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HIV and Nutrition. Unit 16 HIV Care and ART: A Course for Physicians. Learning Objectives. Describe the effect of HIV/AIDS on nutrition Describe the impact of malnutrition on HIV infection in adults Identify the effect of micronutrient supplementation on HIV progression.

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Hiv and nutrition

HIV and Nutrition

Unit 16

HIV Care and ART:

A Course for Physicians

Learning objectives
Learning Objectives

  • Describe the effect of HIV/AIDS on nutrition

  • Describe the impact of malnutrition on HIV infection in adults

  • Identify the effect of micronutrient supplementation on HIV progression

Learning objectives 2
Learning Objectives (2)

  • Review goals and components of nutrition care and support

  • Discuss nutrition recommendations for the symptoms associated with each stage of HIV disease

  • Provide information on how to manage nutrition-related symptoms of HIV

Malnutrition and hiv
Malnutrition and HIV

  • Malnutrition and HIV are prevalent worldwide with the highest rates of both in sub-Saharan Africa

  • Malnutrition influences immune function, the virulence of infectious agents, progression of chronic infections such as HIV, and genetic factors that determine the outcome of sepsis

  • The association between HIV morbidity and malnutrition is bi-directional

    • Malnutrition affects HIV disease progression

    • HIV affects nutritional status

Types of malnutrition protein energy malnutrition
Types of Malnutrition: Protein-Energy Malnutrition

  • Primary PEM caused by inadequate intake

  • Secondary PEM is the result of illness, injuries, or treatments causing altered appetite, digestion, absorption

  • Most common form of malnutrition in HIV disease

Types of malnutrition protein energy malnutrition 2
Types of Malnutrition: Protein-Energy Malnutrition (2)

  • Used to describe nutritional macrodeficiency syndromes

    • Marasmus: deficiency of calories

    • Kwashiorkor: deficiency of protein

    • Nutritional dwarfism in children and wasting syndromes in adults

  • Measured as body size by weight or body mass index [weight (kg) divided by height in (meters)2 ]

    • < 16: severely malnourished

    • 16-16.9: moderately malnourished

    • 17-18.4: mildly malnourished

    • 18.5-24.9: normal nutritional status

Types of malnutrition micronutrient nutrition
Types of Malnutrition: Micronutrient Nutrition

  • Alterations in the stores of fat- and water-soluble vitamins and trace elements

  • Clinical symptoms are subtle unless deficiency is severe

  • Often accompanies infectious diseases

  • Most common examples in children and adults:

    • Iron -> anemia

    • Vitamin A -> susceptibility to infection, associated with HIV-disease progression and increased mortality, increased maternal-fetal transmission

    • Iodine -> thyroid enlargement and hypothyroidism

Effect of hiv aids on nutrition reduced intake
Effect of HIV/AIDS on Nutrition: Reduced Intake

  • HIV is associated with reduced intake of food/nutrients

    • Cognitive impairment and/or depression -> reduced motivation and ability to access and prepare foods

    • Family instability or poverty -> reduced access to food

    • HIV-, OI-, or medication-induced -> anorexia and nausea

    • OIs of mouth and esophagus -> painful swallowing

Effect of hiv aids on nutrition reduced absorption
Effect of HIV/AIDS on Nutrition: Reduced Absorption

  • HIV is associated with reduced absorption of food/nutrients

    • Caused by HIV infection, OIs and ART

    • Mediated by diarrhea and damage to intestinal cells

    • Results in poor absorption of fats

      • Reduces absorption of fat-soluble vitamins, such as vitamins A and E

Effect of hiv aids on nutrition altered metabolism
Effect of HIV/AIDS on Nutrition: Altered Metabolism

  • HIV is associated with altered metabolism of food/nutrients

    • HIV and OIs increase catabolism and energy needs by 10 – 15%

    • Adult man needs an additional 400 calories/day (from 2100->2500)

    • Protein requirements increase by 50%

      • Men: 57 -> 85 of protein grams/day

      • Women: 48 -> 72 grams/day.

Effects of hiv on nutrition wasting
Effects of HIV on Nutrition: Wasting

  • Severe malnutrition in HIV-infected persons is recognized as “wasting”, defined as:

    • Body weight loss of > 10%

    • With associated fatigue, fever, and diarrhea unexplained by another cause

  • Etiology is multifactorial

  • Any weight loss of > 5% is associated with accelerated disease progression, impaired functional status, and increased mortality

  • “Wasting” is a WHO Stage 4 diagnosis and is a criterion for ARV initiation

The vicious cycle of malnutrition and hiv
The Vicious Cycle of Malnutrition and HIV

  • Insufficient dietary intake

  • Malabsorption, diarrhea

  • Altered metabolism and

    nutrient storage

  • Increased HIV replication

  • Hastened disease


  • Increased morbidity

Nutritional deficiencies

  • Increased oxidative stress

  • Immune suppression

Malnutrition and hiv aids
Malnutrition and HIV/AIDS

  • Affect the body in similar ways

  • Affect the ability of the immune system to fight infection and keep the body healthy through:

    • Disrupts CD4 number / function

    • Disrupts CD8 number / function

    • Alters delayed type cutaneous hypersensitivity

    • Alters CD4 / CD8 ratio

    • Impairs antibody response

    • Impairs bacteria killing

Malnutrition and hiv aids 2
Malnutrition and HIV/AIDS (2)

  • Low BMI is associated with disease progression and death

  • Nutrient deficiencies (vitamins A, B12, E, selenium, and zinc) are associated with worse outcomes

    • HIV transmission

    • Disease progression

    • Mortality

Psychosocial factors for malnutrition
Psychosocial Factors for Malnutrition

  • Food scarcity

  • Financial constraints

  • Family disruption

  • Loss of financial breadwinner

  • Loss of primary caregiver due to illness or death

  • Mental health factors: depression

Role of nutrition care and support
Role of Nutrition Care and Support

  • Clinical outcome of HIV is poorer in individuals with compromised nutrition

  • Improving nutrition can help prevent weight loss, strengthen the immune system, and delay HIV disease progression

  • Nutrition is part of comprehensive care along with OI management and ART therapy

Goals of nutrition care and support
Goals of Nutrition Care and Support

  • Improve eating habits and diet to:

    • Maintain weight, prevent weight loss

    • Preserve muscle mass

    • Build stores of essential nutrients

Goals of nutrition care and support 2
Goals of Nutrition Care and Support (2)

  • Prevent food-borne illnesses by promoting

    • Hygiene

    • Food and water safety

  • Manage symptoms affecting food intake by

    • Treating opportunistic infections

    • Treating pain

Components of nutritional care and support
Components of Nutritional Care and Support

  • Nutrition assessment:

    • Weight, height, mid-arm circumference, BMI

    • Access to food

    • Symptoms that may impede intake, absorption

    • Other infections such as TB

  • Nutrition supplementation

    • Food

    • Vitamin and mineral supplements

  • Food and nutrition support for families

    • Food-for-work

    • Community kitchens

    • Home-based care

Components of nutritional care and support 2
Components of Nutritional Care and Support (2)

  • Education and counseling

    • Adequate diet

    • Food handling and safety

    • Sanitation to avoid fecal-oral transmission

      • Water purification – boiling

      • Hand washing after defecation

  • Treat infections which will impact nutritional status such as tuberculosis

Stages of hiv disease and nutrition
Stages of HIV Disease and Nutrition

  • Specific nutrition recommendations vary according to the underlying nutritional status and extent (stage) of HIV disease progression

  • The disease progression may be categorized into three stages:

    • Early: no symptoms, stable weight

    • Middle: significant weight loss

    • Late: symptomatic, full-blown AIDS disease

Early stage
Early Stage

  • No symptoms, stable weight

  • Increased nutritional requirements during HIV-infection

    • Energy increase: 10 - 15%

    • Protein increase: ~ 50%

    • Vitamins and minerals used by the immune system are also increased

  • Main objective: remain as healthy as possible

    • Build stores of essential nutrients

      • Identify locally available and acceptable foods

    • Maintain weight and lean body mass, preserve muscle mass, and increase energy

      • Adequate diet

      • Maintain physical activity

Early stage 2
Early Stage (2)

  • Safe food and water handling practices

    • Wash hands before preparing and eating food, after using the toilet or changing nappies or diapers

    • Wash all food preparation surfaces, utensils and dishes

    • Wash all fruit and vegetables before eating, cooking or serving

    • Avoid letting raw food come in contact with cooked food

    • Cook food thoroughly (especially chicken and meats)

Early stage 3
Early Stage (3)

  • Safe food and water handling practices continued

    • Serve food immediately after preparation

    • Keep food covered and away from insects, rodents and other animals

    • Do not store cooked food

    • Use safe water for drinking, cooking, and cleaning dishes and utensils

    • Never use bottles with teats for feeding infants; use a cup instead

Middle stage
Middle Stage

  • Significant, unintentional or undesirable weight loss as a result of opportunistic infections

  • Main objective: minimize consequences

    • Increase nutrient intake for recovery/weight gain

    • Maintain intake during periods of acute illness and depressed appetite

    • Increase nutrition intake gradually to promote weight and muscle mass gain, and nutritional recovery

      • Make every bite count

      • Daily vitamin-mineral supplements

    • Continue physical activity as able

Middle stage 2
Middle Stage (2)

  • Manage and treat the symptoms that affect food intake:

  • Seek medical attention immediately if

    • Diarrhea is persistent and/or accompanied by fever

    • Fever lasts for more than 3 days

    • Mouth and throat sores are present

  • Avoid unhealthy behaviors

    • Alcohol, smoking and drug use

    • Unsafe sexual practices

Late stage
Late Stage

  • Symptomatic, full-blown AIDS disease

  • Main objective: provide comfort or palliative care

    • Treat all infections that affect intake

    • Modify diet according to symptoms

    • Maintain intake during periods of acute illness and depressed appetite

    • Encourage eating and physical activity as able

    • Provide psychological and emotional support

Symptom based nutrition care and support
Symptom-based Nutrition Care and Support

  • Managing the common symptoms that occur with HIV/AIDS disease will

    • Maximize and improve nutritional intake

    • Maintain weight and muscle mass

    • Improve quality of life

Loss of appetite
Loss of Appetite

  • Eat small, frequent meals throughout the day (5-6 meals/d)

  • “Make every bite count”

  • Drink plenty of liquids

  • Take walks before meals – the fresh air helps to stimulate appetite

  • Have family or friends assist with food preparation

  • Mouth care is advisable

Sore mouth and throat
Sore Mouth and Throat

  • Avoid citrus fruits, and acidic or spicy foods

  • Eat foods at room temperature or cold

  • Eat soft and moist foods

  • Avoid caffeine and alcohol

  • Frequent mouth care

Nausea and vomiting
Nausea and vomiting

  • Eat small, frequent meals and snacks to avoid an empty stomach

  • Eat dry bread or toast, and other plain dry foods, in the morning preferably before getting out of bed

  • Avoid foods with strong or unpleasant odors

  • Avoid fried foods

  • Avoid alcohol and coffee

  • Drink plenty of liquids

  • Avoid lying down immediately (at least 1 to 2 hours) after eating


  • Eat foods that travel slowly through the digestive tract and decrease stimulation of the bowel

    • Bananas, mashed fruits, soft white rice, porridge

  • Eat smaller meals, more often

  • Eliminate milk and milk products to see if symptoms improve

  • Avoid intake of fried and high fat foods

  • Don’t eat foods with insoluble fiber (roughage)

    • For example: Take the skin off fruits and vegetables

Diarrhea 2
Diarrhea (2)

  • Drink plenty of fluids (8-10 cups/day) to prevent dehydration

  • Avoid sweet drinks, drink diluted juice instead

  • Avoid very hot or very cold foods

  • If diarrhea is severe

    • Give oral rehydration solution

    • Food may be withheld for 24 hrs or restricted to only clear fluids (soups or tea) or soft foods (mashed fruit, potatoes, white rice, porridge)


  • Drink plenty of fluids

  • Eat small frequent meals, including snacks between meals

    • As tolerated at regular intervals

  • Mouth care is advisable

  • Add snacks between meals

Altered taste
Altered Taste

  • Use flavor enhancers such as salt and a variety of herbs and spices

  • Try different textures of food

  • Chew food well and move it around the mouth

    • This stimulates taste receptors

Poor fat absorption
Poor Fat Absorption

  • Eliminate oils, butter, margarine, ghee, and foods that contain or were prepared with them

  • Eat lean meats

    • Trim all visible fat and remove skin from chicken

  • Avoid deep fried, greasy, and high fat foods

  • Eat fruits and vegetables and other low-fat foods.

Fatigue lethargy
Fatigue, Lethargy

  • If possible, have someone pre-cook foods

    • This will help the patient conserve energy

  • Eat fresh fruits that don’t require preparation in-between meals

  • Eat smaller, more frequent meals and snacks throughout the day

  • Exercise as able

    • This will increase energy

  • Try to eat at the same time each day.

Foods to avoid
Foods to Avoid

  • Raw eggs

  • Undercooked chicken and meats

    • No raw, rare, or medium rare meats

  • Water that is not boiled or juices that are made from water that is not boiled.

  • Alcohol and coffee

  • “Junk” foods such as chips, biscuits, and sweets with little nutritional value

  • Foods that aggravate symptoms related to diarrhea, nausea/vomiting, bloating, loss of appetite, and mouth sores

Nutrition and medication
Nutrition and Medication

  • Medications used to treat HIV opportunistic infections may cause drug-nutrient interactions or side effects:

    • Vitamin B6 supplementation should be administered with isoniazid therapy for tuberculosis to avoid Vitamin B6 deficiency

    • Iron- and zinc-containing supplements should not be taken with ciprofloxacin

    • Sulfadoxine and Pyrimethamine (Fansidar) is not recommended unless folinic acid supplement is given

Nutrition and medication 2
Nutrition and Medication (2)

  • Antiretroviral drugs may have:

    • Dietary requirements (e.g., with or without food)

    • Side effects with nutritional consequences such as diarrhea or nausea/vomiting

    • An effect on red blood cell production causing anemia (e.g., Zidovudine - AZT)

The multidisciplinary team
The Multidisciplinary Team

  • A multidisciplinary team is crucial to address the many complex and varied factors in the care of HIV-infected patients and their families

  • Each member of the team can help address these issues in their own way:

    • Nurses and nutritionists

    • Counselors

    • Community workers and agencies

Group discussion implementation issues
Group Discussion: Implementation Issues

  • Who will have the expertise, time and resources for nutritional assessment and counseling?

    • Are nutritionists part of military, police and civilian medical institutions?

    • Are clinical nutritionists available for HIV clinics?

  • How is malnutrition currently treated at your site?

    • Are resources for inpatient or outpatient management available?

    • Do you use them?

Key points
Key Points

  • HIV can lead to malnutrition by multiple mechanisms

  • Malnutrition is associated with increased HIV transmission, progression, and mortality

  • Nutritional supplementation is associated with improved HIV-related outcomes in children, pregnant women and other adults

Key points 2
Key Points (2)

  • Maintaining adequate nutrition prolongs well-being of HIV-infected persons but is difficult

  • HIV affects nutrition in three, sometimes overlapping, ways:

    • Reduces amount and type of food consumed

    • Interferes with the digestion and absorption of nutrients

    • Alters metabolism of nutrients

Key points 3
Key Points (3)

  • Counseling and other interventions to prevent or reverse weight loss are likely to have their greatest impact early in the course of HIV infection

  • Nutritional care and support should be part of a comprehensive program that deals with the needs of the patient and his or her family

  • Nutritional supplements, particularly antioxidant vitamins and minerals, may improve immune function and other HIV-related outcomes, particularly in nutritionally vulnerable populations

Key points 4
Key Points (4)

  • Managing common symptoms related to HIV/AIDS such as diarrhea, nausea, and loss of appetite, can minimize their impact on nutritional status

  • Prevention of food- and water-borne infections reduces the risk of diarrhea, a common cause of weight loss, malnutrition and HIV disease progression in people living with HIV and AIDS

  • Continuing physical activity and exercise, as appropriate, increases energy, stimulates appetite and preserves and builds lean body mass