Background:
Africa carries the dual burden of malnutrition co-existing with HIV infection. Undernutrition
underlies almost half of the under-five childhood deaths while HIV/AIDS is
among the top 10 causes of childhood mortality. Though under-nutrition is an
essential problem in under-five children, it has also remained an important issue in
school-aged children from low income settings and has many adverse
consequences that can be immediate or long term. Under-nutrition is often
associated with macronutrient and micronutrient deficiencies. Iron deficiency, a
multisystem disorder leading to anaemia, is the commonest micronutrient deficiency
globally. Less commonly described micronutrients such as selenium deficiency
burden have not been clearly defined in children from low income setting particularly
ones with high HIV infection burden. In addition, there is very limited information
concerning important macronutrient deficiencies such as omega 3 fatty acids which
coupled with the multiple micronutrient deficiencies associated with under-nutrition
plus HIV infection contribute to poor growth and neurodevelopmental outcomes of
children.
The objectives of this thesis were to measure the prevalence of malnutrition,
anaemia, iron deficiency, selenium deficiency and describe the omega 3 fatty acid
status in HIV unexposed and HIV exposed (infected and uninfected) children 7 to 10
years old who were born in a national mother-to-child transmission of HIV infection
prevention programme (The BHAMC study) from a peri-urban setting in Zimbabwe, a
low income country with a high burden of HIV infection.
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Methodology: This cross-sectional study was a sub-study in the BHAMC study
which recruited mother-baby pairs between 2002 and 2004 and was designed to
assess impact of sexually transmitted infections on mother-to-child transmission of
HIV infection. The study was carried out at 3 peri-urban primary care clinics, just
outside Harare the capital city of Zimbabwe, offering maternal and child health
services from August 2011 to June 2012.
Main outcome measures- The main outcome measures were the nutritional
status(stunting, thinness, underweight, overweight), haemoglobin, serum Ferritin,
soluble transferrin receptor, serum selenium and omega 3 fatty acid levels
[Eicosapentaenoic acid (EPA), Docosapentaenoic acid (DPA) and docosahexaenoic
acid(DHA)]. The nutritional status was defined using the World Health Organization
(WHO) criteria for classifying nutritional status of children between 5 and 18 years.
Results: A total of 318 participants 7 to 10 years old were recruited of whom 21
(7%) were HIV infected, 116 (36%) HIV negative exposed and 180(57%) HIV
negative unexposed. Majority of the children were in the 8 and 9 year old age
groups. There were more female participants (57%). Prevalence of stunting,
thinness, underweight and overweight was 12%, 4%, 8% and 5% respectively.
Stunting was associated with HIV infection and exposure. Selenium deficiency
(<0.89μmol/L) was present in 129 (48%) children. Selenium deficiency was
associated with monthly household income below US$250 and was not related to the
participant’s HIV status. The prevalence of anaemia (Hb<11.5g/dL), iron deficiency
(Ferritin<15μg/L) and iron deficiency anaemia (Hb<11.5g/dL and either F<15μg/L or
sTfR>8.3μg/L) were 15%, 4% and 2% respectively. When a higher cut-off for ferritin
(<30μg/L) was applied, prevalence of ID and IDA increased to 32% and 5%
respectively. Anaemia was more likely to be present in HIV infected children (p-
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value<0.001) with an odds ratio of 4.9 (CI 1.9- 12.4). The 7 year old age group had
the lowest EPA levels. There was no difference in EPA, DPA and DHA levels by HIV
status, gender and nutritional status.
Conclusions and recommendations:
Chronic under-nutrition and selenium deficiency were common in these 7-10 year old
children, therefore nutrition programmes targeted for children above 5 years are
recommended in our setting and they should be continuous with the already present
nutrition programmes for under-fives. More research is required to ascertain
selenium status of all children from our setting including rural and urban children
above and below 5 years as this may guide the need for supplementation of this
micronutrient in our setting.
Prevalence of anaemia and ID were of mild public health significance. Anaemia
association with HIV infection calls for strengthening of mother-to-child transmission
of HIV prevention programmes in our setting as preventing HIV infection in children
could help reduce anaemia burden in children above 5 years. ID can be addressed
by teaching consumption of iron rich foods and fortification of basic foods.
This study did not find any differences in omega 3 fatty acid status by HIV status,
gender and nutritional status from a peri-urban setting with high burden of HIV and
under-nutrition. Further and larger studies are recommended that include urban and
rural children to ascertain the relationship of omega 3 fatty acid levels with HIV
status plus nutritional status.