HIV and Nutrition

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

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 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 • 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) • 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 • 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 • 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 • 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 • 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 • 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 • Insufficient dietary intake • Malabsorption, diarrhea • Altered metabolism and nutrient storage • Increased HIV replication • Hastened disease progression • Increased morbidity Nutritional deficiencies • Increased oxidative stress • Immune suppression

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) • 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 • 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 • 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 • 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) • 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 • 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) • 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 • 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 • 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) • 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) • 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 • 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) • 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 • 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 • 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 • 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 • 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 • 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

Diarrhea • 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) • 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)

Fever • 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 • 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 • 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 • 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.

Some Recommended Foods

Some Recommended Foods (2)

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 • 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) • 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 • 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 • 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 • 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) • 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) • 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) • 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

HIV and Nutrition