Malnutrition, VIH et traitement antirétroviral dans les pays à ressources limitées
Introduction: Over the past decade, access to highly active antiretroviral treatment (HAART) has rapidly increased in low and middle income countries (LMIC). In those settings, the HIV epidemic has been superimposed onto preexisting and prevalent conditions of malnutrition. HIV and malnutrition are part of a vicious cycle known to contribute to decreased nutritional status and immune function. Despite access to HAART, malnutrition, either at initiation or in the course of treatment, persists as a prognostic factor for poor health and mortality. Nonetheless, few data exist concerning nutritional trajectories or concerning the determinants of immune and nutritional status amongst patients initiating HAART. Objectives : To document the methodological challenges in nutritional research in LMIC. To investigate the determinants and trajectories of nutritional status at HAART initiation and in the first year of treatment. To investigate immune function and reconstitution according to baseline malnutrition. Results: Among anthropometric measures, only weight and height were found to be reliable. Consequently, these were the only anthropometric measures to be used in longitudinal analyses. Treatment led to a rapid amelioration of the nutritional status for a majority of patients. However, the initial effect quickly tapered off to reach a plateau 6 to 9 months post HAART. One year after treatment initiation malnutrition persisted in many patients active and alive (between 7-29% according to the population and nutritional indicator used). As observed in our cohorts and in our systematic review, attrition was strongly associated with baseline malnutrition. However, there does not appear to be a clear relation between the immunological response and nutritional status either at treatment initiation or during the course of HAART. The limited quantity and quality of available evidence did not permit us to draw definitive conclusions to that effect. Conclusions: In our cohort study, collected evidence suggested the existence of a cross-sectional and longitudinal association between nutritional and immunological statuses in treated patients. However, there exists no consensus concerning these associations. Based on uncovered data, we cannot draw conclusions on the impact of malnutrition on immune function and reconstitution either at baseline or within the first year post HAART. Methodological difficulties pertaining to nutritional status assessment iv and the frequent attrition of malnourished people initiating treatment, complicates the investigation of these relations; as is the coexistence of multiple inflammatory processes in those populations.
Traitement antiretroviral HIV Antiretroviral treatment Antropometric measurements Immune response Low and middle income countries