# Presentation: 175680

## Food, Nutrition and HIV/AIDS:Evidence and Priority Actions for HIV Prevention, Care and Treatment Programs

** ****Ellen Piwoz and**** ****Peter Salama **
**Summer Seminar Series, **
**USAID Washington, **
**August 2004**

## HIV/AIDS, food insecurity, and malnutrition are synergistically inter-related, particularly in Africa

**Malnutrition and food insecurity are endemic in Africa, where more than 25 million people are living with HIV**
**Nearly 40% of African children < 5 are moderately or severely stunted**
**> 50% also suffer from micronutrient deficiency disorders**
**Malnutrition is not limited to children**
**> 50% of all pregnant women are anemic**
**High dependency on single crops and periodic food shortages are common**

**Notes:**
As we all know, HIV and nutrition are inextricably inter-related particularly here in Africa where nutrition and food security are endemic and where more than 25 million people are living with HIV/AIDS.

Nearly 40 percent of African children < 5 years of age are moderately or severely stunted due to chronic undernutrition and disease.  More than 50 percent suffer from micronutrient deficiency disorders.  And the problem of malnutrition is not limited to children – more than 50% of pregnant are anemic and much of the population is at risk of iodine deficiency disorders.

## Orphans and Malnutrition 

**Proportion children malnourished, Zimbabwe 2003**

*Source: Zimbabwe National Nutrition and EPI Survey, Ministry of Health and Child Welfare, Feb 2003*

**Percent (%)**

## How does HIV/AIDS affect  nutrition?

**Notes:**
Now I would like to speak directly to the question – How does HIV/AIDS affect nutrition?

## Malnutrition and HIV work in tandemMacallan,  Proc Nutr Soc, 1999

**HIV compromises nutritional status, increases susceptibility to secondary infections**
**Malnutrition exacerbates the effects of HIV by further weakening the immune system**

**Notes:**
We also know that malnutrition and HIV work in tandem.

As illustrated in this graphic, HIV compromises nutritional status and increases susceptibility to secondary infections.  Malnutrition exacerbates or makes worse the effects of HIV by further weakening the immune system.

## 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 and increased nutrient utilization **

**Notes:**
We know that HIV affects nutrition through multiple mechanisms – the effects of HIV begin early in the course of infection – usually before an individual knows that he or she is infected.

To begin with, HIV increases energy requirements due to elevations in resting energy expenditure (REE) observed in HIV+ adults.  

WHO recently issues a report on nutrient requirements, concluding that energy requirements to maintain body weight and physical or productive activity, are increased by 10 percent during asymptomatic HIV, and by 20-30 percent in the presence of secondary infections.  The increase is much greater for HIV+ children, who need energy to grow as well as to maintain their vital functions and activity.

Reductions in dietary intake are another very common effect of HIV – there are multiple causes here, including appetite loss, oral sores, depression, and loss of livelihoods and access to food.

Nutrient malabsorption occurs during frequent bouts of diarrhea, as well as when HIV infects the cells of the gastro-intestinal tract.

And, importantly, there are many metabolic changes that occur during HIV and AIDS.  The immune system’s response to infection suppresses appetite; the transport, storage and use of some nutrients is also affected.  When the immune system is fighting constant inflammation and infection it is constantly utilizing anti-oxidant vitamins and enzymes.  

## How does nutrition affect  HIV/AIDS?

**Notes:**
Now let’s think about how nutrition affects HIV/AIDS.

## Low food (energy) intake is a primary cause of weight loss and wasting in HIV Macallan, 1999

**Weight loss may be gradual or rapid with acute OI **
**Energy requirements are increased in HIV **
**     ****(WHO, 2003)**
**Weight loss and loss of lean body mass strongly predict risk of illness and death in HIV+ adults (graph)**

***P< 0.01 for all RR***

**Notes:**
Studies throughout the world reveal that low food intake is the primary cause of weight loss and wasting in HIV.  Weight loss has long been recognized as a hallmark of AIDS.  Weight loss in HIV may be gradually, declining slowly over time, or it may be rapid, in the case of acute opportunistic infections such as TB or diarrhea.

We noted before that energy requirements are higher with HIV infection – contributing to weight loss when intakes are not increased.

Studies, like the one illustrated in this slide, show that weight loss, and loss of lean body mass (muscle) strongly predict the subsequent risk of illness and death in HIV+ adults.

## Low intakes and deficiencies of several micronutrients associated with more rapid disease progression and mortality in HIV+ adults 

**These include vitamins A, B****1****, B****6****, B****12****, C, E; folate; selenium; zinc ****(Tang et al, 1993; 1996; Baum et al, 1997; Semba et al, 1994)**
**MN requirements for PLWHA are not known ****(WHO 2003)**
**> 1 RDA may be needed to correct nutritional deficiencies**
**however there is 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 et al, 1996***

- Intake of Vitamin B1 and survival of HIV+ adults

**Notes:**
It has also been shown that low intakes and deficiencies of several micronutrients are associated with more rapid disease progression and mortality among HIV+ adults.

The vitamins and minerals that have been associated with adverse outcomes include VA, B1, B6, B12, C, E, folate, selenium and zinc.  This slide shows data from the US where intakes of vitamin B1 are associated with survival time in HIV-infected adults.

Unfortunately the micronutrient requirements for people living with HIV and AIDS are not known.  Studies suggest that the amounts of MN that must be consumed to correct underlying nutritional deficiencies may be higher in PLWHA than in the general population.

However, it is also known that some MN – particularly VA, iron, and zinc – may produce adverse or dangerous outcomes if consumed in too high amounts.  Studies are currently underway here in Africa and elsewhere to learn more about these relationships in PLWHA.

## What is the impact of nutrition intervention/improvement on HIV/AIDS progression, transmission, and survival?

**Notes:**
So what do we know about the impact of nutrition interventions or improvements on HIV/AIDS progression transmission, and survival?

The evidence is incomplete but there are many promising results.

## Several studies show that high energy/protein food supplements improve weight gain 

**However,  most weight gained is fat, not lean body mass**
**Supplements frequently replace diet, not add to it – counseling needed**
**Increased protein intake does **_**not**_** prevent or reverse muscle wasting **
- No increased protein requirement in HIV (WHO 2003)

*Stack et al, 1996; Piwoz and Preble, 2000*

**Notes:**
To begin with, several studies show that high energy protein food supplements can improve or increase weight gain in PLWHA.  However, most of the weight gained is fat and not lean body or muscle mass.

Studies also reveal that when food supplements are provided, they frequently replace rather than add to total food intake.  Therefore, counseling is needed to help ensure that total intakes are raised when food supplements are given or recommended.

We also know that increased protein intake does NOT prevent or reverse muscle wasting.  The WHO TAG recently concluded that the available evidence do not support a recommendation for increasing protein intakes during HIV.  

This is an important conclusion because many companies and organizations are promoting high protein supplements to treat wasting in AIDS, and these are not likely to be effective alone.

## MN supplementation studies have shown a wide range of benefits

**Reduced **_**hospitalizations**_** in adults ****(Burbano et al, 2003)**
**Increased **_**survival**_** in adults with advanced disease**** ****(Jiamton et al, 2003) **
**Increased **_**weight gain**_** in HIV+ pregnant women**** ****(Villamor et al, 2002)**
**Reduced **_**morbidity and mortality**_** in HIV+ children**** ****(Vitamin A – Coutsoudis et al, 1995)**
**Improved **_**birth outcomes and infant immune status**_** ****(Fawzi et al, 1998; 2003)**
**Reduced **_**MTCT**_** in nutritionally and immunologically vulnerable**** ****(Fawzi et al, 2002)**

**Notes:**
There have been many studies of micronutrient supplements for PLWHA, including several in Africa.  In brief, these studies have shown a wide range of benefits, as shown in this slide, particularly in those with advanced disease or greater levels of malnutrition.

## Proportion of children from households with food deficits dropping out of school in previous year, Zimbabwe, 2003

**Proportion of children from households with food deficits dropping out of school in previous year, Zimbabwe, 2003**

*Source: Zimbabwe Emergency Food Security and Vulnerability Assessment - April 2003, ZIMBABWE Vulnerability Assessment Committee, SADC FANR*
*Vulnerability*

***% of households with at least one child dropping out of primary school***

## 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.  **
**The impact depends on the type of intervention, duration, and underlying vulnerability/nutrition status**
**Nutrition counseling, care and support is an important component of comprehensive HIV-care – consider it from the outset when planning programs**

**Notes:**
So in conclusion, it can be said that there is a complex, synergistic relationship between malnutrition and HIV/AIDS.  HIV affects nutrition and its impact begins early during asymptomatic infection and it continues throughout the lifecycle.

Nutrition interventions have shown a wide range of benefits on HIV-related outcomes.  Their impact depends on the type of intervention, the duration that it is given, and the underlying vulnerability of the person consuming them.  

Nutrition counseling, care and support is an important component of comprehensive HIV-care – it should be considered from the outset when planning HIV programs.

## Nutrition and ARV Therapy

**Notes:**
Now, I would like to say just a few words about nutrition and ARV therapy.  It is sometime believed that once an infected person starts on ARV treatment, their problems are over, their nutrition improves and there is no need for nutrition counseling, care and support.

But this is not the case, as evidenced by experience in the US and other countries.

## Nutrition-related side effects, such as nausea and vomiting affect adherence to HAART, particularly early in treatment (USA)

| Reason | Stopped < =90 d
(n=56) | Stopped >90 d
(n=184) | Overall
(n=24) |
| --- | --- | --- | --- |
| Toxicity
Nausea/Vomiting
Anemia
P. Neuropathy
GI side effects
Lipodystrophy | 35 (62.5)
14 (25.0)
10 (17.9)
0
3 (5.4)
0 | 82 (44.6)
17 (9.2)
7 (3.8)
17 (9.2)
11 (6.0)
9 (4.9) | 117 (48.8)
31 (12.9)
17 (7.1)
17 (7.1)
14 (5.8)
9 (3.8) |
| Poor adherence/
Virologic Failure | 8 (14.3)
 | 46 (25) | 54 (22.5) |
| Financial constraints | 2 (3.6)
 | 11 (6.0) | 13 (5.4) |

*Chen et al, CID, 2003*

**Notes:**
This slide shows data from the USA on reasons for non-adherence and discontinuation of ARV treatment.  As shown here, nausea and vomiting, two conditions that might be mitigated with nutrition counseling/advice were two of the most important reasons for non-adherence to drug treatment in the USA – a population where access to food is not typically limited.  The effects of these conditions may be greater in food insecure populations.  

Note –these studies done with multi-dose drug regimens – side effects and adherence with fixed dose drugs not documented to my knowledge.

## Side effects were also a barrier to adherence to ARV therapy in BotswanaWieser et al, JAIDS, 2003

**Notes:**
Data are limited from Africa, where ART is relatively new, but one study in Botswana showed that side effects were a barrier to ARV adherence.  Both studies – in Botswana and in the USA – were conducted in areas where food insecurity is not a problem.

It is quite possible that side effects may be even more pronounced in food insecure populations – where options are limited.

Note – don’t know about these side effects with fixed dose combination therapy.
J Acquir Immune Defic Syndr. 2003 Nov 1;34(3):281-8. Related Articles, Links   Barriers to antiretroviral adherence for patients living with HIV infection and AIDS in Botswana.Weiser S, Wolfe W, Bangsberg D, Thior I, Gilbert P, Makhema J, Kebaabetswe P, Dickenson D, Mompati K, Essex M, Marlink R.

## Wasting is still a problem in patients on ARV therapy

**Notes:**
Wasting is still a problem in patients on ARV treatment.  This slide shows data from the USA – approximately 32% of all patients on HAART developed wasting.