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)