Care of Women with HIV Living in Limited-Resource Settings

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 CD4 T-lymphocyte number CD8 T-lymphocyte number Delayed cutaneous hypersensitivity CD4/CD8 ratio Serologic response after immunizations Bacteria killing HIV 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 Hastened disease progression Increased morbidity Nutritional deficiencies Increased oxidative stress Immune suppression Source: Semba and Tang 1999. 10 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 Source: 1 Stack et al 1996 2 Hellerstein et al 1996 3 Shabert et al 1999. 13 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 5 Kelly et al 1999. 2 Fawzi et al 1999 3 Baum et al 1995 4 Allard et al 1998 14 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 4 Sullivan et al 1998 5 Moore et al 1998. 2 Mocchegiani et al 2000 3 Tang et al 1996 15 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 Source: 1 Semba et al 1994 2 Nduati et al 1995 3 John et al 1997 4 Baeten et al 2001. 18 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 1 Coutsoudis Source: 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 HIVrelated 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 HIVinfected mothers will improve both maternal and infant health 26