Session 2: Nutrition Complications with HIV and AIDS

1. Session 2: Nutrition Complications with HIV and AIDS Nutrition Management with HIV and AIDS: Practical Tools for Health Workers

2. Objectives • Define nutrition complications related to HIV and AIDS • Identify ways to manage nutrition complications

3. Malnutrition Defined • Malnutrition is when: • A person does not eat enough food • A person eats too much of one food group and not enough of other food groups containing protein, vitamins and minerals • Malnutrition decreases quality of life and ability to work • Serious problem for people with HIV and AIDS

4. Poor Nutrition resulting in weight loss, muscle wasting, weakness, nutrient deficiencies Impaired immune system Poor ability to fight HIV and other infections, Increased oxidative stress Increased Nutritional needs Reduced food intake and increased loss of nutrients HIV Increased vulnerability to infections e.g. Enteric infections, flu, TB hence Increased HIV replication, Hastened disease progression Increased morbidity Vicious Cycle of Malnutrition and HIV Source: RCQHC/FANTA/LINKAGES. 2003 http://www.fantaproject.org/focus/preservice.shtml

5. Weight Loss and HIV • >10% weight loss shown to decrease survival in HIV-positive patients (Wheeler 1998; Tang 2002) • Weight loss associated with onset of opportunistic infections (Wheeler 1998)

6. Micronutrients (MN) and HIV • Since beginning of HIV epidemic, MN deficiencies found in HIV+ individuals • Selenium, B12, C lower in HIV+ compared to HIV- healthy controls • Vitamin A levels lowest in pregnant women in developing countries, but also in injection drug users • Iron deficiency and overload have deleterious effects on immune system • Serum MN levels vary depending on stage of disease and acute phase response therefore difficult to research • MN supplementation shown in many studies to have effect on morbidity and mortality in adults and children on HAART or not

7. Causes of Malnutrition • Unhealthy eating habits (not choosing nutritious foods and drinks), alcohol or cigarette use • HIV infection and co-infections • Side effects of medications (weight loss, diarrhoea, etc) • Food insecurity, poverty • Pregnancy • Metabolic and endocrine changes

8. Wasting syndrome Loss of appetite Nausea and/or vomiting Fevers Diarrhoea or malabsorption Tuberculosis Sores of the mouth or throat Changes in taste Metabolic or endocrine changes Micronutrient deficiencies Specific Complications with HIV/AIDS

9. Extremely dangerous due to: Loss of immune function Increased risk of infection Shortened survival Key interventions: Prevention of weight loss and malnutrition Identify and treat weight loss early Nutrition management Weight, height and body mass index (BMI) Loss of Weight

10. Loss of Weight: Nutrition Management • Address other symptoms or infections • Evaluate causes, check for parasites • Increase energy intake from food (add high-energy meals/snacks) • Address food availability issues • Obtain height and weight at each visit • When available, add multivitamin supplements and/or high calorie protein drinks

11. Wasting Syndrome • Loss of greater than 10% of body weight, unintentionally, with persistent or chronic diarrhoea or unexplained, persistent fevers for greater than 1 month • Loss of >10% body weight (measured and unintentional) over preceding 12 months OR loss of 5% body weight in 6 months sustained for 1 year

12. Nausea and/or Vomiting • Nausea: a stomach distress with distaste for food and an urge to vomit • Caused by medications, HIV, and other infections • Leads to poor food intake and weight loss • Management: • Small meals, frequently • Dry foods • Avoid lying down after meal • Drink liquids between or after meal • Assure adherence to medications and, if possible, take medications with food

13. Fever • A rise of body temperature above the normal (36.7 degrees Celsius) • High body temperature leads to high energy use and weight loss • Need increased energy intake from food • Need increased fluid intake

14. Persistent Diarrhoea • Diarrhoea: 3 or more loose or watery stools in a 24 hour period • Persistent diarrhoea: diarrhoea that lasts for 2 weeks or more • Caused by malabsorption, HIV, other infections, and/or medications • Leads to weight loss, dehydration, malnutrition • Chronic diarrhoea can lead to malabsorption of medications, leading to suboptimal levels of ART

15. Nutrition Management of Persistent Diarrhoea • Treat dehydration (ORS, home solution) • Easy-to-digest foods (porridge, rice, bread, bananas, cooked apples, yoghurt/omaere) • Small meals, frequently • Avoid rough foods like some raw greens or cabbage; instead cook these until soft and easier to digest • Avoid fatty foods (with fat malabsorption) • Avoid high sugar foods

16. Loss of Appetite or Anorexia • Caused by medications or illness • Management: • Small, high energy meals, frequently • Eat most when feeling hungry • Add locally available herbs or spices to meals • Exercise

17. Changes in Taste • The loss or change in taste sensation causing less desire to eat food • Mouth often tastes metallic • Caused by medications or mouth sores • Management • Maintain oral hygiene • Treat sores • Add herbs/seasonings to foods • If meat is not appealing, encourage other protein foods like chicken, eggs, fish, beans or milk

18. Thrush or Sores in the Mouth • A fungal infection causing painful sores in mouth and throat affecting food intake • Caused by medications or infections (more persistent with low CD4 level) • Management: • Maintain oral hygiene: rinse mouth with warm water plus salt or bicarbonate of soda • Choose soft, mashed foods • Drink liquids with straw • Avoid high acid foods (ex: oranges, tomatoes) • Avoid sugary foods (sugar promotes yeast growth) • Assure adherence to medications

19. Iron Deficiency and Anaemia • Anaemia has multiple causes • Chronic illness, low serum Fe • Nutrient deficiency (Fe, folate, B12) • Hookworm, malaria, malignancy, OI, and AZT use

20. Iron Deficiency and Anaemia (2) • Iron supplements, especially if anaemia is not iron deficiency related, may be more harmful • Recommend: multivitamin/mineral (MVM) supplement and encourage iron-rich foods

21. Vitamin A Deficiency and Supplementation • Vitamin A Deficiency • Most significant in children and post-partum women • Indications for supplementation: • Preventative vitamin A supplement immediately after birth to all women and to all children 0-5 years old • Treatment doses for diarrhoea, measles, pneumonia in children • Unclear if beneficial in addition to MVM for PLWHA; best taken in MVM

22. Zinc and Selenium • Zinc and Selenium • Some research indicates zinc deficiency in PLWHA on HAART • Selenium supplementation shown to improve HAART response • Ensure adequate levels in MVM supplement • Zinc supplements (20mg) beneficial in diarrhoea treatment (but not yet available in state sector in Namibia)

23. Calcium and Bone Problems • HIV and HAART shown to promote bone loss, still under research • Could lead to early osteoporosis • Encourage calcium and vitamin D-rich foods: • Milk, cheese, yoghurt • Spinach • Dried fish • Beans, lentils, peas • Prescribe multivitamin/mineral supplement • Avoid alcohol and excessive caffeine use

24. Specific Nutrient Considerations with TB • Increased calorie intake (10-30% more) • Increase foods rich in protein, vitamins and minerals to rebuild and heal lung tissues • Increase vitamin B6-rich foods if having skin irritations or numbness • Beans, brown bread, bananas, potatoes, oilseeds, unsifted maize, green leafy vegetables • Increase fermented foods and drinks to increase “good” bacteria, often destroyed by TB medications

25. Nutrition During Illness • All people need food at all times – if they are sick or not • For terminally ill clients, provide extra comfort and hydration • Assist patients in hospital with eating • For out-patients, ask about home based care or other support in the home or community

26. “Nutrition Management” • What does this mean? • “Management” involves counselling, education and giving nutrition advice • Food is not a cure for HIV, but it can help a person feel better and live longer • Integrate with other health interventions like medications, immunisations, etc.

27. Nutrition Counselling • Listen to the client • Each client is different • Allow client to make decision, but provide guidance • Consider household/food situation • Refer for community assistance • Follow-up

28. Case Study

29. Key Points • Malnutrition and weight loss are serious for people living with HIV and AIDS, impacting the rate of morbidity and mortality • Proper nutrition can help manage complications • Make sure clients are still eating, even when they are sick • Help clients address difficulties early to prevent malnutrition