Aim: To identify risk factors for severe childhood malnutrition in a rural South African district with a high HIV/AIDS prevalence. Design: Case-control study. Setting: Bushbuckridge District, Limpopo Province, South Africa. Participants: 100 children with severe malnutrition (marasmus, kwashiorkor, and marasmic kwashiorkor) were compared with 200 better nourished (>-2 SD weight-for-age) controls, matched by age and village of residence. Bivariate and multivariate analyses were conducted on a variety of biological and social risk factors. Results: HIV status was known only for a minority of cases (39%), of whom 87% were HIV positive, while 45% of controls were stunted. In multivariate analysis, risk factors for severe malnutrition included suspicion of HIV in the family (parents or children) (OR 217.7, 95% CI 22.7—2091.3), poor weaning practices (OR 3.0, 95% CI 2.0—4.6), parental death (OR 38.0, 95% CI 3.8—385.3), male sex (OR 2.7, 95% CI 1.2—6.0), and higher birth order (third child or higher) (OR 2.3, 95% CI 1.0—5.1). Protective factors included a diverse food intake (OR 0.53, 95% CI 0.41—0.67) and receipt of a state child support grant (OR 0.44, 95% CI 0.20—0.97). A borderline association existed for family wealth (OR 0.9 per unit, 95% CI 0.83—1.0), father smoking marijuana (OR 3.9, 95% CI 1.1— 14.5), and history of a pulmonary tuberculosis contact (OR 3.2, 95% CI 0.9—11.0). Conclusions: Despite the increasing contribution of HIV to the development of severe malnutrition, traditional risk factors such as poor nutrition, parental disadvantage and illness, poverty, and social inequity remain important contributors to the prevalence of severe malnutrition. Interventions aiming to prevent and reduce severe childhood malnutrition in high HIV prevalence settings need to encompass the various dimensions of the disease: nutritional, economic, and social, and address the prevention and treatment of HIV/AIDS.
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