guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM In-patient: SAM and HIV/AIDS 96
pharmacokinetics have not been assessed in the severely malnourished child 155 . They particularly
affect mitochondrial function [111] 156 , which is already compromised in the severely malnourished child
[109,112]; the degree of dysfunction is related to mortality and any further mitochondrial insult is likely
to have serious effects. Furthermore, there is excessive mortality of patients shortly after commencing
ART, that appears to be related to nutritional status [107,113]; initiation of ART and other long-term
treatment of illnesses that are not immediately lethal should be delayed until the metabolism of the
major organs has improved through nutritional therapy. Other drugs used in HIV/AIDS patients with
opportunistic infections are particularly toxic to the malnourished patient (e.g. Amphotericin B).
There are also major interactions between ARV drugs and some of the drugs that may be used
in severe malnutrition. For example co-artem and rifampicin should be avoided at the same time as
some of the ARVs. These interactions are likely to be even more serious in the malnourished patient
who already has a compromised hepatic function. This is another cogent reason why the treatment of
HIV with ARVs should be delayed until the drugs used in malnutrition have been administered. In
areas where there is a high prevalence of HIV there is a danger of patients being enrolled in both
programmes where either the nutrition team or the staff of other programme is unaware of the
potential drug interactions in the malnourished patient; with ARVs then alternative anti-malarial and TB
drugs may be indicated.
Rifampicin-isoniazid appears to have a particular hepato-toxicity in the malnourished patient and
should be avoided until the nutritional status of the children has improved [114].
� The treatment of malnutrition should be started at a minimum two weeks before the
introduction of anti-retroviral drugs to diminish the risk of serious side effects from the antiretroviral
drugs. Preferably anti-retroviral treatment should be delayed until the recovery phase is
well established in OTP.
Children with HIV should be given co-trimoxazole prophylaxis against pneumocystis pneumonia.
This is inadequate antibiotic cover for the severely malnourished patient; amoxicillin should be
given in addition to prophylactic doses of co-trimoxazole.
� Once the patient’s SAM is being treated satisfactorily and s/he have had adequate amounts of the
essential nutrients to resist the toxic effects of the drug treatment HIV and TB, treatment should
be started and should follow the national guidelines.
Children with SAM and TB should not be immediately transferred to a TB centre where they have
little experience in treating SAM; the treatment of the SAM takes precedence in view of the
respective mortality rates. The treatment of TB can be carried out within the IMAM programme
more easily and efficiently than the treatment of SAM at a TB centre.
There are major opportunity costs for families to attend clinics, particularly if the clinic is distant from
their home. This is one of the main reasons for promoting out-patient management of severe
malnutrition. If the child has HIV then it is extremely likely that the mother also is infected. The clinic
that looks after the mother should also care for the child; the parent should not have to make two visits
to the clinic, one for herself and the other for her child.
The care and treatment centres that have been established for HIV should not only see both the
mother and child together, they should also be able to provide treatment for severe malnutrition and
TB, on an out-patient basis according to this protocol. There should be access to in-patient facilities
155
In moderately malnourished children in Malawi the pharmacokinetics of Nevirapine is not abnormal. Toxicity was not
assessed [110].
156
The nucleoside reverse transcriptase inhibitors (NRTI) which are the backbone of ART treatment are associated with
mitochondrial toxicity in children comparable to children with congenital mitochondrial disorders and NRTI-exposed
adults; they may develop serious lactic acidosis, pancreatitis, cardiomyopathy and neuropathy. Children with severe
malnutrition already have mitochondrial abnormalities making them much more vulnerable than well-nourished children.