This study found that RUTF treated HIV-positive children under ART had lower proportions of underweight and wasting compared to RUTF naïve HIV-positive children under ART. Furthermore, children treated by RUTF for at least four months had lower proportions of underweight, wasting, and stunting compared to their counterparts. Our study is the first to show the effect of RUTF treatment duration on both acute and chronic undernutrition in the era of ART scaling up.
In this study, about 97% of children treated with RUTF were found to have normal weight-for-age and weight-for-height. This is an important achievement. This is because, all of these children were either severely wasted or underweight or both at the baseline. Compared with RUTF-naïve, the RUTF treated children had a significantly better nutrition status. Such significant achievement of RUTF treatment can be explained as follows. First, RUTF ingredients are energy dense, with lipids and proteins [5
], which play an important role to recover the wasted lean tissue [3
]. Previous studies also reported the improvement of severe acute undernutrition among ART naïve HIV-positive children treated with RUTF [6
]. Second, children have an additional advantage of frequent contact with nutrition specialists [36
], in the presence of nutrition supplement interventions [38
]. This might improve their undernutrition status through closer monitoring, follow up, and nutritional and hygienic counseling. In a long run, it may also improve their chronic undernutrition status [37
While our results showed low wasting and underweight proportions among RUTF treated children compared to RUTF naïve children, proportions of stunting were not significantly different among them. Stunting has many persistent determinants including poverty, food insecurity [42
], and poor caregivers’ education [44
]. To improve this chronic undernutrition, longer treatment duration may be necessary. In our stratified analysis, children who received the treatment for at least four months were less likely to be stunted compared to their counterparts. This may be due to the cumulative effect of the high energy and protein nutrients they obtain from the high energy and protein diet [3
], and frequent contact with nutritionist as we have stated above.
Apart from RUTF intervention, this study also found other factors associated with undernutrition among ART treated children. These factors include male sex, low birth weight, lower economic status, and food insecurity. Previous study conducted among ART-treated children in Tanzania [16
] and among ART naïve HIV-positive children in South Africa [45
] also supports these findings.
Our results should be interpreted with care owing to some limitations. First, the cross-sectional design would limit direction of causal relationship. Using this design, it may be difficult to examine the effect of food in a population that has high food insecurity. In our multivariate analyses, however, we controlled for food insecurity and other factors that were found to be associated with undernutrition in a previous study in the same region [16
]. Moreover, the effectiveness of RUTF has also been shown among HIV-negative children [46
] and ART-naïve HIV-positive children in Sub Saharan Africa [6
]. According to the treatment protocol, all the children in the intervention group had severe underweight or wasting before the treatment initiation. Second, our results may not be generalized beyond the urban settings where this research was conducted. However, these results may be considered in the townships or cities in Tanzania or countries in the region with similar socio-economic characteristics.
In conclusion, among HIV-positive children under ART, provision of RUTF was associated with low proportions of wasting and underweight statuses. Furthermore, RUTF treatment for at least four months was associated with lower proportions of underweight, wasting and stunting. This result suggests that supplementation with RUTF at least for four months has a potential to improve undernutrition among HIV-positive children under ART in the clinical settings. RUTF may be useful in countries like Tanzania and others with high proportion of undernutrition among ART-treated HIV-positive children [16
]. It is therefore important to consider scaling up the RUTF intervention in the same pace as ART programs in Tanzania and other countries in the region.