**5. Nutrition as an adjunct therapy**

The introduction of therapeutic nutrition support and appropriate fluid rehydration has improved the rehabilitation process, shortened hospital stays of HIV-uninfected severely malnourished children, and addressed micronutrient and macronutrient deficiencies [19]. In the stabilization phase, F-75 is given as a therapeutic food. It is a low-protein milk-based formula diet. It is followed gradually by F-100 over a couple of days. The transitional phase until rehabilitation phase is reached. F-100 is a milk formula with higher protein and energy content than F75. However, the ready-to-use therapeutic food (RUTF) has replaced the F-100, especially in cases of severe acute malnutrition. In general, RUTF are pastes, no liquids, containing a combination of milk powder, electrolytes, and micronutrients. They provide the child with the same nutrients as F-100 plus iron [3, 4, 7]. As for rehydration, ReSoMal is commonly used. It contains approximately 45 mmol Na, 40 mmol K, and 3 mmol Mg per liter [19]. However, the metabolic and nutrient needs of HIV-infected children, in whom persistent anorexia is frequent, should be more clearly defined. In case of severe diarrhea often associated with high mortality rates, the provision of suitable feeding protocols is highly recommended. In brief, protocols for appropriate nutrition support therapy for severely malnourished infants below age 6 months are needed [23].

Although wasting can be treated in HIV-uninfected children with nutritional therapy alone, effective regimens for HIV-infected children need to be developed. The use of high-energy therapeutic nutrition support (e.g., F100 or RUTF) is part of standard care that can start the soonest regardless of the ART starting date. However, high mortality (38%), within 4–6 weeks, remains an issue. Many children will gain weight with nutrition support alone. Sometimes, CD4 cell count could be used to monitor the nutritional needs and to identify those needing treatment [15]. However, other reports pointed out that CD4 cell counts do not seem to improve after the provision of nutritional therapy. In brief, community therapeutic care methods, strengthened by local production of ready-to-use therapeutic foods, require fewer staff to run programs and ensure compliance. It is also worth noting that the HIV epidemic has generated a new group of children requiring nutrition rehabilitation unit-based care [20].

The situation becomes more complicated when opportunistic infections enter the picture, necessitating the use of anti-infective medications in malnourished children. Such drugs have a wide range of toxicity, which worsen the nutritional status of the children [18, 21]. Such children require urgent stabilization of multiple physiological parameters including hypoglycemia, dehydration, and electrolyte imbalance. Nutritional support is generally tailored to each case with consideration given to the rate of weight gain [10, 21].

Although interventions with multiple nutritional regimens increase energy and protein intake, in such situations, they led to no improvement in the morbidity and mortality rates compared to placebo. Observational studies have reported that the recovery from acute malnutrition and underweight using ready-to-use therapeutic food (RUTF) in populations of malnourished children, including some infected with HIV, was often complete with these products [2, 17, 19]. It was also noted that severe wasting makes the clinical assessment of dehydration difficult, so the presence of metabolic acidosis and lethargy are often the clinical indications available to prompt rehydration and nutritional interventions. Unfortunately, there are also currently inadequate data on the optimum regimen of supportive care (e.g., for shock) in the malnourished child who has adapted to a reduced body mass and organ system function. Appropriate dietary therapies are needed for this increasing population, as the standard F-75 and F-100 formulas are likely unsuitable [3, 21]; they might lead to the refeeding syndrome. Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding whether enterally or parenterally [19].

Besides, in Jesson and Leroy review, vitamin A was used as a primary therapy; it decreased pediatric mortality by 50% whatever the cause and improved short-term growth, in untreated HIV-infected children in Tanzania [2].

### **6. Antiretroviral therapy (ART) and nutrition**

It is well documented that the availability of highly active antiviral therapy (HAART) for the past two decades or so has decreased remarkably the mortality and morbidity of the disease in both adults and children, thus transforming it into a chronic infections disease [9]. The prognosis of HIV-infected children has markedly improved in the HAART era, both in terms of morbidity and mortality as mentioned earlier, despite the fact the mortality rate in HIV-infected children is still considerably higher than the pediatric general population [9, 23].

In Tanzania, when ART became available, the recovery was improved, especially when ART was initiated in children at the same time as nutritional support than when it was initiated later [2].

In the literature, there seems to be conflicting recommendations about when and how to begin nutrition support with ART. Some studies have reported that if ART

**23**

*HIV-Infected Children and Nutrition: The Friend and The Foe*

with limited resources with a higher two to three times risk of death.

resistance and/or safety issues [2, 5, 14].

in rural areas [21].

**7. Recommendations**

Nutritional evaluation, monitoring, and support are strongly recommended, especially at the initiation period and the first 2 months. Such measures proved to decrease morbidity and mortality [2, 10]. Children severely immunodeficient at initiation of ART may have a better growth outcome than nonimmunodeficient children at initiation. Children treated with ART become less immunodeficient, and their nutritional status improves [2]. In general, protease inhibitors (PI)-based treatments result in decreasing viral load, less resistant mutation, and better growth compared to non-PI-based regimens. Many authors focusing on this issue have reported that the earlier the treatment was initiated in children, the better the nutritional response in weight and height was [2, 23]. Malnourished children treated with ART may develop a kwashiorkor-like syndrome of IRIS (immune reconstitution inflammatory syndrome) [21]. However, in children with severe malnutrition, there has been a concern that standard dosing of ART may be inappropriate. This concern is based on the malnourishment metabolic alterations that could lead to subtherapeutic or toxic drug levels that may contribute to viral

Implementation challenges in starting and maintaining children on ART also persist and are found throughout the chain of care in sub-Saharan Africa, especially

In children, transmission of HIV through breastfeeding remains a problem. Efforts have moved in support of safer feeding by promoting exclusive breastfeeding for 6 months coupled with concomitant antiretroviral prophylaxis delivered to breastfeeding mothers or the infant [1, 18]. However, nutritional management of HIV-infected children remains a challenge in view of all the studies reviewed.

HIV-positive women living in resource-poor environments must balance opposing risks. In 2010, the WHO revised its position by recommending exclusive breastfeeding for the first 6 months of life followed by complementary foods and then accompanied by postnatal infant or maternal antiretroviral prophylaxis (WHO). In contrast,

is started when children have severe wasting due to malnutrition, they have higher rates of mortality compared to those with less clinical markers of malnutrition. However, studies were not conclusive about the time to start nutritional support [5, 15]. A recent retrospective study finding suggests that starting ART early in malnourished children results in higher rates of nutritional recovery and weight gain than if ART is delayed. In a study performed on a cohort of children in Africa, 59% of Zambian children were initially underweight and almost three quarters (72%) had slowed down or stopped growth when ART was administered. In these children, prominent improvements in both weight and height were recorded when nutritional support started in the initial stage after diagnosis at the same time as ART. In fact, the best increase was observed among children who were most underweight. Therefore, these lifesaving medications should not be delayed, and child health systems should embrace this approach in a programmatic manner [5, 21]. On the other hand, ART in children has been reported to result in metabolic disorders, which negatively affect the nutrition status, particularly, at the initiation and first few months of treatment. Such side effects include nausea, vomiting, dysregulated lipid metabolism [5, 11], low bond density, and increased fractures [11, 22]. Consequently, at the initiation of ART, the nutritional status must be evaluated, particularly that about half of the children taking such treatment will be underweight. Such a condition could lead to chronic malnutrition of about two-thirds of HIV-infected children in countries

*DOI: http://dx.doi.org/10.5772/intechopen.85417*

#### *HIV-Infected Children and Nutrition: The Friend and The Foe DOI: http://dx.doi.org/10.5772/intechopen.85417*

*Nutrition and HIV/AIDS - Implication for Treatment, Prevention and Cure*

rehabilitation unit-based care [20].

given to the rate of weight gain [10, 21].

The use of high-energy therapeutic nutrition support (e.g., F100 or RUTF) is part of standard care that can start the soonest regardless of the ART starting date. However, high mortality (38%), within 4–6 weeks, remains an issue. Many children will gain weight with nutrition support alone. Sometimes, CD4 cell count could be used to monitor the nutritional needs and to identify those needing treatment [15]. However, other reports pointed out that CD4 cell counts do not seem to improve after the provision of nutritional therapy. In brief, community therapeutic care methods, strengthened by local production of ready-to-use therapeutic foods, require fewer staff to run programs and ensure compliance. It is also worth noting that the HIV epidemic has generated a new group of children requiring nutrition

The situation becomes more complicated when opportunistic infections enter the picture, necessitating the use of anti-infective medications in malnourished children. Such drugs have a wide range of toxicity, which worsen the nutritional status of the children [18, 21]. Such children require urgent stabilization of multiple physiological parameters including hypoglycemia, dehydration, and electrolyte imbalance. Nutritional support is generally tailored to each case with consideration

Although interventions with multiple nutritional regimens increase energy and protein intake, in such situations, they led to no improvement in the morbidity and mortality rates compared to placebo. Observational studies have reported that the recovery from acute malnutrition and underweight using ready-to-use therapeutic food (RUTF) in populations of malnourished children, including some infected with HIV, was often complete with these products [2, 17, 19]. It was also noted that severe wasting makes the clinical assessment of dehydration difficult, so the presence of metabolic acidosis and lethargy are often the clinical indications available to prompt rehydration and nutritional interventions. Unfortunately, there are also currently inadequate data on the optimum regimen of supportive care (e.g., for shock) in the malnourished child who has adapted to a reduced body mass and organ system function. Appropriate dietary therapies are needed for this increasing population, as the standard F-75 and F-100 formulas are likely unsuitable [3, 21]; they might lead to the refeeding syndrome. Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished

patients receiving artificial refeeding whether enterally or parenterally [19].

growth, in untreated HIV-infected children in Tanzania [2].

considerably higher than the pediatric general population [9, 23].

**6. Antiretroviral therapy (ART) and nutrition**

Besides, in Jesson and Leroy review, vitamin A was used as a primary therapy; it decreased pediatric mortality by 50% whatever the cause and improved short-term

It is well documented that the availability of highly active antiviral therapy (HAART) for the past two decades or so has decreased remarkably the mortality and morbidity of the disease in both adults and children, thus transforming it into a chronic infections disease [9]. The prognosis of HIV-infected children has markedly improved in the HAART era, both in terms of morbidity and mortality as mentioned earlier, despite the fact the mortality rate in HIV-infected children is still

In Tanzania, when ART became available, the recovery was improved, especially when ART was initiated in children at the same time as nutritional support than

In the literature, there seems to be conflicting recommendations about when and how to begin nutrition support with ART. Some studies have reported that if ART

**22**

when it was initiated later [2].

is started when children have severe wasting due to malnutrition, they have higher rates of mortality compared to those with less clinical markers of malnutrition. However, studies were not conclusive about the time to start nutritional support [5, 15]. A recent retrospective study finding suggests that starting ART early in malnourished children results in higher rates of nutritional recovery and weight gain than if ART is delayed. In a study performed on a cohort of children in Africa, 59% of Zambian children were initially underweight and almost three quarters (72%) had slowed down or stopped growth when ART was administered. In these children, prominent improvements in both weight and height were recorded when nutritional support started in the initial stage after diagnosis at the same time as ART. In fact, the best increase was observed among children who were most underweight. Therefore, these lifesaving medications should not be delayed, and child health systems should embrace this approach in a programmatic manner [5, 21].

On the other hand, ART in children has been reported to result in metabolic disorders, which negatively affect the nutrition status, particularly, at the initiation and first few months of treatment. Such side effects include nausea, vomiting, dysregulated lipid metabolism [5, 11], low bond density, and increased fractures [11, 22]. Consequently, at the initiation of ART, the nutritional status must be evaluated, particularly that about half of the children taking such treatment will be underweight. Such a condition could lead to chronic malnutrition of about two-thirds of HIV-infected children in countries with limited resources with a higher two to three times risk of death.

Nutritional evaluation, monitoring, and support are strongly recommended, especially at the initiation period and the first 2 months. Such measures proved to decrease morbidity and mortality [2, 10]. Children severely immunodeficient at initiation of ART may have a better growth outcome than nonimmunodeficient children at initiation. Children treated with ART become less immunodeficient, and their nutritional status improves [2]. In general, protease inhibitors (PI)-based treatments result in decreasing viral load, less resistant mutation, and better growth compared to non-PI-based regimens. Many authors focusing on this issue have reported that the earlier the treatment was initiated in children, the better the nutritional response in weight and height was [2, 23]. Malnourished children treated with ART may develop a kwashiorkor-like syndrome of IRIS (immune reconstitution inflammatory syndrome) [21]. However, in children with severe malnutrition, there has been a concern that standard dosing of ART may be inappropriate. This concern is based on the malnourishment metabolic alterations that could lead to subtherapeutic or toxic drug levels that may contribute to viral resistance and/or safety issues [2, 5, 14].

Implementation challenges in starting and maintaining children on ART also persist and are found throughout the chain of care in sub-Saharan Africa, especially in rural areas [21].

#### **7. Recommendations**

In children, transmission of HIV through breastfeeding remains a problem. Efforts have moved in support of safer feeding by promoting exclusive breastfeeding for 6 months coupled with concomitant antiretroviral prophylaxis delivered to breastfeeding mothers or the infant [1, 18]. However, nutritional management of HIV-infected children remains a challenge in view of all the studies reviewed.

HIV-positive women living in resource-poor environments must balance opposing risks. In 2010, the WHO revised its position by recommending exclusive breastfeeding for the first 6 months of life followed by complementary foods and then accompanied by postnatal infant or maternal antiretroviral prophylaxis (WHO). In contrast,

the American Academy of Pediatrics recommends that HIV-infected mothers not to breastfeed their infants, regardless of maternal disease status, viral load, or ART and the British HIV association concurs [1, 18].

The important issue is to meet all nutrient needs and provide the required energy requirements. However, according to the WHO, some considerations are needed for safely replacing food. Such considerations are based on the fact that untreated HIV-infected patients have an increased resting energy expenditure, decreased appetite, digestion of food, and absorption of nutrients. In brief, such patients often have a range of micronutrient deficiencies. However, there are no evidence-based guidelines on the appropriate types and amounts of micronutrient supplements for HIV-infected children. The WHO has previously endorsed the use of ready-to-use therapeutic foods to reduce mortality and undernutrition [18].
