Early Initiation of Antiretroviral Therapy Among Young Children: A Long Way to Go

should be done to determine whether this increase in grip strength is associated with improvements in morbidity or quality of life. Curiously, an increase in grip strength was not seen in the delayed supplementation group although weight and LBM improved at a faster rate than in the early supplementation group. Ultimately, the investigators saw no effect of supplementation on viral load at any of the time points in their study and similar to the other studies in our systematic review, all groups showed significant declines in viral load 3 months after ART initiation, as would be expected. Although there was some suggestion of an improvement in CD4+ cell counts with whey protein, this effect diminished 3 months after supplementation ended. Finally, as Olsen et al observe in their article, the scale-up of nutritional supplementation that Ethiopia undertook for all patients with HIV and BMI ,18.5 after the study ended did not seem to fare well, with more than 70% of patients defaulting from supplementation. Although the delayed intervention design is one that should be encouraged more widely in research studies of nutritional supplementation to answer some of the remaining scientific questions, it is clear that information from these types of efficacy trials is not enough to translate promising results into policy. A case study or an effectiveness trial of the program in Ethiopia could provide important information on how countries can successfully scale-up nutritional assessment, counseling, and support and avoid some of the challenges that Ethiopia has faced.