Higher rates of moderate to severe stunting and underweight were observed among children with CD4 <15% (P < .001) compared to those at higher CD4 counts. There was a moderate correlation between WAZ and CD4% (r = 0.3, P < .005) and between HAZ and CD4% ref 3 (r = 0.28, P < .005). Even at CD4 counts >25% indicating normal immune status, 33 to 45% of children had moderate to severe malnutrition. The sensitivity and specificity of stunting (HAZ < ?2) to predict CD4 <15% was 63% and 67% while undernutrition (WAZ < ?2) could predict a CD4 <15% with a sensitivity of 60% and specificity of 61%, respectively. Further, the area under the ROC Curve for WAZ and CD4% was 0.66 (95% CI 0.58�C0.74) while for HAZ and CD4% area under the curve was 0.69 (95% CI 0.62�C0.77), Figures 2(a) and 2(b).

Figure 2 (a) Receiver Operator Characteristic curve between WAZ score and CD4 percentage, and (b) HAZ score and CD4 percentage. Table 4 Prevalence of underweight, stunting, and wasting at different levels of immunodeficiency. 4. Discussion The overall prevalence of moderate to severe underweight and stunting in this population of HIV-infected children from South India was 63% and 58%, which is cause for concern. In children under 5 years, the prevalence was 66% and 62%, respectively��this is much higher than the national average of 48% underweight and 40% stunting reported by NFHS-3 for under-five children [9]. Our findings are similar to rates of undernutrition among HIV-infected children reported from other parts of India, which vary from 60 to 62% [4, 10].

These figures are higher than those reported among HIV infected children in Africa, which varies between 14% for undernutrition and 31% for stunting to 38% for malnutrition, [11�C13]. Our data highlights the much higher rate of moderate and severe grades of malnutrition among HIV-infected children in India. The children included in this report were seeking care at government health facilities and represent the majority of HIV-infected people in India, who are from the socioeconomically vulnerable group. This is important as malnutrition has a major impact on the outcome of HIV disease as it not only increases mortality [12, 13] but also results in an impaired response to antiretroviral therapy [14]. Rajasekaran et al. showed that children who were severely malnourished at baseline, had a hazard ratio of 6.7 (0.9�C49.

4) for mortality after initiation of ART, compared to children who were GSK-3 normally nourished [14]. However nutritional recovery and growth after treatment of malnutrition is similar to that observed in HIV uninfected children, stressing the need for early recognition and management [15]. We explored this area in depth as none of the previous studies from India have examined the pattern and type of malnutrition in detail or attempted to study its correlation with age, gender, or immune status.