HIV AIDS AND NUTRITION An Update On Current Knowledge Mod2 Link Nutrition and HIV

Nutrition and HIV/AIDS: A Training Manual Session 2 Acknowledgment Most of the slides in this presentation are the work of Ellen Piwoz (and Elizabeth Preble) of the SARA Project, Academy for Education Development Purpose To provide basic concepts of the relationship among food, nutrition, and HIV/AIDS; general dietary needs; and practices to reduce morbidity, mortality, and the progression of HIV to AIDS Session Outline • Link between HIV/AIDS and nutrition • Effects of HIV/AIDS on nutrition • Effects of nutrition (macronutrients, micronutrients and existing nutritional status) on HIV/AIDS Vicious Cycle of Malnutrition and HIV Poor Nutrition resulting in weight loss, muscle wasting, weakness, nutrient deficiencies Increased Nutritional needs, Reduced food intake and increased loss of nutrients HIV Increased vulnerability to infections e.g. Enteric infections, flu, TB hence Increased HIV replication, Hastened disease progression Increased morbidity Impaired immune system Poor ability to fight HIV and other infections, Increased oxidative stress Source: Adapted from RCQHC and FANTA 2003 Effects of Malnutrition and HIV on the Immune System Malnutrition CD4 T-lymphocyte number HIV CD8 T-lymphocyte number Delayed cutaneous hypersensitivity CD4/CD8 ratio Serologic response after immunizations Bacteria killing Affects of HIV/AIDS on Nutrition • Decrease in the amount of food consumed • Impaired nutrient absorption • Changes in metabolism Causes of Decreased Food Consumption • Mouth and throat sores • Loss of appetite leading to fatigue, depression, and changes in mental state • Side effects from medication • Abdominal pain • Household food insecurity and poverty Poor Nutrient Absorption • Nutrient absorption impaired during many infections • Poor absorption of fats and carbohydrates at all stages of HIV infection because of  HIV infection of intestinal cells  Frequent diarrhea and vomiting  Opportunistic infections • Poor absorption of fats that affects use of fat-soluble vitamins such as A and E Changes in Metabolism • Infection increases energy (10%-15%) and protein (50% or more) requirements • Infection increases demand for and utilization of antioxidant vitamins (E, C, beta-carotene) and minerals (zinc, selenium, iron) • Insufficient antioxidants from increased utilization causes oxidative stress  Increases HIV replication  Leads to higher viral loads HIV-Associated Wasting Syndrome Body weight is the most common body composition measurement but is inaccurate because of: • Fluid overload (e.g., severe renal disease, IV rehydration) • Fluid deficits (e.g., dehydration from diarrhea, poor fluid intake) • Inability to differentiate between changes in lean tissues or fat HIV-Associated Wasting Syndrome, Cont. Body cell mass is superior to body weight • Measures the metabolically active tissue compartment in the body • Includes the muscles, organs, and circulating cells and so can differentiate between lean tissues and fat Studies show • Progressive depletion of body cell mass in the late stages of HIV disease (Kotler 1985) • Significant prolonged survival in patients with body cell mass >30% of body weight or serum albumin levels exceeding 3.0g/dl (Suttman 1991) Body Habitus Changes Metabolic changes in HIV infection result in • Increased resting energy expenditure • Prompter use of amino acids to fuel energy needs • Continued fat accumulation • More adipose tissue compared to lean tissue • Lack of preservation and restoration of lean tissue • Weight loss (HIV-associated wasting syndrome) • High triglyceride levels in blood Effects of Nutrition on HIV/AIDS: Observational Studies Findings • Weight loss associated with HIV infection, disease progression, and mortality • Some nutrient deficiencies (vitamins A, B12, and E, selenium and zinc) associated with HIV transmission, disease progression, and mortality Observational studies do not tell us whether these conditions caused or resulted from more rapid progression. Clinical trials are needed to show that improving nutrition can slow HIV disease progression and increase survival. Effects of Nutrition on HIV/AIDS: Clinical Trials (1) Interventions to increase energy and protein intake in HIV+ people may reduce vulnerability to weight loss and muscle wasting  High-energy, high-protein drink + counseling (Stack et al 1996)led to weight gain and maintenance in HIV+ with no symptoms  Omega-3 fatty acids common in fish oils and seeds (Hellerstein et al 1999) led to weight gain in some AIDS patients  Glutamine+antioxidants+counseling (Shabert et al 1999) led to weight gain and improved body cell mass in HIV+ who had begun to lose weight Effects of Nutrition on HIV/AIDS: Clinical Trials (2) Improvements in micronutrient intake and status may help strengthen the immune system, reduce consequences of oxidative stress, and lengthen survival  Vitamin A (Tanzania, South Africa) improved immune status, reduced diarrhea and mortality in HIV+ children.  Vitamin B12 (USA-men) improved CD4 cell counts in HIV+ men  Vitamins E and C (Canada,Zambia) reduced oxidative stress and HIV viral load  Multivitamins (A,B,C,E, folic acid) improved pregnancy related outcomes and immune status Effects of Nutrition on HIV/AIDS: Clinical Trials (3)  Selenium and beta-carotene (France) increased antioxidant enzyme functions  Zinc (Italy)reduced incidence of opportunistic infections, stabilized weight, improved CD4 counts in adults with AIDS  Iron-reversing anemia (USA) slowed HIV progression and improved survival Conclusions • HIV affects nutrition in three overlapping ways • Nutritional status affects HIV disease progression and mortality • Improving nutritional status may improve some HIVrelated outcomes • Counseling and other interventions to prevent weight loss probably have their greatest impact early in the course of HIV infection • Nutritional supplements, particularly antioxidant vitamins and minerals, may improve HIV-related outcomes, particularly in nutritionally vulnerable populations