HIV This Week

Thurstans S, Kerac M, Maleta K, Banda T, Nesbitt A. HIV prevalence in severely malnourished children admitted to nutrition rehabilitation units in Malawi: Geographical & seasonal variations A cross-sectional study A cross-sectional study. BMC Pediatr. 2008;8:22.

Severe malnutrition in childhood associated with HIV infection presents a serious humanitarian and public health challenge in Southern Africa. The aim of this study was to collect country wide data on HIV infection patterns in severely malnourished children to guide the development of integrated care in a resource limited setting. A cross sectional survey was conducted in 12 representative rural and urban nutrition rehabilitation units, from each of Malawi’s 3 regions. All children and their caretakers admitted to each nutrition rehabilitation unit over a two week period were offered HIV counselling and testing. Testing was carried out using two different rapid antibody tests, with PCR testing for discordant results. Children under 15 months were excluded, to avoid difficulties with interpretation of false positive rapid test results. The survey was conducted once in the dry/post-harvest season, and repeated in the rainy/hungry season. 570 children were eligible for study inclusion. Acceptability and uptake of HIV testing was high: 523 (91.7%) of carers consented for their children to take part; 368 (70.6%) themselves accepted testing. Overall HIV prevalence amongst children tested was 21.6% (95% confidence intervals, 18.2-25.5%). There was wide variation between individual nutrition rehabilitation units: 2.0-50.0%. Geographical prevalence variations were significant between the three regions (p<0.01) with the highest prevalence being in the south; Northern Region 23.1% (95%CI 14.3-34.0%), Central Region 10.9% (95%CI 7.5-15.3%) and Southern Region 36.9% (95%CI 14.3-34.0%). HIV prevalence was significantly higher in urban areas, 32.9% (95%CI 26.8-39.4%) than in rural 13.2% (95%CI 9.5-17.6%)(p<0.01). Nutrition rehabilitation unit HIV prevalence rates were lower in the rainy/hungry season 18.4% (95%CI 14.7-22.7%) than in the dry/post-harvest season 30.9% (95%CI 23.2-39.4%) (p<0.001%). There is a high prevalence of HIV infection in severely malnourished Malawian children attending nutrition rehabilitation units with children in urban areas most likely to be infected. Testing for HIV is accepted by carers in both urban and rural areas. Nutrition rehabilitation units could act as entry points to HIV treatment and support programmes for affected children and families. Recognition of the wide geographical variation in childhood HIV prevalence will ensure that limited resources are initially targeted to areas of highest need. These findings may have implications for the other countries with similar patterns of childhood illness and food insecurity.

Editors’ note: The five-fold difference in HIV prevalence between the highest rate nutrition rehabilitation units in the south and the lowest rate units in the central region has practical implications for efficient resource allocation. Southern units will need larger food allocations as kids stay longer in the programme and they will require more antiretroviral drugs, cotrimoxasole and antifungal agents. Paediatric HIV testing is clearly acceptable in Malawi nutrition rehabilitation units and should be promoted everywhere that access to effective prevention, treatment, and care services can be assured.