Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

Nutritional Status of HIV-infected Adolescents Enrolled into an HIV-care Program in Urban and Rural Uganda: A Cross-sectional Study

Francis Lwanga*, Rhoda K. Wanyenze, Joseph KB Matovu, Teddy Chimulwa, Christopher G. Orach

Makerere University School of Public Health-Centers for Disease Control (MakSPH-CDC) Fellowship Program, Kampala Uganda

Abstract: Malnutrition is a major threat to the health of HIV infected individuals and is associated with increased risks of morbidity and mortality. We assessed the nutritional status of HIV-infected adolescents enrolled into HIV care program in Uganda. We carried out across-sectional study. Data were collected on 205 adolescents aged 10-19 years attending The AIDS Support Organization (TASO) HIV care services in Uganda. All adolescents attending an adolescent clinic day in the respective TASO centers were enrolled into the study. Nutritional status was assessed using BMI-for-Age (BAZ) and Height-for-age (HAZ) as measures of thinness and stunting respectively. Standard deviation (SD) scores (Z scores) were applied to determine the nutritional status. Adolescents whose BAZ and HAZ was ≤-3SD were considered severely undernourished; those ≤-2SD were considered malnourished while those > -2SD were well-nourished. Statistical analysis was done using STATA statistical software package. The prevalence of stunting was 36.2% (72/199) with 11.1% (22/199) of adolescents being severely stunted. The risk factors for stunting included being male (AOR: 4.0; 95% CI: 1.81- 7.02) and residence in rural settings (AOR: 6.0; 95% CI 2.70-12.16). Eighteen percent of the adolescents (36/200) were thin, 8% (16/200) being severely thin. The prevalence of stunting and thinness was high among the HIV infected adolescents. Male adolescents and residing in rural settings are important risk factors of malnutrition among the HIV infected adolescents. There is need for development of comprehensive care and support systems including adequate nutritional care and support for HIV infected adolescents.

Keywords: adolescence, stunting, thinness, HIV, rural, urban, Uganda

Received March 07, 2015; Revised April 20, 2015; Accepted April 26, 2015

Citation: Francis Lwanga, Rhoda K. Wanyenze, Joseph KB Matovu, Teddy Chimulwa, Christopher G. Orach, Nutritional Status of HIV-infected Adolescents Enrolled into an HIV-care Program in Urban and Rural Uganda: A Cross-sectional Study. World Journal of Nutrition and Health, 3 (2). 35-40. January 2015. doi:10.12691/jnh-3-2-2

1. Introduction

Malnutrition is a major threat to the health of HIV infected individuals. Severe forms of malnutrition are associated with increased risks of mortality and morbidity occurring among HIV infected children [1,2]. Worldwide, an increase in HIV related deaths among adolescents (aged 10-19 years) was reported between 2001 and 2012 [3]. However, as the overall number of HIV-related deaths fell by 30%, that of adolescents increased by 50% between 2005 and 2012 [4].

According to the World Health Organization, the increase in HIV-related deaths among adolescents has been attributed primarily to several factors including poor prioritization of adolescents in national HIV plans, inadequate provision of accessible and acceptable HIV testing and counseling (HTC) and treatment services as well as lack of support for adolescents to remain in care and adhere to antiretroviral therapy (ART) [4]. Prioritization of adolescents’ nutrition services is a current area of concern. Adolescent nutrition services receive inadequate attention as most nutrition-related resources are traditionally directed towards young children and pregnant women. For example, whereas there are nationally recognized policy guidelines for infant and young child feeding in the context of HIV, none exists for the feeding of adolescents in Uganda [5]. Furthermore, the Uganda Nutrition Action Plan (UNAP) for 2011-2016 does not have specific actions directed towards adolescents [6].

The physical and psycho-social changes occurring during childhood and adolescence makes this age group more vulnerable to health and nutrition concerns compared to others. The total nutrient needs of adolescents are higher than at any other time in the human lifecycle [7]. A combination of these factors, at a time of high growth spurt, makes adolescents more vulnerable to nutritional deficiencies. The role played by nutrition in determining the physical, mental and social aspects of HIV-exposed children has been documented [8,9]. Additionally, the HIV infection and drugs such as antiretroviral drugs may compromise nutrients intake as well as increasing the nutrients demanded through a number of metabolic pathways [10]. Despite the increased vulnerability to malnutrition, limited research has been conducted to inform adolescent policy and programs especially in the context of HIV care.

Malnutrition is a common problem occurring among HIV infected individuals. An estimated 20 to 25% of adult HIV infected patients starting ART were estimated to be mildly to severely malnourished in Uganda [11]. Approximately 30-40% of the severely malnourished children admitted in Mulago Hospital’s nutrition unit were reported to be HIV-positive [2]. There is however, limited documentation of adolescent nutrition in the context of HIV especially in sub-Saharan Africa where the prevalence of both HIV infection and malnutrition is highest. We assessed the nutritional status of HIV infected adolescents receiving HIV care services at The AIDS Support Organization (TASO) in Uganda.

2. Methods

2.1. Study Setting

The study was conducted in the TASO centers across Uganda. TASO is an indigenous HIV and AIDS service initiative, registered in Uganda as a Non-Governmental Organization (NGO). The organization has cared for over 300,000 individuals living with HIV and reached out to over 900,000 members of their families. Over 50,000 people living with HIV under TASO are receiving antiretroviral drugs (ARVs). TASO operates in the central, eastern, northern and western regions of Uganda having a total of eleven HIV-care centers.

TASO provides adolescent HIV services in all the eleven centers and currently serves 3,143 adolescents (10-19 years). Data were collected from six TASO centers including Mulago in the Capital City of Kampala, Entebbe, Jinja, Masaka, Mbale and Soroti.

2.2. Data Collection Procedures

This was a cross-sectional study involving 205 HIV infected adolescents selected from six out of the eleven TASO centers. Data were collected for a period of two months between August and September 2014. Data collection took place on clinic days which did not coincide across the study centers. All adolescents attending an adolescent clinic day in the respective TASO centers were enrolled into the study.

Anthropometric measurements of height and weight were undertaken following Gibson’s guidelines [12]. Socio-demographic data were collected using a structured interviewer-administered questionnaire which captured sex, age, education level, orphanage-hood, residence and number of household occupants.

Weight measurement: Adolescents were weighed using Seca scales. The scales were validated with standard weights before actual weighing of the adolescents. The scales were placed on a hard flat surface and adolescents weighed while wearing only lightweight clothing (excluding shoes, belts, socks, watches and jackets). Each child was measured twice and the average of the two measures recorded. For cases where the difference between the two measures exceeded the tolerance limit (the degree to which the two measurements are close), the child was repositioned and weighed a third time.

Height measurement: The adolescent stood with his or her back against the measuring board, heels, buttocks, shoulders and head touching a flat upright sliding head piece. The adolescents’ legs were placed together making the knees and ankles touch each other. The study participants were asked to take in a deep breath. Height measurement was taken at maximum inspiration. The headpiece was then brought down onto the upper most point on the head and the height recorded to the nearest 0.1 cm.

2.3. Data Management and Analysis

Data were entered in an Epi-Info 2007 validated entry screen. It was later exported to STATA (ver. 12.0) for data cleaning and analysis using zanthro extensions which generate the standardized anthropometric measures for children and adolescents with reference to the WHO child growth standards [13].

The nutrition status of adolescents was assessed using BMI-for-Age (BAZ) and Height-for-age (HAZ) indices. Standard deviation (SD) scores (Z scores) were applied to determine the nutritional status. Adolescents whose BAZ and HAZ was equal or below -2SD scores were considered malnourished and those above -2SD scores as being well-nourished. All those scoring -3SD and below were considered severely undernourished. Statistical analysis was performed using STATA (Ver. 12.0). We performed both descriptive and multivariate linear regression analysis to determine the predictors of malnutrition including sex, age, education level, orphanage-hood, residence and number of household occupants.

2.4. Ethical Clearance

The study was approved by TASO Institutional Review Committee and the National Council for Science and Technology. Permission to carry out the study was sought from TASO program management at TASO Headquarters. TASO center managers were informed in advance about the study and made arrangements for adolescents to come with their parents or caretakers for purposes of consent and ascent. Adolescents had the right to accept or refuse to join the study without any consequences. Adolescents 18 years and above provided written informed consent while the younger adolescents provided assent and consent was obtained from their parents/guardians. Adolescents who were identified as malnourished were referred to providers for support.

3. Results

3.1. Prevalence and Factors Associated with Stunting

Table 2 reveals that 36.2% of the study subjects were stunted with 11.1% being severely stunted. Over three quarters (76.4%) of the stunted adolescents were aged between 15-19 years as shown in Table 3. Males were more likely to be stunted than females (p=0.002). Adolescents living in rural areas were more likely to be stunted than those from the urban setting (p<0.001). The majority (62%) of adolescents lived in households with more than five occupants. Table 4 reveals that males and being a resident of the rural areas had 4 and 6 fold risks (AOR: 4; 95% CI 1.8-7.0; AOR: 6; 95% CI 2.7-12.2) of being stunted respectively.

Table 1. Socio-demographic Characteristics of the respondents

Table 2. Nutritional status of adolescents as measured by height-for-age (Stunting)

Table 3. Bivariate analysis for predictors of stunting

Table 4. Multivariate analysis for stunting

3.2. Prevalence and Factors Associated with Thinness

Table 5 reveals that 18% of the adolescents were thin 8% of them severely affected. Majority (58%) of the thin adolescents was aged 15-19 years as seen in Table 6. The percentage of adolescents who were thin was higher (52%) among males compared to females. Majority (69%) of the thin adolescents had achieved an education level of primary level and below. More than a half (53%) and 58% of the adolescents lived in urban areas as well as in households with five occupants or more respectively.

Table 5. Nutritional status as measured by BMI-for-Age (Thinness)

Table 6. Bivariate analysis for thinness

4. Discussion

Our study revealed that one third of the adolescents were stunted with 11% severely affected. While male adolescents had a 4-fold risk of being stunted, those living in rural Uganda were 6 times more likely to be stunted as compared to their counterparts in urban areas. Eighteen percent of the respondents were thin with 8% of them being severely thin.

The prevalence of stunting reported by our study is higher than the 22.5% reported among adolescents studied in Uganda [14]. The high prevalence of stunting noted among HIV infected adolescents is not surprising given the pathophysiology of HIV/AIDS in relation to nutrition and health [15]. Stunting may be associated with chronic diarrhoea and mal-absorption caused by HIV enteropathy which is a common occurrence in HIV infected individuals [1]. The relationship between diarrohea and stunting has been studied among children [16]. This observation indicates that dietary interventions are important in nutrition care of HIV infected individuals when combined with clinical management of HIV related conditions.

High levels of stunted growth among HIV infected children and adolescents have been reported in developing countries. A study done in Zimbabwe revealed that 62% of HIV infected children and adolescents aged 8-19 years were stunted [17]. In India, 58% of the 0-15 year old HIV infected children were stunted [18]. Similarly, a study conducted in Brazil revealed a higher (25.5%) prevalence of stunting among HIV infected children and adolescents compared to only 6% in those not infected [19]. Several factors including secondary infections and inadequate dietary intake have been implicated in the causation of stunted growth among those infected with HIV [20,21]. Furthermore, an inverse relationship between viral burden and linear growth has been noted indicating that use of antiretroviral medications that reduce viral load would lead to improvements in anthropometric indices of growth [22]. Reduction of viral load is however, associated with adherence to ART [23,24]. Poor adherence to ART reported among adolescents may therefore partly explain the existence of stunted growth among this age group [4]. However, this study did not evaluate the impact of adherence and ART on nutritional status, an area that requires further assessments.

Adolescents living in rural settings were 6 times more likely to be stunted as compared to their counterparts in urban areas. Our findings (49%) are somewhat similar to Uganda’s general prevalence of stunting (41.8%) occurring among children aged below 5 years in rural Uganda as compared to only 16.9% in urban settings [25].This may be attributed to the higher levels of food insecurity and poverty common in rural settings as noted in the recent comprehensive food security and vulnerability analysis done in Uganda [26]. This observation suggests a need for development of programs specifically designed to economically empower HIV infected and affected individuals especially those living in rural areas.

The study revealed significantly higher levels of stunting among boys than girls. Studies by Lwanga et al and Ingunn et al revealed similar observations in the general population of children and adolescents in Uganda [14,27]. This difference may be explained by the increased caloric requirements experienced by males due to the greater increases in height, weight, and lean body mass as opposed to that occurring among females [7]. However, although this biological explanation stands, some behavioral factors specific to boys may influence their health and nutritional status. Adolescent males are more likely to get involved in substance abuse than girls; a condition that may compromise the food intake and bioavailability of nutrients both of which result in malnutrition [28,29]. Drug use among HIV infected individuals is reported to be associated with lower Body Mass Index (BMI) as well as CD4 counts which are key indicators for survival [30]. The findings suggest that boys should receive more attention in any program geared at improving the health and nutrition of adolescents.

We found that 18% of the adolescents enrolled in our study were thin. This prevalence is higher than that documented in many of the studies conducted among the general populations of adolescents in countries of the Sub-Saharan region. Studies conducted in Southern Nigeria and Cameroon found that 8.3% and 9.5% of the adolescents studied were thin [31,32]. The higher prevalence rate of thinness revealed in our study is attributed to HIV related factors affecting dietary intake as well as nutrients bioavailability and diseases [1,20,33]. Ramalho et al, reported a 4.7 fold risk of thinness among HIV infected children and adolescents with Protease Inhibitor Antiretroviral (ARV) drug usage being related to thinness [20]. Thinness related to ARV usage may be a result of a number of biochemical reactions including insulin resistance (33). This observation shows a critical aspect of drug-nutrient interaction which has been a subject of intensive research suggesting a need for routine monitoring and evaluation of ARV drug regimen to avoid development of severe forms of thinness which lead to increased morbidity and mortality. Severe forms of malnutrition have been reported to be potential risk factors for HIV-related morbidity and mortality [33,34,35,36]. The findings suggest that, efforts to minimize the development of severe forms of malnutrition among HIV infected adolescents will tremendously reduce HIV related adolescents deaths which have been on increase [3].

5. Study Limitations

Our study had some limitations. We did not examine some potentially important factors that could influence the nutritional status of HIV infected adolescents including antiretroviral therapy, co-infections as well as dietary intake. However, the findings of our study highlight nutrition as an important element of care for HIV infected adolescents and will inform larger studies to fully ascertain predictors and interventions to mitigate the problem of malnutrition in HIV infected adolescents.

6. Conclusion

The prevalence of stunting and thinness was high among the HIV infected adolescents. Male sex and residing in rural Uganda are risk factors for malnutrition among the HIV infected adolescents. The findings suggest development of comprehensive care and support systems that integrate adequate nutritional support for HIV infected adolescents.

Statement of Competing Interests

The authors declare no competing interests.

Acknowledgement

The authors thank The AIDS Support Organization (TASO) and Makerere University School of Public Health-Centers for Disease Control (MakSPHCDC) Fellowship Program for the material and technical support.

References

[1]   | Rose A.M, Hall CS, Martinez-Alier N. Aetiology and Management of Malnutrition in HIV-positive Children. January 9, 2014.
[2]   | Bachou, H, T Thorkild, R Downing, and J Tumwine. Severe malnutrition with and without HIV-1 infection in hospitalised children in Kampala, Uganda: differences in clinical features, haematological findings and CD4+ cell counts. Nutrition Journal 2006 5:27.
[3]   | Joint United Nations Programme on HIV/AIDS. UNAIDS report on the global AIDS epidemic 2013.
[4]   | World Health Organization HIV and adolescents: Guidance for HIV testing and counseling and care for adolescents living with HIV: recommendations for a public health approach and considerations for policy-makers and managers. 2013 Geneva, 27, Switzerland.
[5]   | Uganda Nutrition Action Plan. Scaling up Multi-Sectoral Efforts to Establish a Strong Nutrition Foundation for Uganda’s Development, 2011. Available at: http://www.unicef.org /Uganda/Nutrition_Plan_2011.pdf.
[6]   | Ministry of Health-Uganda Policy Guidelines on Infant and Young Child Feeding. 2009 Available at: https://extranet.who.int/nutrition/gina/sites/default/files/UGA%202009%20IYCF%20Guidelines.pdf.
[7]   | Stang, J., Story, M. In Guidelines for Adolescent Nutrition Services. Available at: http://www.epi.umn.edu/let/pubs/img/adol_preface_materials.pdf.
[8]   | Christine M. McDonald, Karim P. Manji, Roland Kupka et al. Stunting and Wasting are Associated with Poorer Psychomotor and Mental Development in HIV-Exposed Tanzanian Infants 2012 J. Nutr. 143: 204-214,
[9]   | Christine J. McGrath; Michael H. Chung; Barbra A. Richardson; Sarah Benki Nugent; Danson Warui and Grace C. John-Stewart. Younger age at HAART initiation is associated with more rapid growth reconstitution, AIDS 2011 28; 25(3): 345-355.
[10]   | Shalini Duggal, Tulsi Das Chugh, and Ashish Kumar Duggal. HIV and Malnutrition: Effects on Immune System. Clinical and Developmental Immunology Vol. 2012, Article ID784740.
[11]   | FANTA-2. The Analysis of the Nutrition Situation in Uganda. Food and Nutrition Technical Assistance II Project (FANTA-2) 2010, Washington, DC: AED.
[12]   | Rosalind S.G. Nutritional Assessment; A Laboratory Manual; Oxford University Press 1993: New York, NY, USA.
[13]   | World Health Organization. Global Database on Child Growth and Malnutrition; WHO: 1997 Geneva, Switzerland.
[14]   | Francis Lwanga, Barbara Eva Kirunda and Christopher Garimoi Orach. Intestinal Helminth Infections and Nutritional Status of Children Attending Primary Schools in Wakiso District, Central Uganda. Int. J. Environ. Res. Public Health 2012. 9, 2910-2921.
[15]   | Banerjee T. Pensi T. Banerjee D. Grover G (2010). Impact of HAART on survival, weight gain and resting energy expenditure in HIV-1-infected children in India. Annals of Tropical Paediatrics 2010, 30:27-37.
[16]   | William Checkley, Leonardo D. Epstein, Robert H. Gilm an, Lilia Cabrera and Robert E. Black. Effects of Acute Diarrhea on Linear Growth in Peruvian Children. Am J Epidemiol 2003; 157:166-175.
[17]   | Rashida A. Ferrand; Ruedi Luethy; Filda Bwakura; Hilda Mujuru; Robert F. Miller and Elizabeth L Corbett. HIV Infection Presenting in Older Children and Adolescents: A Case Series from Harare, Zimbabwe. Clinical Infectious Diseases 2007; 44:874-8.
[18]   | C.Padmapriyadarsini; N.Pooranagangadevi; K.Chandrasekaran and Sudha Subramanyan. Prevalence of Underweight, Stunting, and Wasting among Children Infected with Human Immunodeﬁciency Virus in South India. Vol. 2009.

[19]  
L C de Barros Ramalho, E M Goncalves, W R G de Carvalho, G Guerra-Junior, M Centeville, F H Aoki, A M Morcillo, M M dos Santos Vilela and M T N da Silva. Abnormalities in body composition and nutritional status in HIV-infected children and adolescents on antiretroviral therapy. International Journal of STD & AIDS 2011; 22: 453-456.

[20]   | Stephen M. Apadi. Growth failure in HIV-infected children. Consultation on Nutrition and HIV/AIDS in Africa: Evidence, lessons and recommendations for action. 2005. [http://www.who.int/nutrition/topics/Paper_4_Growth_failure_bangkok.pdf].
[21]   | Aranka Anema, Nicholas Vogenthaler, Edward A. Frongillo, Suneetha Kadiyala, and Sheri D. Weiser. Food Insecurity and HIV/AIDS: Current Knowledge, Gaps, and Research Priorities. Current Medicine Group LLC 2009. ISSN 1548-3568., 6:224-231.
[22]   | Steven Hirschfeld. Dysregulation of Growth and Development in HIV-Infected Children. J. Nutr. 1996. 126: 2641S-2650S.

[23]  
Bijal Shah, Louise Walshe, Dattary G. Saple, Shruti H. Mehta, Jeetender P. Ramnani, R. D. Kharkar, Robert C. Bollinger and Amita Gupta. Adherence to Antiretroviral Therapy and Virologic Suppression among HIV-Infected Persons Receiving Care in Private Clinics in Mumbai, India. HIV/AIDS 2007. CID:44, 1235.

[24]   | Ajay K. Sethi, David D. Celentano, Stephen J. Gange, Richard D. Moore, and Joel E. Gallant Association between Adherence to Antiretroviral Therapy and Human Immunodeﬁciency Virus Drug Resistance. HIV/AIDS 2003. CID:37, 1112.
[25]   | Uganda Bureau of Statistics (UBOS) and ICF International Inc. 2012. Uganda Demographic and Health Survey 2011. Kampala, Uganda: UBOS and Calverton, Maryland: ICF International Inc.
[26]   | Uganda Bureau of Statistics and the World Food Programme. A comprehensive food security and vulnerability analysis (CFSVA) 2013. [http://documents.wfp.org/stellent/groups/public/documents/ena/wfp257002.pdf].
[27]   | Ingunn Marie, S.E.; Thorkild, T.; Wamani, H.; Karamagi, C.; Tumwine, J.K Determinants of infant growth in Eastern Uganda: A community-based cross-sectional study. BMC Public Health 2008.
[28]   | The World Health organization. Health for the World’s Adolescents. A second chance in the second decade. Geneva 27, Switzerland 2014. [http://apps.who.int/adolescent/second-decade/files/1612_MNCAH_HWA_Executive_Summary.pdf].
[29]   | Santolaria-Fernández FJ, Gómez-Sirvent JL, González-Reimers CE, Batista-López JN, Jorge-Hernández JA, Rodríguez-Moreno F, Martínez-Riera A, Hernández-García MT Nutritional assessment of drug addicts. Drug Alcohol Depend, 1995; 38(1):11-8.
[30]   | Lien A. Quach, Christine A Wanke, Christopher H. Schmid, Sherwood L. Gorbach, D. Mkaya Mwamburi, Kenneth H. Mayer, Donna Spiegelman and Alice M. Tang. Drug Use and Other Risk Factors Related to Lower Body Mass Index among HIV-Infected Individuals. Drug Alcohol Depend. 2008; 95(0).
[31]   | Ene-Obong H, Ibeanu V, Onuoha N, Ejekwu A. Prevalence of overweight, obesity, and thinness among urban school-aged children and adolescents in southern Nigeria. Food Nutr Bull. 2012 Dec; 33(4): 242-50.
[32]   | Ponce Cedric Fouejeu Wamba, Julius Enyong Oben, and Katherine Cianflone. Prevalence of Overweight, Obesity, and Thinness in Cameroon Urban Children and Adolescents. Journal of Obesity 2013, ID 737592.
[33]   | Philippa M Musoke and Pamela Fergusson. Severe malnutrition and metabolic complications of HIV-infected children in the antiretroviral era: clinical care and management in resource-limited settings. Am J Clin Nutr 2011; 94(suppl):1716S-20S.
[34]   | Fergusson P, Tomkins A. HIV prevalence and mortality among children undergoing treatment for severe acute malnutrition in sub-Saharan Africa: a systematic review and meta-analysis. Trans R Soc Trop Med Hyg, 2009. 103(6):541-8.
[35]   | Eduardo Villamor, Lara Misegades, Maulidi R Fataki, Roger L Mbise and Wafaie W Fawzi. Child mortality in relation to HIV infection, nutritional status, and socio-economic background. IJE 2005. vol. 34 no. 1; 34 :61-68.
[36]   | Taye B, , Enquselassie F. The impact of malnutrition in survival of HIV infected children after initiation of antiretroviral treatment (ART). J 2010; 48(1):1-10.