1. Session 2: Nutrition Complications with HIV and AIDS
Nutrition Management with HIV and AIDS: Practical Tools for Health Workers
Session 2 should take approximately 2 hours
Step 1: Introduction and Learning Objectives (Slides 2-6) - 10 minutes
Step 2: Causes of Malnutrition (Slide 7) – 10 minutes
Step 3: Nutrition Complications with HIV and AIDS (Slides 8-29) - 40 minutes
Step 4: Case studies (Slide 30) – 45 minutes
Step 5: Key Points (Slides 31) – 5 minutes
Step 1: Introduction and Learning Objectives (Slides 1-6) - 10 minutes
Introduce this session by asking participants what nutrition complications they have seen in clinics. Ask how these complications can impact nutrition. Why are we discussing nutrition and these complications?
This discussion should touch on the fact that nutrition complications like having a poor appetite, diarrhoea, etc, can reduce the amount of food that one eats, leading to weight loss or micronutrient deficiencies leading to a decline in immune system function and overall health.

2. Objectives Define nutrition complications related to HIV and AIDS
Identify ways to manage nutrition complications
Review session learning objectives.
Before showing the next Slide, ask participants what they think is the definition of malnutrition.

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
Stress that malnutrition is not only when a person does not eat enough, which is one part of the definition. Malnutrition is also when a person eats too much of one food and not enough of another.
Malnutrition is a very serious problem for PLWHA because we know from research that malnutrition, in the form of very low body weight, can decrease rates of survival for PLWHA.

4. Vicious Cycle of Malnutrition and HIV
Poor Nutrition
resulting in weight loss, muscle wasting, weakness, nutrient deficiencies
Increased Nutritional needs
Reduced food intake and increased loss of nutrients
Increased vulnerability to infections
e.g. Enteric infections, flu, TB hence Increased HIV replication, Hastened disease progression Increased morbidity
Impaired immune system
Poor ability to fight HIV and other infections, Increased oxidative stress
HIV
This represents the vicious cycle of malnutrition and HIV where poor nutrition leads to an impaired immune system, and in turn an increase in opportunistic infections and progression of HIV, leading to an increase in nutrient needs.
Keep this cycle in mind throughout this session as we discuss how to change this to a positive cycle
Source: Nutrition and HIV/AIDS: A Training Manual Regional Centre for Quality Health Care, FANTA, LINKAGES, Kampala, Uganda. Online:
Source: RCQHC/FANTA/LINKAGES

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)
Research has linked HIV with nutrition status where we see decreased survival rates with a greater than 10% weight loss. We also see greater risk of OI onset with weight loss.
References:
Wheeler DA, Gilbert CL, Launer, CA, Muurahainen N, Elion RA, Abrams DI, Bartsch GE, The Terry Beirn Community Programs for Clinical Research on AIDS. Weight loss as a predictor of survival and disease progression in HIV infection. J Acquir Immune Defic Syndr 1 May 1998;18(1):80-85.
Tang AM, Forrester J, Spiegelman D, Knox TA, Tchetgen E, Gorbach SL. Weight loss and survival in HIV-positive patients in the era of highly active antiretroviral therapy. J Acquir Immune Defic Syndr Oct 1;31(2):230-6

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
Several studies have shown a relationship between micronutrients and HIV. Since early research on HIV, MN deficiencies have been found in HIV-infected individuals, such as selenium, B12, C. Also pregnant women had lowest vitamin A levels, as well as injection drug users.
Iron deficiency and overload have both been problems with HIV, as well. This will be discussed a bit later in this session when we talk about iron deficiency anaemia
In many studies, micronutrient supplementation has shown to have a positive effect on reducing morbidity and mortality in both adults and children whether on HAART or not.
Study References: [not to be read by facilitator]
Tang AM, Lanzillotti J, Hendricks K, Gerrior J, Ghosh M, Woods M, Wanke C. Micronutrients: Current issues for HIV care providers. J Acquir Immune Defic Syndr 2005, 19:
Jones CY, Tang AM, Forrester JE, Huang J, Hendricks KM, Knox TA, Spiegelman D, Semba RD, Woods MN. Micronutrient levels and HIV disease status in HIV-infected patients on highly active antiretroviral therapy in the Nutrition for Health Living Cohort. J Acquir Immune Defic Syndr 2006.
Fawzi W, Msamanga G, Spiegelman D, Renjifo B, Bang H, Kapiga S, Coley J, Hertzmark E, Essex M, Hunter D. Transmission of HIV-1 through breastfeeding among women in Dar es Salaam, Tanzania. J Acquir Immune Defic Syndr Nov 1;31(3):331-8.
Fawzi WW, Msamanga GI, Spiegelman D, Wei R, Kapiga S, Villamore E, Mwakagile D, Mugusi F, Hertzmark E, Essex M, Hunter DJ. A randomized trial of multivitamin supplements and HIV disease progression and mortality. N Engl J Med 2004 Jul 1; 351(1):
Jiamton S, Pepin J, Suttent R, Filteau S, Mahakkanukrauh B, Hanshaoworakul W, Chaisilwattana P, Suthipinittharm P, Shetty P, Jaffar S. A randomized trial of the impact of multiple micronutrient supplementation on mortality among HIV-infected individuals living in Bangkok. J Acquir Immune Defic Syndr 2003 Nov 21;17(17):
Kaiser JD, Campa AM, Ondercin JP, Leoung GS, Pless RF, Baum MK. Micronutrient supplementation increases CD4 count in HIV-infected individuals on highly active antiretroviral therapy: a prospective, double-blinded, placebo-controlled trial. J Acquir Immune Defic Syndr 2006 Aug 15; 42(5):523-8.

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
Step 2: Causes of Malnutrition (Slide 7) – 10 minutes
There are direct and indirect causes of malnutrition: Direct are ones that can more immediately be remedied, such as behaviors and side-effects to HIV or medications. Indirect causes require larger efforts and interventions to address, but are essential to realise.
Discuss each of these causes and write down discussion points on a flip chart.
For example:
What food behaviours do participants feel lead to malnutrition? Are some of these related to cultural beliefs, i.e. women shouldn’t eat eggs because it will lead to infertility, or choosing cool drinks over nutritious foods.
How does HIV disease contribute to malnutrition?
What side effects of medications or HIV do they see in their clients? How do these contribute to malnutrition?

8. Specific Complications with HIV/AIDS
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
Step 3: Nutrition Complications with HIV and AIDS (Slides 8-27) - 40 minutes
Refer participants to Symptom Management Guide Handout 2.1.
Each of these will be discussed in detail now.
For these complications, we provide suggestions for management, but need to always take a client’s individual situation into consideration so that we’re not just telling the client what to do, but suggesting things they can do to improve their nutrition and health.

9. Loss of Weight Extremely dangerous due to: Key interventions:
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)
Any amount of weight loss is dangerous for a person with HIV because as soon as a person begins to lose weight unintentionally, their immune function decreases, their risk of infection increases, and their chances of survival diminish. This is particularly true for children as well.
The first key intervention related to weight loss is to prevent any loss from the time of diagnosis. This can be done with nutrition promotion and identification of gaps in food availability or access early on. Weight loss can also be managed appropriately with early detection and treatment. Nutrition management of weight loss and other related side effects (diarrhoea, poor appetite, etc) can also help manage weight loss and promote weight gain.
Each client assessment should include measuring height, weight, and calculating the body mass index. This index will be discussed in more detail in Module 7, but it basically provides an estimate of how appropriate one’s weight is for their height, not taking into account sex or age.

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
Nutritionally, weight loss can be managed by encouraging the client to increase their energy intake from food. This would include adding higher calorie foods to staple foods: i.e. groundnuts, oils, butter, eggs, milk/milk products, etc. They can also increase the energy intake by eating more frequently.
Other symptoms such as diarrhoea, poor appetite, mouth sores, etc, should be addressed as well. Management of these symptoms will be discussed in the coming Slides. Health workers should also discuss food availability and access issues with clients. Clients who have lost significant amounts of weight should be monitored closely and weighed regularly to track their progress.

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
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
Nausea and/or vomiting are caused by either medications, HIV infection itself, or other infections.
This can lead to poor food intake and weight loss because a person who is nauseous may not want to eat anything.
To manage nausea and/or vomiting we can suggest the following:
Eat smaller meals, more frequently through the day
Try eating dry foods, as these tend to ease the stomach such as eembe (dried or fresh), mahangu bread/cake, other dry breads or fruits.
Avoid lying down after meal. Suggest that after eating a meal, remain sitting up for at least 30 minutes. Lying down after eating or drinking anything might worsen the nausea
Drink liquids between or after meal. Liquids fill the stomach fast, so try and avoid drinking a lot while eating. Suggest eating foods then after 30 minutes or more, they can drink something. It is also important to prevent dehydration so ensure clients do drink enough fluids during the day.
Other tips include drinking tea with ginger, if available.
Assure adherence to medications and as 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
When a person has a fever, their body temperature rises, making the body work much harder. Because of this, a person with a fever needs more energy for the body to keep up.
Because the body uses a lot of energy, fevers can lead to weight loss.
Therefore more food is needed to increase energy intake. Since the body temperature increases and decreases in waves, it might be most useful to feed someone with a fever more during the lows in body temperature. Food should be high in energy from carbohydrates, proteins and fats.

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
Diarrhoea can be one of the most serious problems for people with HIV.
It is mainly caused by malabsorption (or poor absorption of nutrients into the body), HIV or other infections, or medications.
Explain the term malabsorption, and ask participants what they think it means.
Diarrhoea can lead to rapid weight loss, dehydration, and 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
To manage diarrhoea, the first priority is to treat dehydration. This can be done by using oral rehydration solution (ORS) or if that is not available, using a homemade solution for rehydration.
Home solution for dehydration:
Sugar-salt solution: 8 teaspoons sugar plus ½ teaspoon salt added to 1 litre clean water
Cereal and salt solution: 2 handfuls of powdered cereal or grain (mahangu, maize, etc) plus ½ teaspoon of salt added to 1 litre clean water.
These solutions should be made correctly and given in small portions throughout the day, especially after each loose stool.
Other suggestions for managing diarrhoea include eating more easy-to-digest foods, small meals more frequently, avoiding fatty foods if having malabsorption, and avoiding high sugar foods. We suggest avoiding high sugar foods because sugars are digested very fast in the GI tract leading to a decrease in absorption of water by the GI tract, making diarrhoea and malabsorption worse.

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
When dealing with an illness, people often lose their desire to eat and consequently do not eat very much. This is called anorexia or loss of appetite. This can be serious because it means that the person is probably not getting all the nutrients they need.
Poor appetite or loss of appetite can be managed by eating smaller meals more frequently, but high energy meals.
We also suggest that one eats the most when they are hungry or have an appetite to make up for times when they do not want to eat.
Add locally available herbs or spices to meals Discuss herbs available in area. How can clients use herbs to flavour foods – are herbs used often? Which ones?
Exercise, like walking, gardening, etc can help improve the appetite as well.

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
Medications that PLWHA often take, such as ART, can cause changes in taste or a metallic taste in the mouth. This can also happen when someone has many mouth sores or mouth infections.
To manage changes in taste, it is important to first treat any mouth sores if applicable. Health workers can help clients by providing treatment or ointments. In addition to medical treatment, adding herbs or seasonings to foods can improve the flavour. Also, clients should be encouraged to practice good oral hygiene, such as brushing teeth often.

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
Mouth sores can be caused by medications or infections and are fairly common among HIV-infected clients.
To manage mouth sores with nutrition, clients can be encouraged to try softer, mashed food or drinks such as porridge, mashed vegetables (pumpkin), yoghurt, bananas, etc.
Because mouth sores can be irritating, acidic foods might worsen the pain. Therefore, these foods should be avoided – foods such as oranges, lemons/lemon juice, and tomatoes. For extra vitamin C from non-acidic foods, suggest that the client eat more potatoes, which have vitamin C but will not irritate the mouth.
Liquids should be taken through a straw to keep the mouth dry, promote healing, and prevent dehydration. The more moist the mouth remains, the slower wounds may heal. But we do not want clients to become dehydrated by not drinking enough liquids.

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
Multiple causes of anemia:
Anemia of chronic disease (ACD)
 Hb,  Reticulocytes,  Serum Fe,  Transferrin,  % Fe saturation, normal or  serum ferritin, low serum EPO, normal or  Fe stores in bone marrow
Nutrient deficiencies (Fe, folate, B12)
Hookworm, malaria
Malignancies
Opportunistic infections of bone marrow
ART use (ZDV), other OI drugs suppress RBC production
(adapted from Piwoz, EG. Micronutrients HIV and AIDS: Review of knowledge, gaps and recommendations Presentation. AED 2006)

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
Iron supplements, especially if anaemia is not iron deficiency related, may be more harmful
Recommend: take 1 daily multivitamin/mineral supplement that includes iron and encourage iron-rich foods like meats, beans, eggs, and spinach

21. Vitamin A Deficiency and Supplementation
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
Vitamin A supplementation not recommended for pregnant women except as part of a multivitamin
Vitamin A supplementation recommended for post-partum women
Adult dose for vitamin A supplementation: 200,000 U within the first month post-partum
Children: 100,000 u at 6-9 months, then 200,000 U every 6 months until 6 years old.

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)
Zinc and selenium both play an important role in immune function
Research has shown that PLWHA on HAART tend to have low levels of zinc (Jones et al., JAIDS 2006) and that selenium can improve ART response (Odonukwe NN et al. 2006). Supplementation may be necessary to correct the deficiencies.
Since zinc and selenium supplements are likely not available, the recommendation is to provide a daily multivitamin/mineral supplement that contains adequate levels of zinc and selenium.
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
Both HIV and HAART have shown to accelerate bone loss, potentially leading to early osteoporosis
Recommend intake of calcium and vitamin D-rich foods:
Milk, cheese, yoghurt (best sources for both calcium and vit D)
Spinach
Dried fish
Beans, lentils, peas
Also provide a multivitamin/mineral supplement. *very important that the supplement has BOTH vitamins and minerals in it, not only vitamins*
And recommend avoiding 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
People with TB may need increased calorie intake (from 10-30%) depending on severity of disease or other infections. With a lot of weight loss (more than 10% of usual weight), a person may need up to 30% increase in calorie intake from foods. This could be equivalent to one additional, nutritious snack each day
Increase foods rich in protein, vitamins and minerals to rebuild and heal lung tissues
Increase vitamin B6-rich foods with skin irritations or numbness
These foods include 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
When people are ill, they often do not feel like eating or cannot physically feed themselves. These are times when people need extra support from family or community members to ensure they eat enough.
Terminally ill clients should be cared for with extra comfort to manage pain. In terms of food, they should not be forced to eat, but encouraged to eat small amounts of food and drink plenty of fluids as tolerated as part of comfort care.
Patients in the hospital may need assistance with eating, as family members may not always be available to assist. This should be considered by health workers in wards where patients are often too ill to eat. Patients can recover much faster if they are able to eat well.
As with patients in the hospital, those who are at home may also need assistance with eating. Home based care and other support systems should be considered to provide assistance.

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.
When we talk about “nutrition management” we are referring to the provision of counselling and nutrition advice to assist a person in improving their nutrition and overall health status.
We need to always remember that food is not a cure for HIV, but can help a person feel better and live longer with HIV.
Nutrition counselling and education should be given in an integrated way, with other medical treatments or services such as provision of 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
When providing nutrition counselling, it is very important to remain open-minded and non-judgmental with the client. Listen to him/her carefully and respond to what they are saying. Remember that each client is different with different needs.
The health worker is there to provide advice, counselling and information, but the decisions around food are to be made by the client after receiving all information from the health worker. Also, each client’s household situation is different; therefore counselling needs to be tailored to their specific situation. In many communities, assistance may be available through community programmes/initiatives.
Keep an eye out for such programmes and refer clients as appropriate. Lastly, ALWAYS follow up with clients. Follow up also with home-based care, if this is available in the community. Many times, HBC volunteers see many more sick clients and can provide feedback on a client’s progress.

28. Case Study Step 4: Case studies (Slide 28) – 45 minutes
Refer to the Facilitator Guide and Worksheet 2.1 for this activity

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
Step 5: Key Points (Slides 29) – 5 minutes
Review key points as listed on the Slide.