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Care of Women with HIV Living in Limited-Resource Settings

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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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