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Care of Women with HIV Living in
Limited-Resource Settings
Overview of HIV and Nutrition
Ellen G. Piwoz, ScD
Director, Center for Nutrition
Nutrition Advisor, SARA Project
Academy for Educational Development
1
Objectives
Review effect of HIV and AIDS on nutrition
Discuss impact of nutrition interventions on HIV
progression and mortality
Describe nutritional considerations in mother-to-child
transmission of HIV
2
Types of Malnutrition
Protein-energy malnutrition (PEM)
Measured in terms of body size
Micronutrient malnutrition
Often referred to as “hidden hunger”
Not easy to see unless it is severe
Iron, vitamin A and iodine are the most commonly
reported micronutrient deficiencies in both children and
adults
Deficiencies of other nutrients common in settings with infectious
diseases, food insecurity
3
Consequences of Malnutrition in Women
Increases women’s morbidity and mortality
Zinc, vitamin A deficiencies increase the risk of sexually
transmitted diseases
Iron deficiency reduces resistance to disease, causes fatigue,
and reduces women’s productivity
Low calcium intake increases risks of pre-eclampsia, high blood
pressure and hypertension during pregnancy
Anemia increases risks of prolonged labor, and death due to
hemorrhage
Affects infant birth outcome and health
Intrauterine growth and birth weight
Nutrient stores for later development
Growth and survival
Source: Huffman et al 2001. 4
Effects on Immune System
Malnutrition HIV
CD4 T-lymphocyte number
CD8 T-lymphocyte number
Delayed cutaneous hypersensitivity
CD4/CD8 ratio
Serologic response after immunizations
Bacteria killing
5
How Does HIV/AIDS Affect Nutrition?
Causes a decrease in the amount of food consumed
Impairs nutrient absorption
Changes metabolism
6
Causes of Decreased Food Consumption
Mouth and throat sores
Fatigue, depression, changes in mental state
Loss of appetite
Side effects from medication
Household food insecurity
7
Poor Nutrient Absorption
Nutrient absorption impaired during many infections
Poor absorption of fats and carbohydrates occurs at all
stages of HIV infection
Causes:
HIV infection of intestinal cells
Frequent diarrhea
Poor absorption of fats affects use of fat-soluble
vitamins, such as vitamins A and E
8
Changes in Metabolism
Infection increases energy and protein requirements
10–15% increase in energy needs
50% or greater increase in protein requirements
Infection also increases demand for antioxidant vitamins
and minerals
Vitamins – E, C, beta-carotene
Minerals – zinc, selenium, iron
When antioxidants are not sufficient, oxidative stress
occurs.
Increases HIV replication
Leads to higher viral loads
9
The Vicious Cycle of Malnutrition and HIV
Insufficient dietary intake
Malabsorption, diarrhea
Altered metabolism and
nutrient storage
Increased HIV
replication
Nutritional
Hastened disease
deficiencies
progression
Increased morbidity
Increased
oxidative stress
Immune suppression
10
Source: Semba and Tang 1999.
Can Improved Nutrition Slow
HIV Disease Progression?
11
Observational Studies on Nutrition on HIV/AIDS
Early observational studies showed:
Weight loss associated with HIV infection, disease progression,
mortality
Some nutrient deficiencies (vitamins A, B12, E, selenium, zinc)
associated with HIV transmission, disease progression and
mortality
Observational studies do not tell us whether these
conditions caused more rapid progression or resulted
from it
Clinical trials are required to show that improving
nutrition can slow HIV disease progression and increase
survival
12
Clinical Trials on Nutrition and HIV/AIDS
Interventions to increase energy and protein intake in
people living with HIV may reduce vulnerability to weight
loss and muscle wasting.
High-energy, high-protein drink + counseling1
Weight gain, maintenance in HIV+ with no symptoms
Omega-3 fatty acids (common in fish oils, seeds)2
Weight gain in some AIDS patients
Glutamine+antioxidants+counseling3
Weight gain, improved body cell mass in HIV+ who had begun to
lose weight
13
Source: 1 Stack et al 1996 2 Hellerstein et al 1996 3 Shabert et al 1999.
Clinical Trials on Nutrition and HIV/AIDS
continued
Improvements in micronutrient intake and status may help
strengthen the immune system, reduce consequences of
oxidative stress and lengthen survival.
Vitamin A1,2
Improved immune status, reduced diarrhea and mortality in HIV+
children.
Vitamin B123
Improved CD4 cell counts in HIV+ men
Vitamin E, C4,5
Reduced oxidative stress and HIV viral load
Source: 1 Coutsoudis et al 1995 2 Fawzi et al 1999 3 Baum et al 1995 4 Allard et al 1998 14
5 Kelly et al 1999.
Clinical Trials on Nutrition and HIV/AIDS
continued
Selenium and beta-carotene1
Increased antioxidant enzyme functions
Zinc2,3
Reduced incidence of opportunistic infections, stabilized weight,
improved CD4 counts in adults with AIDS
Reversing anemia4,5
Slowed HIV progression and improved survival
Source: 1 Delmas-Beauvieux et al 1996 2 Mocchegiani et al 2000 3 Tang et al 1996 15
4 Sullivan et al 1998 5 Moore et al 1998.
How Does Nutrition Affect
Mother-to-Child Transmission of HIV?
16
Mother-to-Child Transmission (MTCT) of HIV
HIV is transmitted from mother to infant during
pregnancy, at the time of childbirth, and through
breastfeeding.
Not all infants become infected
Difficult to distinguish between transmission in late pregnancy,
labor and delivery, or early breastfeeding
Without interventions to prevent MTCT, about 25-40% of
infants become infected.
5-10% are infected during pregnancy
10-20% are infected during childbirth
10-20% are infected over 2 years of breastfeeding
~ 600,000 infants infected per year worldwide
17
Nutrition and MTCT – Possible Mechanisms
Maternal malnutrition can lead to:
Impaired immune system
More severe and frequent secondary infections
Decreased CD4 cell counts
Increased viral load in blood, genital secretions, breast milk
Low serum retinol1,2,3
Low serum selenium4
Increased risk of low birth weight, prematurity
Low fetal nutrient stores
Weakened infant immune system
Impaired integrity of mucosal barrier
Genital mucosa, placenta
Infant gastrointestinal tract, impaired mucosal immunity
18
Source: 1 Semba et al 1994 2 Nduati et al 1995 3 John et al 1997 4 Baeten et al 2001.
Clinical Trials on Nutrition and MTCT
Clinical trials providing Vitamin A or multivitamin
supplements to prevent MTCT carried out in several
African countries
Tanzania, South Africa, Malawi, Zimbabwe
Supplements provided during pregnancy, after childbirth
Generally, these supplements had no overall impact on
MTCT during pregnancy or delivery
In South Africa, MTCT by 6 weeks reduced by 47% in preterm
infants in vitamin A group1
Impact of vitamin A and multivitamin supplementation on
MTCT during breastfeeding still under study
Tanzania, Zimbabwe
19
Source: 1 Coutsoudis et al 1999.
Clinical Trials on Nutrition and MTCT continued
Although MTCT was not reduced, other benefits for
mother and newborn were observed:
In South Africa, daily vitamin A in 3rd trimester reduced risk of
preterm birth by 34%1
In Tanzania, daily multivitamin supplements (B1, B2, B6, Niacin,
B12, C, E, folic acid) improved maternal immune status and
reduced risks of:
Fetal death by 39%
Low birth weight by 44% (if HIV- at birth)
Small size for gestational age by 43%
Severe preterm birth (< 34 wks) by 39% 2
20
Source: 1 Coutsoudis et al 1999 2 Fawzi et al 1998, 2000.
Other Considerations During Pregnancy
Physiological changes that occur during pregnancy
require extra nutrients for:
Adequate gestational weight gain
Growth of the developing fetus
Poor absorption and excess nutrient losses due to HIV
further increase nutritional requirements
Recommended levels still unknown
HIV-infected women may be more vulnerable to anemia,
a common problem during pregnancy
In West Africa, 78-83% of HIV+ pregnant women are anemic1
21
Source: 1 Ramon et al 1999.
Impact of Breastfeeding on Maternal HIV
Disease Progression
The impact of breastfeeding on maternal HIV disease is
not well understood
The increased nutritional demands of lactation may affect weight
loss, a risk factor for disease progression
In Kenya, breastfeeding mothers were more likely to die than
mothers who did not breastfeed (11% vs. 4%)1
In South Africa, breastfeeding mothers were not at increased risk
of morbidity or death (0.5% vs. 1.9%)2
WHO recommends further research on the impact of
breastfeeding on maternal health before any change to
breastfeeding policy
22
Source: 1 Nduati et al 2001 2 Coutsoudis et al 2001.
Nutrition Recommendations for HIV+ Women
Improve weight, nutrient stores
Improve diet and eating habits
Take multivitamin supplements if diet is not adequate
Promote hygiene and food safety
To avoid pathogenic contamination, diarrhea
Provide a holistic package of care including:
Supportive counseling
Medical care
23
Nutrition Recommendations for Pregnant
HIV+ Women
Provide optimal antenatal, postpartum care
Ensure adequate weight gain during pregnancy
Give iron-folate supplements
Provide other nutritional supplements, where available
Promptly treat all conditions that affect food intake or risk of
MTCT
Provide ARV drugs, if available
Fully inform women about infant feeding options, risks
Support women in feeding decisions
Provide nutrition support for breastfeeding mothers
24
Summary
HIV affects nutrition in many ways
The impact begins early in the course of HIV infection,
even before other symptoms are observed
Nutritional status also affects HIV disease progression
and mortality
Improving nutritional status may improve some HIV-
related outcomes
25
Summary continued
The impact of different nutrition interventions depends
on the stage of disease
Counseling and other interventions to prevent weight loss are
likely to have their greatest impact early in the course of HIV
infection
Nutritional supplements, particularly antioxidant vitamins and
minerals, may also improve HIV-related outcomes, particularly in
nutritionally vulnerable populations
HIV-positive women are at greater risk of malnutrition
than uninfected women during pregnancy and
breastfeeding
Meeting the nutrient and energy requirements of HIV-
infected mothers will improve both maternal and infant
health 26
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