This study investigates the financial costs of providing nutritional supplementation to a rural cohort of HIV-infected children in a public health HIV treatment programme using standardised international guidelines, with costs based on the nutritional supplements available and used in the country. Applying these guidelines, we found that almost half the children initiated on ART in 2010 would have been eligible for nutritional supplementation, reflecting the levels of poverty and comorbid TB in the area (Houlihan et al. 2010b
). Whilst the proportion of children found to be undernourished at initiation of ART in this study is similar to that found in previous studies (Bolton-Moore et al. 2007
), further generalisability of our results may be limited by a lack of similar nutritional supplements and differences in programmatic costs in other settings which were not accounted for in this study.
In our programme, the estimated annual cost of purchasing the recommended quantities of nutritional supplementation for 26 weeks for all eligible children initiated during the study period was approximately $11 136. This represents 11.6% of the cost of procuring ART for 26 weeks for all children initiating ART during 2010. Nutritional supplements are provided until exit criteria are achieved with a 26-week time frame used in this study (see above). Thereafter, with appropriate supplementation, follow-up and the initiation of ART, children should remain adequately nourished and only require an additional 10% daily energy requirement (NCP-A), which is provided at the household level. Thus, supplementation should only be required once for a maximum period of 26 weeks during a 52-week (1-year) period, whereas ART is required for the entire period. The proportional costs of supplementation in this ART programme for a 1-year period equates to 5.8% of ART costs.
The estimation of costs for purchasing nutritional supplementation will be affected by a number of factors. The proportion of children who would have been eligible for supplements is likely to have been underestimated for three reasons. First, our inability to assign a NCP to 21 children because of missing documentation of clinical staging or prevalent TB may have led to an underestimation of the number of children requiring supplementation. Second, as heights or MUACs were not recorded at initiation for the majority of children, we depended on WAZ to estimate undernutrition, which may have resulted in misclassification of some children. Finally, accurate documentation of comorbidities and clinical signs indicative of SAM may have been missing in the case files resulting in an underestimation of the extent of undernutrition and inaccurate assignment of children to a NCP.
Difficulties in the accurate recording and interpretation of anthropometric measures by field staff in resource-poor settings have been found to range from a lack of confidence in calculating accurate age from birth dates (Hamer et al. 2004
), difficulties in plotting growth charts appropriately (resulting in inaccurate WAZ and WHZ) (Qayad 2005
), and limited access to, and training in, the use of reference growth charts and equipment such as scales and stadiometers (Duggan 2010
). These issues are likely to have been present within the Hlabisa HIV Programme and to have affected the accurate detection of children who were undernourished and required supplementation during the study period.
It is also possible that an overestimation of costs per child may have occurred when using the 26-weeks time frame for the supply of supplementation. In practice, the actual time taken to nutritional recovery defined by the exit criteria is often <26 weeks (except for those with concurrent TB who require supplementation until the completion of their TB treatment). Clinically, we found that children with moderate malnutrition often achieved exit criteria, and moved to NCP-A, by approximately 12 weeks and those with SAM by 12–16 weeks. Assessing each child carefully and exiting them from additional supplementation appropriately would reduce supply costs to a total of ZAR57,079 ($7363) (ZAR20,960 for the management of children requiring 12-week NCP-B only, and ZAR36,119 for those requiring NCP-C initially (10-weeks Sibusiso and 6-weeks Future Life Porridge)). This reduces the proportional costs further to 7.6% of ART costs for 26 weeks and approximately 3.8% over the course of 52 weeks.
Alternatively, if we assume that the 48 children eligible for NCP-B who did not have prevalent TB at diagnosis required only 13-weeks NCP-B instead of 26 weeks (and continued to provide 26-week NCP-B to those with prevalent TB), the cost of supplying NCP-B would be reduced to ZAR34,072 ($4395). Furthermore, if we assume that children with SAM recover more quickly than the 10 weeks allowed for here and require only 6 weeks of NCP-C followed by 20-week NCP-B, the costs of supplying nutritional supplements to this groups is reduced to ZAR29,528 ($3809). Combining these two estimations would reduce the overall cost of supplementation for all children to ZAR63,600 ($8204), which would represent 4.2% of the cost of 52-weeks ART to the same group.
This analysis is limited to the costs of purchasing supplements and compares these to purchase costs of ART. It does not account for the costs of staff training, transport, distribution and wastage of goods, inpatient care, outpatient review, and opportunity costs for carers to attend clinics. Further analyses are required to estimate these additional costs, which may impact on the feasibility of adopting the Guidelines.
The provision of nutritional supplements by the Programme during, and prior to, 2010 was relatively unstructured and relied on physicians or nurses identifying undernourished children. Studies in HIV-uninfected children have found improvements in anthropometric status and clinical outcomes, including greater rates of weight gain and reduced nutritional relapse and mortality, following the implementation of formalised nutritional supplementation with RTUF (Weisstaub & Araya 2008
) even when compared with traditional milk and flour supplementation (Ciliberto et al. 2005
; Bhutta et al. 2008
). It is possible that, in the absence of Guidelines, undernourished children or those with comorbidities would not receive supplementation in the correct amounts for a prescribed period of time.
Good nutritional management is essential for the improvement of nutritional outcomes and anthropometric measures in HIV-infected children (Kim et al. 2012
), but especially important for those who are undernourished or have additional comorbidities (including tuberculosis) to reduce their higher burden of morbidity and mortality (Hesseling et al. 2005
). Assuming the level of undernutrition is representative of other paediatric populations initiating ART in resource-poor regions, this additional cost should be budgeted for in programmes.
Undernourished children and those with comorbidities represent an extremely vulnerable group of HIV-infected children. This study illustrates the low proportional cost of procuring nutritional supplements for HIV-infected children in resource-poor areas. The provision of nutritional supplements should be considered for the optimal management of these children to improve their poor outcomes. We recommend that programmes explore the integration of nutritional care for HIV-infected children along with the provision of ART either by providing supplements themselves or through partnership with organisations that have the resources to provide these.