1. Nutritional Implications of HIV/AIDS Presented by Sharmaine E. Edwards Director, Nutrition Services Ministry of Health, Jamaica 2006 March 29

2. Outline Causes and manifestations of malnutrition in HIV/AIDS Nutrition screening

3. Outline Causes and manifestations of malnutrition in HIV/AIDS Managing Nutrition and Food-related Problems Antiretroviral Medications and Food- Drug Interactions

4. Introduction Nutritional problems are prevalent Complex, multi-factorial etiology Negative impact on immunity & overall health Decreased quality of life and ability to perform activities of daily living Increased health care costs

5. Link Between Malnutrition and HIV

6. Link Between Malnutrition & HIV/AIDS Malnutrition Wasting Decreased Immunity Opportunistic Infections Increased risk of mortality Increased requirements Decreased Intake Increased losses HIV Disease progression to AIDS

7. Malnutrition in HIV/AIDS Starvation inadequate energy intake or malabsorption adaptation to conserve energy and protein responds to refeeding Cachexia sepsis, trauma, neoplasm increased metabolic rate and hypercatabolism of somatic protein treat infection to improve response to feeding

8. Causes of Malnutrition Inadequate Dietary Intake Loss of appetite Gastrointestinal complications Nausea Early satiety Delayed gastric emptying Oral/esophageal complications Herpes, Candidiasis, CMV Abnormal taste, dental problems Eating disorders

9. Causes of Malnutrition Increased Nutrient Losses Diarrhoea Side effect of medications Opportunistic infections HIV enteropathy Malabsorption Carbohydrates, protein, fats, micronutrients, electrolytes Possible in asymptomatic individuals Vomiting Opportunistic infections Side effects of medications Sweats Lose electrolytes and fluids

10. Causes of Malnutrition Increased Requirements Energy Elevated with high viral load, opportunistic infection and need to gain weight, activity Protein Elevated for immune cell replication, maintenance of lean body mass, during periods of opportunistic infection Micronutrients Elevated to treat deficiencies and may have a role in preventative therapy

11. Causes of Malnutrition Other Factors Metabolic abnormalities Drug-food interactions and side effects Nausea, stomach ache, & early satiety Diarrhea, bloating, malabsorption Neuropathy and limited mobility Co-morbidities

12. Causes of Malnutrition Other Factors Special needs groups pregnancy, lactation, childhood Socioeconomic factors Poverty, homelessness Illicit drug use

13. Manifestations of Malnutrition Weight Loss Lose adipose and lean tissue Typical pattern 60% adipose, 40% lean Acute or rapid weight loss is linked to opportunistic infections Chronic or slow weight loss is linked to gastrointestinal disease or high viral load

14. Implications of Weight Loss 3% change = normal variation 5% unintentional loss = risk for wasting, mortality, opportunistic infections 10% loss = wasting syndrome 20% loss with OI = hospitalization

15. Manifestations of Malnutrition Wasting Diverse clinical presentation Maladaptive response to reduced intake Progressive loss of body cell mass Lipoatrophy associated with lipodystrophy

16. Wasting due to systemic inflammatory response Neuroendocrine mediation: catecholamines glucagon, growth hormone, corticosterone mobilize glucose, fatty acids, amino acids Cytokine production anorexia & semi-starvation decreased muscle protein synthesis increased muscle protein catabolism

17. HIV-Associated Wasting Wasting Syndrome 10% weight loss in context of diarrhea/fever Proposed definition for HIV-Wasting >10% loss in 6 months >5% loss in 3 months > 3% loss in 1 month BMI < 20 loss of 5% Body Cell Mass (m) BCM < 35% total weight (BMI <27) (f) BCM < 23% total weight (BMI < 27)

18. Manifestations of Malnutrition Micronutrient Deficiencies Common, especially in persons with CD4 < 200 Due to Inadequate dietary intake Malabsorption Increased turnover Metabolic abnormalities Associated with increased mortality and faster disease progression

19. Identify Nutritional Risk Methods include Nutrition screening Classification of risk by category Subjective global assessment Need to identify method, who will screen, and referral process

20. Conclusion Nutritional problems are common and may be experienced in clusters The etiology of malnutrition is complex Nutrition screening identifies individuals in need of more in depth nutritional care

21. Exercise Handouts of 3 tools Determine which tool if any would be most useful in your setting Who will administer the tool How will referrals be made On what basis To whom Who will refer