fever, cough and chronic diarrhoea.

prevalence in relation to the age, gender and socio-

economic status as shown in this study. These factors

Table 3: The Socio-Economic Class of Children with Protein-

seem not to confer any protection against HIV infection

Energy Malnutrition in relation to HIV Infection

among the undernourished under-5 children. The most

Socio-Economic

HIV- Status

affected clinical type of PEM is marasmus as shown in

Class

HIV-Positive

HIV-Negative

Total

this study. This is consonance with the findings of ear-

lier workers

7-16

Upper

2(18.2)

9(81.8)

. HIV infection increases susceptibility to

Middle

6(46.2)

7(53.8)

recurrent opportunistic infections which in turn reduces

Lower

19(25)

57(75)

food intake, increases the basal metabolic rate, break-

All

27(27)

73(73)

100

down of muscle proteins, chronic diarrhoea and malab-

Figures in brackets are percentages of total.

sorption . This results in wasting culminating in PEM

χ =3.01, p=0.25

and increased morbidity and mortality among under-5s.

In view of this observation, there is need for increased

Table 4 shows that the prevalence of HIV infection was

index of suspicion of HIV infection in under-5 children

highest among patients with marasmus while no patient

presenting with marasmus and such should be offered

with kwashiorkor was infected.

HIV screening.

Twenty-three (85.2%) were commenced on antiretrovi-

ral drugs. Twenty-two (81.5%) of the 27 of the HIV

The most common mode transmission of paediatric HIV

positive patients were discharged to Paediatric HIV

-infection is vertical transmission i.e. mother-to-child

clinic of the hospital while 5(18.5%) died on admission.

transmission. In the current study, mothers of the HIV

Among the deaths, there were 4(80%) males and 1

infected patients were HIV positive. This suggests that

(20%) female ( χ =1.1, p=0.59); while all were aged less

all the cases of HIV-infection in this series were likely

than two years ( χ =12.0, p=0.002), 3(60%) presented

through mother-to-child transmission. This is compara-

with marasmus and 2(40%) with marasmic-kwashiorkor

ble to what has been reported in the literature

8-10

. This

( χ =7.3, p=0.83).

may imply low coverage of prevention of mother to

child transmission (PMTCT) interventions in our com-

Table 4: Types of Protein-Energy Malnutrition and HIV

munity. Therefore, there is need for more concerted ef-

Status among Under-5 with Protein-Energy Malnutrition

forts to strengthen coverage of PMTCT interventions in

Types of PEM

HIV-Status

our community. This, when implemented simultane-

HIV-Positive

HIV-Negative

Total

ously with other child survival strategies, will go a long

Marasmus

13(65)

7(35)

way in reducing the prevalence of PEM and indeed un-

Underweight

9(45)

11(55)

der-5 morbidity and mortality in our community in par-

Marasmic-Kwashiorkor 3(15)

17(85)

ticular and the country at large.

Underweight-

The mortality rate observed in the present study was

kwashiorkor

2(10)

18(90)

high but however lower than the earlier reported fig-

Kwashiorkor

20(100)

ures

10,11,21,23

. The high mortality rate may reflect the fact

All

27(27)

73(73)

100

that significant number of perinatally HIV-infected in-

Figures in brackets are percentages of total.

fants tend to have fast progression of the disease with

χ =29.73, p=0.0001

poor prognosis . Perhaps, the lower figure reported in

this study may be related to prompt detection and com-

mencement of antiretroviral drugs and control of co-

morbid conditions as majority of the diagnosed cases

were commenced on antiretroviral drugs while on

344

admission. The high mortality rate associated with HIV

Conclusion

infection co-existing with PEM could be related to the

combined deleterious effects of these conditions on the

In conclusion, there is high prevalence of HIV-infection

immune system namely acquired immunodeficiency

among under-5 children with PEM, mainly transmitted

syndromes (AIDS) and nutritionally acquired immune-

vertically, and the most affected clinical type of PEM in

deficiency syndromes (NAIDS).

7,9

These make them

this study was marasmus. There is need, therefore, to

susceptible to potentially life-threatening co-morbidities

provide counseling and testing for children with PEM,

like PTB, bacteraemia and diarrhoeal diseases which

especially those presenting with marasmus. This may

may worsen their chances of survival. It could also be

improve early detection and prompt treatment of chil-

related to the fact that HIV-infected children are more

dren with HIV infection and ultimately improves the

likely to have complicated case management issues like

outcome and survival of these children in our commu-

multiple pathology, drug-drug interactions and drug

nity. Furthermore, the prevention of MTCT of HIV in-

toxicities.

fection should be given urgent and very serious attention

in Nigeria.

Conflict of interest: None

Funding: None

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