The role of enteropathy in the pathogenesis of severe acute malnutrition in HIV-infected African children

Lead Research Organisation: Queen Mary University of London
Department Name: Blizard Institute of Cell and Molecular


Globally, malnutrition is a common cause of death in children less than 5 years of age. In Africa, many children who are admitted to hospital with severe malnutrition (termed SAM) have underlying HIV infection. Compared to children who develop SAM because of food shortage, children with HIV and SAM together (termed HIV-SAM) have a higher risk of dying or developing severe infections like blood poisoning (septicaemia), pneumonia or protracted diarrhoea. The reason why the outcome of HIV-SAM is so much worse than SAM alone is not clear. We believe that one important factor may be severe damage to the lining of the gut. Both SAM and HIV target the gut, which becomes inflamed and 'leaky'. Usually harmless bacteria living in the gut are then able to pass across the damaged gut wall into the bloodstream (so-called microbial translocation). Bugs from the gut may therefore cause infections like septicaemia and pneumonia, or may continually stimulate the immune system (a process called inflammation), which may be particularly dangerous in children with malnutrition. We believe that the 'double hit' of HIV and SAM together causes more severe gut damage (termed enteropathy), leading to a higher chance of dying, a lower chance of recovering from malnutrition and a greater risk of infections and inflammation. We plan to recruit 100 children with SAM and 100 children with HIV-SAM from three hospitals in southern Africa (one in Zambia and two in Zimbabwe), to compare the amount of gut damage, microbial translocation and inflammation. These children will be compared to 200 well-nourished children, half of whom are HIV-positive, and half of whom are HIV-negative. We will investigate how damaged, inflamed and leaky the gut is in each group of children, by doing tests on blood, urine and stool samples. In children with SAM and HIV-SAM we will see how acidic the stomach contents are. Stomach acid is a very important barrier against harmful bugs getting into the intestines, and we think the acid may be weaker in children with HIV-SAM, compared to children with SAM. Some children with SAM and HIV-SAM have very protracted diarrhoea and have a high chance of dying, although we do not understand exactly what causes the diarrhoea. By using a small telescope to look inside the gut and take biopsy samples, we can see how damaged the lining of the small intestine (the part of the intestine just beyond the stomach) is, and try to work out exactly what components of the gut wall have been damaged. We will compare microbial translocation between groups by looking for evidence of bacteria, or bits of bacteria, in the bloodstream. We can also look to see if the immune system is being triggered to respond to bugs more in children with HIV-SAM than children with SAM. If we find bacteria in the bloodstream, even at very low levels, we can see whether they have come from the gut by analyzing a sample of stomach juice. We will extract the DNA of any bacteria from the stomach juice, and amplify up the amount to be able to 'read' the sequence of the DNA (like a barcode) to see exactly which bugs are present. We will measure how much the immune system is being stimulated in each group of children, and try to work out if a higher level of inflammation is damaging to the body's metabolism when a child is malnourished. With the very best treatment available at the moment, around 1 in 3 children with HIV-SAM die, and there is an urgent need to find ways of reducing this high mortality. If we show that enteropathy is an important factor, and that it does lead to microbial translocation and inflammation, we could use extra medicines when treating children with HIV-SAM to try to repair the gut wall, stop bugs crossing into the bloodstream, or switch off inflammation, which may improve children's survival.

Technical Summary

In sub-Saharan Africa, around one-third of children hospitalized for severe acute malnutrition (SAM) have underlying HIV infection, and HIV has transformed the epidemiology, clinical presentation and outcome of SAM. Mortality in children with HIV and SAM (termed HIV-SAM) is 4-fold higher than in children with SAM alone, for reasons that remain unclear. Both HIV and SAM are characterized by intestinal damage (enteropathy). Intestinal barrier function is critical to health, and loss of this structural and functional barrier enables translocation of intestinal bacteria and proinflammatory molecules to the systemic circulation. We believe that breakdown of the intestinal mucosal barrier is an often-overlooked pathological process underlying SAM, and that the combined impact of HIV and SAM leads to more severe and extensive enteropathy and slower mucosal recover. We will recruit children with SAM HIV-SAM and well-nourished controls from three sites in Zambia and Zimbabwe, to characterize the enteropathy of SAM and HIV-SAM. A longitudinal series of investigations will compare gastric and small intestinal barrier function. In a subgroup with severe symptomatic enteropathy, endoscopy and biopsy will allow detailed assessment of gut architecture, correlation of structure and function, and investigation of the causes of persistent diarrhoea. To investigate the extra-intestinal consequences of enteropathy, we will first compare the microbial composition of the upper gut and plasma using deep sequencing, to determine whether translocation of enteric organisms underlies sepsis and pneumonia in malnourished children; and, second, characterize gene expression profiles to determine whether differences in host inflammatory response underlie the increased morbidity and mortality of HIV-SAM. Overall, this study will provide a rationale for a future trial of interventions to restore mucosal integrity, block microbial translocation and lower chronic inflammation to reduce mortality.

Planned Impact

Who will benefit from this research?

There is a recognised critical need for research into HIV-SAM (Heikens et al, Lancet 2008) to better inform clinical management, which remains suboptimal, with mortality rates exceeding 30%. Ultimately, the aim of this study is to better understand the pathophysiology of HIV-SAM to inform changes in clinical management. We therefore anticipate that children with SAM and HIV-SAM, particularly in sub-Saharan Africa where >90% of HIV-infected children live, will be beneficiaries of this research in the longer term. In the short term, the children recruited to this study will receive high-quality clinical care, with additional diagnostic interventions and clinical follow-up in addition to their contribution to research. We plan to share our research findings with families through 'open laboratory' events and design of an interactive science communication tool (discussed in Pathways to Impact). In the UK, our research findings will be disseminated to an estimated 8000 visitors per year to the Centre of the Cell; internationally, our nutrition interactive tool will be available online and since March 2007, the CoC website has had 18.9 million hits, including 640,000 unique hits from 168 countries.

As discussed in the 'Academic Beneficiaries' section, our research is addressing a recognised knowledge gap, and international guideline-setting committees will be engaged in dissemination of these results, and in discussion of plausible future interventions. At national level, we intend to share any relevant clinical results with relevant bodies within the Ministry of Health, such as the Nutrition Cluster of the MoHCW in Zimbabwe.

How will they benefit from this research?

This study will collect unique clinical and biological data on children with SAM and HIV-SAM and we ultimately expect that this work will inform a trial of interventions to improve morbidity and mortality. The outcome of children with SAM after discharge from hospital is not well studied, and we will provide short-term follow-up data that will increase our understanding of outcomes of children beyond acute hospitalisation. Clinician researchers will benefit from new data to characterize the pathophysiology of a frequently encountered, but poorly understood, clinical entity. We expect that data will be published in year 3 of the study (end of 2016) and that this will inform a potential trial, with funding sought in 2017 for a randomized trial of interventions.

Study staff employed on this project will develop new clinical or basic science skills, together with mentoring from investigators and experience in data analysis and publication. There is a critical need to develop scientific capacity in southern Africa to equip a cadre of future researchers to lead important public health research in-country. By linking Zimbabwean and Zambian academic institutions, we hope to strengthen existing links such as the SACORE network to enhance research capability in southern Africa. Researchers studying related conditions, such as schistosomiasis, oral vaccine responses and stunting malnutrition, within our research groups will benefit from discussion of data from this new project, which similarly focuses on enteropathy, and from introduction of new techniques to the labs in each country.


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Bwakura-Dangarembizi M (2022) Recovery of children following hospitalisation for complicated severe acute malnutrition. in Maternal & child nutrition

Description Confidence in Global Nutrition and Health Research
Amount £195,682 (GBP)
Funding ID MC_PC_MR/R019436/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 03/2018 
End 02/2019
Description Global Challenge Research Fund Foundation Award
Amount £599,945 (GBP)
Organisation Research Councils UK (RCUK) 
Sector Public
Country United Kingdom
Start 04/2017 
End 03/2019
Description Long-term clinical and nutritional outcomes of HIV-infected children surviving inpatient management of Severe Acute Malnutrition .
Amount $264,258 (USD)
Funding ID 107634/Z/15/Z 
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 03/2016 
End 03/2020
Description META-SAM (Metagenomics and Metabolomics of Severe Acute Malnutrition)
Amount £250,000 (GBP)
Funding ID 206455/Z/17/Z 
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 09/2017 
End 03/2022
Description Multimorbidity in children with HIV and severe acute malnutrition in sub-Saharan Africa
Amount £4,979,419 (GBP)
Funding ID NIHR201813 
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 09/2021 
End 08/2025
Description The relationship between innate immune cell function and bacterial infections in severe acute malnutrition
Amount £1,159,877 (GBP)
Funding ID 206225/Z/17/Z 
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 09/2017 
End 09/2022
Title HOPE-SAM database 
Description We have now developed the database to collect clinical and outcome data for the children recruited into this study. The database has been custom built and tested and data entry is now underway. 
Type Of Material Database/Collection of data 
Provided To Others? No  
Impact This database will allow us to characterize the baseline factors and outcomes of children recruited to this study 
Description Human geography, QMUL 
Organisation Queen Mary University of London
Department School of Geography
Country United Kingdom 
Sector Academic/University 
PI Contribution We have enrolled several cohorts of women and children in urban and rural Zimbabwe with rich quantitative data collection
Collaborator Contribution Training, capacity building and research in qualitative methodology, thereby bringing a social science lens to several major global health challenges
Impact 1. Manuscript on a One Health approach to stunting ( 2. Manuscript on maternal mental health in rural Zimbabwe (DOI 10.1017/gmh.2021.32) 3. Co-investigators on joint grant submitted to NIHR (awarded) 4. Capacity building and training for three Zimbabwean social scientists
Start Year 2018
Description Immunohistochemistry 
Organisation University of Chicago
Country United States 
Sector Academic/University 
PI Contribution Collaboration made between Prof Paul Kelly (co-investigator on this grant) and Prof Jerry Turner at University of Chicago, to undertake immunostaining on gut biopsy samples collected as part of this grant
Collaborator Contribution Collaboration sought out; biopsies obtained and shipped to Chicago
Impact Laboratory data on immunostaining for gut biopsy samples from chidlren with severe acute malnutrition
Start Year 2014
Description Metabolomics analysis 
Organisation Imperial College London
Department Computational and Systems Medicine
Country United Kingdom 
Sector Academic/University 
PI Contribution Provision of samples for analysis
Collaborator Contribution Analysis and interpretation of samples
Impact Regular joint meetings
Start Year 2017
Description UNICEF Zimbabwe 
Organisation UNICEF
Country United States 
Sector Public 
PI Contribution We have formed a partnership with UNICEF Zimbabwe to help interpret the results of the HOPE-SAM study, and to undertake operational research to understand the reasons underlying poor clinical outcomes of children with severe acute malnutrition. We are working together to build on the findings of this study by developing a package of care for children being dischaged from hospital following management of SAM.
Collaborator Contribution UNICEF are a major policy and programming organization both globally, and locally in Zimbabwe. They are providing technical expertise, the capacity to bridge the evidence-action divide, and financial support leading on from the primary MRC funding, to utilise the data collected in this study and ensure that it is translated into policy and practice.
Impact Two "Brown Bag" meetings were held in March 2022 with actors from the Zimbabwean Ministry of Health, the academic community in Zimbabwe, NGOs, clinicians and policymakers, to present and discuss the results of the HOPE-SAM study. The first meeting focused on outpatient outcomes, and the need to refocus attention on convalescence to reduce mortality and improve nutritional recovery, and included a round-table discussion; the second meeting focused on reducing mortality among children hospitalized with severe acute malnutrition.
Start Year 2019
Description UTH Zambia 
Organisation University Teaching Hospital
Country Zambia 
Sector Hospitals 
PI Contribution Collaboration with coinvestigators at UTH leading to writing this grant and receiving the MRC award. This collaboration has been strengthened as the award has started, with collaborative planning meetings and review of protocol, study forms etc. We have now enrolled and trained a full study team, begun study recruitment at this site and started data entry and analysis.
Collaborator Contribution Coinvestigators are based here, who will recruit patients into the study. Lab work will be undertaken in country. All staff have been trained and enrolment is underway.
Impact MRC Project grant
Start Year 2014
Description University of British Columbia, Vancouver 
Organisation University of British Columbia
Country Canada 
Sector Academic/University 
PI Contribution We have established a collaboration with a microbiome group led by Dr Amee Manges at UBC, to conduct microbiome analyses on samples collected from children with seere acute malnutrition
Collaborator Contribution Sought out a collaboration with Dr Manges's group and established the partnership
Impact Academic collaboration established and central questions for these analyses defined so far
Start Year 2015
Description University of Zimbabwe 
Organisation University of Zimbabwe
Country Zimbabwe 
Sector Academic/University 
PI Contribution Collaboration established between Queen Mary University of London and University of Zimbabwe for the purposes of this award, plus between University of Zimbabwe and University of Zambia. A full study team has now been recruited and trained at this site and the study has started enrolment after full ethical review and approvals. Laboratory work is ongoing and data entry underway.
Collaborator Contribution Co-investigators are based at UZ, will recruit patients into the proposed study and lab work will be undertaken in country
Impact This MRC grant was awarded as a result of the proposal written in collaboration with these co-investigators, and the collaboration has been strengthened through this award by initiating the study at this site
Start Year 2014
Description Caregiver dissemination event 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Study participants or study members
Results and Impact We held a caregiver dissemination event attended by almost 150 children and 250 caregivers in Harare, Zimbabwe. We provided flyers on the findings of several recent studies of severe acute malnutrition, had an interactive Q&A session about the findings, invited testimonials from study participants, and had a song and short drama from our community advisory board to explain the study findings. Children who had participated in the study had activities arranged by the Discovereum, a children's museum in Harare. The event triggered discussion about future research studies, what the participants' priorities were, and the multifactorial nature of malnutrition.
Year(s) Of Engagement Activity 2023
Description Interactive malnutrition game 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact We have developed an interactive science communication game called Baby Grow in conjunction with the Centre of the Cell at QMUL. The game involves trying to 'grow' a baby and introduces the challenges caregivers face with malnutrition in developing countries. It includes embedded links to science vox pops and information regarding enteropathy and inflammation in malnutrition. We engaged members of the public at the science museum to get end-user feedback about the game-play, to help develop the final version prior to its launch in the Centre of the Cell in London, and as a tablet version in our project sites in Zimbabwe and Zambia.
Year(s) Of Engagement Activity 2019