1. Food, Nutrition and HIV/AIDS Jonathan Gorstein, PhD. Department of Health Services / Global Health I-TECH Seminar 9 November 2007

2. Malnutrition and HIV  Malnutrition, particularly micronutrient deficiencies, exacerbates HIV by further weakening immune function  HIV compromises nutritional status, increases susceptibility to OI’s  Improving nutritional status impacts HIV progression, ART adherence and efficacy Macallan DC. Nutrition and immune function in human immunodeficiency virus infection. Proceedings of the Nutrition Society ( 1999) 58(3):743-748.

3. Malnutrition and HIV – Etiology and Links Underlying Social and Economic Factors High risk behaviorsPoor Nutrition Unsafe Environment Interventions to improve nutritional intake and nutritional status HIV Impaired immune system Poor ability to fight infections, Increased oxidative stress Increased Nutritional needs Due to reduced food intake and increased loss of nutrients

4. Malnutrition and HIV – Roberto Thinking about the critical link between Nutrition and HIV, we will consider the case of Roberto Kellano (fictional), a 33 year old man from Mozambique Married to Louisa, 28 years old They have eight children, although Louisa was pregnant eleven times Roberto works as a truck driver, employed with transport company shipping wood products between Beira, Mozambique and Harare, Zimbabwe Roberto is only home four months of each year

5. HIV/AIDS Timeline – where does nutrition fit ? Sero- conversion Death HIV - OIs Impact ART Treatment Support Death Impact Mitigation Death Symptomatic Food assistanceFood security Livelihood support Food security Nutritional Counseling Positive Living Slow Disease Prevention Asymptomatic

6. Risk of Death Associated with Malnutrition Hazard ratio for death for those on HAART with moderate to severe malnutrition is 6-fold higher than for those with normal nutritional status Similar risks for those with significant HIV wasting or weight loss Paton NI, Sangeetha, S., Earnest, A. and Bellamy, R. The impact of malnutrition on survival and the CD4 count response in HIV-infected patients starting antiretroviral therapy. HIV Medicine (2006) 7(5):323-30 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. 2002 Oct;31(2):230-6

7. Malnutrition and HIV – Roberto Roberto was first diagnosed with HIV+ eighteen months ago Recently had CD4 declines and was eligible to begin ARV treatment At time of first treatment, Roberto’s BMI was 16.3 and he was classified as moderately malnourished Prognosis?

8. Low dietary energy intake leads to weight loss and wasting increasing impact of HIV Weight loss and loss of lean body mass strongly predict risk of illness and death in HIV+ adults p < 0.01 for all RR Macallan, D.C. Wasting in HIV infection and AIDS. Journal of Nutrition (1999) 129(1S Suppl):238S-242S. Wheeler DA, Gibert CL, Launer CA, et al. Weight loss as a predictor of survival and disease progression in HIV infection. JAIDS (1998)18(1):80-5.

9. Nutrition and Optimal ARV Outcome – Roberto After receiving his drugs, Roberto was lethargic and had limited motivation His family knew that he needed more food, and better nutrition, but what was optimal? They asked the main doctor at the clinic, but he only knew that there were some guidelines on nutrition for PLWHA – a poster he saw at a training How do the nutritional needs of individuals on ART differ from those with asymptomatic HIV? With no infection?

10. HIV affects Nutrition through Multiple Mechanisms Increased energy requirements –10% increase during asymptomatic infection –20-30% increase during secondary infections –50-100% increase for children (WHO, 2003) Reductions in dietary intake –Due to appetite loss, depression, oral sores –Food insecurity/loss of livelihoods Nutrient malabsorption and loss –HIV-infection of GI cells –Diarrhea-related losses Metabolic changes –Impaired nutrient utilization

11. Nutrition and ARV Adherence – Roberto At the clinic, Roberto was given his supply of ARVs and asked to take them according to protocol After four months, he stopped coming to the clinic A community activist and a local health worker visited Roberto at his home and asked him why he did not come back What were the main reasons Roberto may not have come back?

12. Food vs. Nutrients – “A food pill”, asks Roberto Roberto explained that he was hungry all the time and the drugs increased his appetite The local doctors told him that there was research that vitamins and minerals were important and they would provide him with some nutritional supplements with his drugs Are dietary supplements important in the management and treatment of HIV/AIDS?

13. Micronutrients and HIV Progression Tanzania study among HIV+ pregnant women Daily MN supplements of multivitamins on progression of HIV disease –MN Group = 67 disease progression among 271 women –Placebo group - 83 progressed of 267 (24.7% vs. 31.1%) –RR= 0.71 (95 % C.I.: 0.51 to 0.98, p=0.04) MNs resulted in significantly higher CD4+, CD8+ cell counts and significantly lower viral loads MNs delayed progression of HIV disease Fawzi WW, Msamanga GI, Spiegelman D et al. A randomized trial of multivitamin supplements and HIV disease progression and mortality. New England Journal of Medicine (2004) 351: 23–32.

14. Intake of Vitamin B 1 and survival of HIV+ adults Low micronutrient intake associated with more rapid disease progression and mortality in HIV+ adults These include vitamins A, B1, B6, B12, C, E; folate; selenium; zinc MN requirements for PLWHA are not known ( WHO 2003 ) > 1 RDA may be needed to correct nutritional deficiencies Concern that high doses of some nutrients may cause adverse outcomes (e.g., vitamin A, iron, zinc) Recommendation of 1 RDA until more data available Tang AM, Graham NM, Saah AJ. Effects of micronutrient intake on survival in human immunodeficiency virus type 1 infection. Am J Epidemiol. 1996;143:1244–1256.

15. Food as a Factor of Adherence Hunger has been identified as a threat to ART because patients cannot afford to feed themselves as their body metabolism improves and demands more food. In qualitative research conducted in a Nairobi slum, a lack of food was cited as the most likely cause of non- adherence to ARV therapy One participant succinctly stated, "If you give us ARVs, please give us food, just food.“ Marston, B. and De Cock, K. Multivitamins, Nutrition, and Antiretroviral Therapy for HIV Disease in Africa New England Journal of Medicine (2004) 351 (1):78-80 Hardon, A.P., Akurut, D., Comoro, C. et al. Hunger, waiting time and transport costs: Time to confront challenges to ART adherence in Africa. AIDS Care (2007) 15(5): 658 - 665

16. Delivery of Food Assistance Linked to ART – Roberto Roberto returned to the clinic to get his drugs and supplements, but complained that he was simply hungry, the pills were not enough A local NGO was starting a new program Each time he visited the clinic and received his drugs, he would now receive a voucher to get basic foods He thought about it for awhile and considered the impact that this would have on him, as well as on his family. What are some of the positive/negative aspects of Direct Food Aid programs linked to ATV treatment ?

17. Limitations of Direct Food Aid Lack of Choice Dependence on International Donors Not sustainable Unclear who receives and consumed food Social stigma Little engagement of local markets

18. Interventions to improve nutrition and reduce HIV/AIDS progression – from Individual to Community Therapeutic Direct food assistance Food aid provided in conjunction with ARVs Social protection Cash transfers Sustainable Livelihoods Income generating opportunities Small-scale fortification Agriculture, e. small-farmer initiatives

19. Consultation on Nutrition and HIV/AIDS in Africa A direct response to Resolution 57.14 of the World Health Assembly, 22 May 2004 on "Scaling up treatment and care within a coordinated and comprehensive response to HIV/AIDS". This resolution urges Member States as a matter of priority to pursue policies and practices that promote integration of nutrition into a comprehensive response to HIV/AIDS article [2(3)(h)].

20. Current Operations Research Develop clear guidelines for World Food Program Food Aid as part of ARV programs Recent changes in protocols for different target groups Qualitative research to understand perspectives of clients and health workers re: Nutrition and ARVs Kenya Uganda Mozambique (?) Explore alternative delivery mechanisms to increase food availability among patients on ARVs

21. Recent Events Partners in Health Meeting on Integrating health, nutrition, and food security: Making the case - October, 2007 RENEWAL Third Phase Strategy – October, 2007 WHO/UNICEF Consultation on Food and HIV – July, 2007 PEPFAR Food and Nutrition and HIV/AIDS Consultation – March, 2007

22. Conclusions There is a complex, synergistic relationship between malnutrition and HIV/AIDS HIV affects nutrition – its impact begins early during asymptomatic infection and continues throughout Nutrition interventions have shown a wide range of benefits on HIV-related outcomes Interventions are necessary for individuals (therapeutic) and for communities Nutrition counseling, care and support is an important component of comprehensive HIV-care, but guidelines without program options can be counterproductive.