1. HIV and Nutrition Unit 16 HIV Care and ART: A Course for Physicians

2. Unit 16: HIV and Nutrition 2 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

3. Unit 16: HIV and Nutrition 3 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

4. Unit 16: HIV and Nutrition 4 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

5. Unit 16: HIV and Nutrition 5 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

6. Unit 16: HIV and Nutrition 6 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

7. Unit 16: HIV and Nutrition 7 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

8. Unit 16: HIV and Nutrition 8 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

9. Unit 16: HIV and Nutrition 9 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

10. Unit 16: HIV and Nutrition 10 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.

11. Unit 16: HIV and Nutrition 11 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

12. 12 Increased HIV replication Hastened disease progression Increased morbidity Nutritional deficiencies Increased oxidative stress Immune suppression Insufficient dietary intake Malabsorption, diarrhea Altered metabolism and nutrient storage The Vicious Cycle of Malnutrition and HIV

13. Unit 16: HIV and Nutrition 13 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

14. Unit 16: HIV and Nutrition 14 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

15. Unit 16: HIV and Nutrition 15 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

16. Unit 16: HIV and Nutrition 16 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

17. Unit 16: HIV and Nutrition 17 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

18. Unit 16: HIV and Nutrition 18 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

19. Unit 16: HIV and Nutrition 19 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

20. Unit 16: HIV and Nutrition 20 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

21. Unit 16: HIV and Nutrition 21 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

22. Unit 16: HIV and Nutrition 22 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

23. Unit 16: HIV and Nutrition 23 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)

24. Unit 16: HIV and Nutrition 24 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

25. Unit 16: HIV and Nutrition 25 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

26. Unit 16: HIV and Nutrition 26 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

27. Unit 16: HIV and Nutrition 27 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

28. Unit 16: HIV and Nutrition 28 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

29. Unit 16: HIV and Nutrition 29 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

30. Unit 16: HIV and Nutrition 30 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

31. Unit 16: HIV and Nutrition 31 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

32. Unit 16: HIV and Nutrition 32 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

33. Unit 16: HIV and Nutrition 33 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)

34. Unit 16: HIV and Nutrition 34 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

35. Unit 16: HIV and Nutrition 35 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

36. Unit 16: HIV and Nutrition 36 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.

37. Unit 16: HIV and Nutrition 37 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.

38. Unit 16: HIV and Nutrition 38 Some Recommended Foods Food GroupFood Protein (body-building foods) All animal products, fish, dairy products, legumes (beans, lentils), groundnuts and cooked eggs Carbohydrate (energy-giving foods) Breads, cereals (maize, millet, wheat, sorghum), rice, noodles, potatoes, cassava, yam, sweet potatoes, plantain

39. Unit 16: HIV and Nutrition 39 Some Recommended Foods (2) Food GroupFood Fruits/Vegetables (source of many vitamins and minerals) Any fruits or vegetables Fats/Oils (source of fat soluble vitamins A, E, D &k and energy) Palm oil, vegetable oils, lard, margarine, butter, ghee

40. Unit 16: HIV and Nutrition 40 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

41. Unit 16: HIV and Nutrition 41 Nutrition and Medication  Medications used to treat HIV opportunistic infections may cause drug-nutrient interactions or side effects:  Vitamin B 6 supplementation should be administered with isoniazid therapy for tuberculosis to avoid Vitamin B 6 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

42. Unit 16: HIV and Nutrition 42 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)

43. Unit 16: HIV and Nutrition 43 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

44. Unit 16: HIV and Nutrition 44 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?

45. Unit 16: HIV and Nutrition 45 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

46. Unit 16: HIV and Nutrition 46 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

47. Unit 16: HIV and Nutrition 47 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

48. Unit 16: HIV and Nutrition 48 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