Comparative Effectiveness of Fixed and Standard RUTF Dosing Protocols for Treatment of Uncomplicated Severe Acute Malnutrition in Afghanistan.

Afghanistan has experienced persistently high wasting levels. To improve treatment accessibility and reduce costs, a simplified treatment protocol (STP) with a fixed daily dose of two sachets of ready-to-use therapeutic food (RUTF) for severe wasting was introduced. This study evaluated the effectiveness on recovery of a fixed RUTF dosage versus the standard weight-based dosage among children aged 6-59 months across 10 provinces in Afghanistan, five implementing the STP and five implementing the standard protocol. Per-protocol and intention-to-treat (ITT) analysis were conducted on secondary data, with generalised linear mixed-effects models and time-dependent weighted Cox proportional hazards models assessing the association between dosing strategy and outcomes. Using a mixed-methods design, primary quantitative and qualitative data were also collected from caregivers and program stakeholders to contextualize and explain these findings, including treatment satisfaction, barriers to access, and perceived costs. In the ITT 3265 children were included and 2912 children in the per-protocol analysis. In the ITT analysis, recovery was similar between STP (85.6%) and standard protocol (86.4%). For STP, adjusted models indicated a 5.8-day longer length of stay (LOS) (95% CI: 1.34, 12.93), and a lower MUAC gain velocity (-0.56 mm/week, 95%CI: -1.01, -0.11) compared to the standard protocol. Caregivers faced higher costs and an average of one additional visit under the STP due to the longer LOS. The fixed dosage for treating severe wasting in Afghan children yielded similar results to the standard dosage in terms of recovery and total weight gain. Adopting this reduced dosing strategy as standard should be weighed carefully against the potential for prolonged LOS, cost-effectiveness, additional financial burden and access constraints experienced by caregivers.