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In South Africa, prevention of mother to child transmission (PMTCT) has reduced MTCT from 3.6% in 2011 to 1.3% in 2017. However, there are challenges in reaching vulnerable HIV-positive children; those at increased risk of malnutrition or present late with advanced disease. Macro – and micronutrient deficiencies, common in HIV, may accelerate disease progression. This was a prospective cohort study of paediatric patients (aged 1–10 years) initiating ART between 08/2014 and 09/2016 at a public health facility in Johannesburg, South Africa. Trained clinic staff collected anthropometric indices and dietary intake at ART initiation and at one and three months post initiation. A blood sample was collected at ART initiation and at six months post initiation for biochemistry. We describe demographics, anthropometry, dietary intake, dietary diversity at enrolment and changes in anthropometry and biochemistry from ART initiation until six months for paediatric HIV-positive patients initiating antiretroviral therapy (ART). Twenty-seven patients were enrolled. The World Health Organization dietary intake recommendations for children were not met for the majority of nutrients including energy, fats, iron, calcium and Vitamin A at ART initiation. At least 40% of patients were receiving less than four of the main food groups. At initiation, 18.5% of children presented with severe acute malnutrition (MUAC <11cm), 14.3% were underweight (weight-for-age Z score <-2SD), 19.1% stunted (height-for-age Z score <-2SD) and 33.4% were wasted (weight-for-height <-2SD). At six months, there was a general increase in WHZ (<5 years), BMI (≥5 years), C-reactive protein, iron and albumin but a significant increase in Vitamin A. The results highlight the need for dietary counselling and provision of nutritional supplementation at ART initiation for paediatric patients. Adequate nutrition should be established early at initiation, to improve growth, development and health outcomes. [ABSTRACT FROM AUTHOR]