Public Health Nutrition

Special groups

Self-reported dietary intake and appetite predict early treatment outcome among low-BMI adults initiating HIV treatment in sub-Saharan Africa

John R Koethea1a2 c1, Meridith Blevinsa3a4, Claire Bosirea5a6, Christopher Nyirendaa1a7, Edmond K Kabagambea5, Albert Mwangoa3a8, Webster Kasongoa3a9, Isaac Zulua1a7, Bryan E Shepherda4 and Douglas C Heimburgera1a3a6

a1 Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia

a2 Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, A2200-MCN, 1161 21st Avenue South, Nashville, TN 37232-2582, USA

a3 Institute for Global Health, Vanderbilt University, Nashville, TN, USA

a4 Department of Biostatistics, Vanderbilt University, Nashville, TN, USA

a5 Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA

a6 Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA

a7 Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia

a8 Zambian Ministry of Health, Lusaka, Zambia

a9 Tropical Diseases Research Centre, Ndola, Zambia


Objective Low BMI is a major risk factor for early mortality among HIV-infected persons starting antiretrovial therapy (ART) in sub-Saharan Africa and the common patient belief that antiretroviral medications produce distressing levels of hunger is a barrier to treatment adherence. We assessed relationships between appetite, dietary intake and treatment outcome 12 weeks after ART initiation among HIV-infected adults with advanced malnutrition and immunosuppression.

Design A prospective, observational cohort study. Dietary intake was assessed using a 24 h recall survey. The relationships of appetite, intake and treatment outcome were analysed using time-varying Cox models.

Setting A public-sector HIV clinic in Lusaka, Zambia.

Subjects One hundred and forty-two HIV-infected adults starting ART with BMI <16 kg/m2 and/or CD4+ lymphocyte count <50 cells/μl.

Results Median age, BMI and CD4+ lymphocyte count were 32 years, 16 kg/m2 and 34 cells/μl, respectively. Twenty-five participants (18 %) died before 12 weeks and another thirty-three (23 %) were lost to care. A 500 kJ/d higher energy intake at any time after ART initiation was associated with an approximate 16 % reduction in the hazard of death (adjusted hazard ratio = 0·84; P = 0·01), but the relative contribution of carbohydrate, protein or fat to total energy was not a significant predictor of outcome. Appetite normalized gradually among survivors and hunger was rarely reported.

Conclusions Poor early ART outcomes were strikingly high in a cohort of HIV-infected adults with advanced malnutrition and mortality was predicted by lower dietary intake. Intervention trials to promote post-ART intake in this population may benefit survival and are warranted.

(Received November 16 2011)

(Revised May 01 2012)

(Accepted May 04 2012)

(Online publication June 13 2012)


  • HIV;
  • Malnutrition;
  • Antiretroviral therapy;
  • Africa


c1 Corresponding author: Email