Nutrition and HIV AIDS Thought for Food

Nutrition and HIV/AIDS: Thought For Food Global Health Mini-University October 14, 2005 Protein-Energy Malnutrition & HIV Have Similar Effects on the Immune System Beisel, J Nutr, 1996 PEM CD4 T-lymphocyte cell number Delayed hypersensitivity to recall and new antigens B-cell responses Production of IL-1, IL-2, TNF-alpha Bacteria killing HIV NAIDS “Nutritionally Acquired Immune Deficiency Syndrome” AIDS “Slim Disease” 2 The Vicious Cycle of Malnutrition & HIV Insufficient dietary intake Malabsorption, diarrhea Altered metabolism and nutrient storage Increased HIV replication Hastened disease progression Increased morbidity Increased oxidative stress Immune suppression 3 Nutritional deficiencies Low BMI (< 18) is associated with increased risk of death in HIV+ adults independent of immune status (The Gambia; N=1657; van der Sande et al, JAIDS, 2004) 4 Hazard ratio 3.6 2.6 2.5 2 1.9 0 < 200 200-500 > 500 Overall Adj Risk* Baseline CD4 Each unit decrease in BMI ≈ 13% increased risk of death after adjusting for baseline CD4 4 Macronutrients  No evidence that food & dietary improvements alone can prevent progression to AIDS, but comprehensive care for PLWHAs (pre-ART & ART) should include good nutrition.  Resting energy expenditure rates (REE) are increased during HIV infection.  Asymptomatic: 10% increase (kcal/day) Symptomatic: 20-30% increase (kcal/day)   Children w/ weight loss: 50-100% increase (kcal/day) 5 Macronutrients  Protein metabolism is affected by HIV infection, but no evidence to date that increased protein intake improves protein status or lean muscle mass in PLWHAs.  Therefore, data are insufficient to support an increased protein requirement due to HIV infection.  12-15% of energy intake should come from protein 6 Daily MN supplementation reduced mortality in HIV+ Thai adults, particularly those with low CD4 cell counts Jiamton et al, AIDS, 2003 0.6 0.53 (P=0.10) Adjusted Mortality Risk 0.37 (P=0.05) 0.3 0.26 (P=0.03) 0 Overall CD4 <200 CD4 < 100 There was no effect on HIV viral load or genital shedding 7 Tanzanian mothers receiving daily high-dose MNs (B, C, E) were less likely to experience HIV-related disease progression or death during follow up … Relative Risk 95% CI 0.51-0.04 0.28-0.90 0.58-0.90 0.52-0.84 P-value 0.09 0.02 0.003 <0.001 AIDS-related death Progression to stage 4 Progression to stage 3 >= 2 stage increases 0.73 0.50 0.72 0.66 Mean diff in viral load = -0.18 log – or est. 30% increase in survival time (Fawzi et al, NEJM, 2004) 8 … less likely to experience HIV-related morbidity during follow-up … Relative Risk Thrush Oral ulcers Dysentery 95% CI 0.30-0.73 0.28-0.68 0.45-0.95 P-value <0.001 <0.001 0.03 0.47 0.44 0.66 ARI 0.79 0.66-0.96 0.02 Other protective effects – gingival erythema, angular chelitis, nausea and vomiting, difficulty swallowing, painful mouth, fatigue, rash (Fawzi et al, NEJM, 2004) 9 … and less likely to experience adverse birth outcomes. Outcome Birth Weight <2500g Birth Weight <2000g Preterm (<37wk) Preterm (<34wk) Small for Gestational Age No Multivitamins Multivitamins n (%) n (%) 36 (8.8) 7 (1.7) 96 (21.1) 28 (6.2) 39 (10.0) 62 (15.8) 16 (4.1) 106 (24.5) 44 (10.2) 66 (17.6) RR (95%CI) 0.56 (0.38-0.82) P 0.003 0.05 0.23 0.03 0.002 0.42 (0.18-1.01) 0.86 (0.68-1.10) 0.61 (0.38-0.96) 0.57 (0.39-0.82) Fawzi et al, AIDS, 1998 10 Micronutrients  Vitamins A, B1, B6, B12, C, D, E, folate; Minerals selenium; zinc, calcium  MN requirements for PLWHAs are not yet known • • > 1 RDA may be needed to correct some deficiencies high doses of some nutrients may cause adverse outcomes – U-shaped curve • • best source through diet, incl fortified foods recommendation of 1 RDA until more data available  Recommendations for MN supplementation remain the same for HIV+ & HIV- populations • • Vitamin A supplementation - children Iron-folate – pregnant & lactating women • Zinc – diarrhea case management 11 HIV-Infected Children  HIV-infection impairs growth early in life, even before the onset of other HIV symptoms – wt loss associated w/ increased risk of mortality.  Appetite, nutritional status, growth & survival of HIV-infected children improved by prophylactic cotrimoxazole, ART & early prevention & treatment of OIs. 12 Community Therapeutic Care (CTC) for severe malnutrition using a nutrient-dense ready-to-use food (RTUF) in HIV+ & HIVchildren in Malawi Recovery (> -5 WHZ) is slower but still possible in HIV+ children with severe wasting 100 80 60 40 20 0 95 59 70 43 30 3 Recovery Rate (%) Average # Days to Recovery 6 Month Relapse or Death Rate (%) 13 HIV+ HIV- Sandige et al, 2004 Timing of Mother-to-Child Transmission: No intervention Early Antenatal (<36 wks) Early Postpartum (0-6 months) Late Postpartum (6-24 months) Pregnancy Labor and Delivery Breastfeeding Late Antenatal (36 wks to labor) 5-10% 10-20% 5-20% Adapted from CDC 14 Adjusted Cox hazard ratios for risk of postnatal MTCT at 6, 12, & 18 months according to feeding pattern over 1st 3 mos EBF PBF MBF * 3.79 5 4 3 2 1 0 1 2.63 * 4.03 2.69 1.61 1 1 * 2.6 6 months 12 months 18 months Models adjusted for BW (18), maternal age, MUAC, CD4 count, maternal Hb < 70 g/L, maternal death during follow-up, marital status . 15 Cumulative risk of postnatal MTCT from 6 wks - 18 mos by maternal baseline CD4 count 40 HIV infection 6 wks-18 m (%) 35 30 25 20 15 10 5 0 33.7 13.2 9.7 6.3 <200 201-349 350-499 500+ Maternal CD4 16 WHO recommendations on infant feeding for HIV+ women • When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended. • Otherwise, exclusive breastfeeding is recommended during the first months of life. • To minimize HIV transmission risk, breastfeeding should be discontinued as soon as replacement feeding is AFASS, taking into account local circumstances, the individual woman’s situation and the risks of replacement feeding (including infections other than HIV and malnutrition). 17 Breast milk contributes > 50% of the nutrient intake of children > 6 months in developing countries and won’t be easy to replace 100 90 80 70 60 50 40 30 20 10 0 Energy Protein Calcium Vitamin A Vitamin C Folate Zinc % contribution of BM 6-8 months 9-11 months Adapted from WHO, 1998; Dewey and Brown, 2002 using data from Bangladesh, Ghana, Guatemala, Peru 18 WHO has recently issued new guiding principles on feeding the non-breastfed child 6-24 months of age    Adaptation of guiding principles for feeding breastfed children Addresses feeding frequency, variety, density, and fluid requirements Principles need to be adapted to local context & diets 19 www.who.int/child-adolescent-health Nutrition & ART  Dietary/nutritional assessment essential to clinical mgmt of HIV/AIDS before & during ART.  ART typically improves appetite – need food to satiate hunger, reduce nausea, and support weight maintenance/recovery Long-term use of ARVs can result in metabolic complications:    The value of ART far outweighs the risks. Metabolic complications must be adequately managed, including dietary mgmt, as they occur. 20 HIV/AIDS a chronic, “manageable” disease Muscle wasting & weakness/lethargy Lipodystrophy associated w/ HIV & certain ARVs  Subcutaneous fat loss  Visceral fat accumulation  Hyperlipidemia  ↑ LDL & ch/olesterol  ↓ HDL  Lactic Acidosis  Cardiovascular Disease Insulin Resistance and diabetes Osteoporosis Cancer risk? 21 Research Priorities 1. Effects of macro/micronutrient interventions on clinical outcomes a) b) c) d) e) 2. Feeding/nutrition strategies for early weaned infants, esp >6 mo of age. 3. Effects of maternal ART, OI treatment, & improved nutrition/health status, incl breast health, on post-natal MTCT & HIV-free CS. 4. Interactions of traditional and novel dietary supplements and “remedies” on HIV & response to ART/OI treatments. Progression Birth outcomes MTCT Response to ART Chronic disease 22 23 Food & Nutrition: 1. 2. 2/7/ 10 Contribute directly to prevention, treatment & care goals of the Emergency Plan Based on evidence of malnutrition & WHO guidelines for nutritional assessment & care 3. 4. Specifically targeted to PLWHAs, affected family members, OVCs and caregivers Food procurement as a last resort (“wrap around”) and maximum 6-month time-limit 24 Key Food & Nutrition Activities  Policy/guideline development, training & capacity building to provide food & nutrition support  Nutritional Assessment   Clinical mgmt of pre-ART & ART patients Targeting of food & nutrition interventions to malnourished adults & children infected/ affected by HIV/AIDS Recovery/maintenance of nutritional status Mgmt of effects of infections & treatments Safe infant & young child feeding (PMTCT)  Nutrition Education & Counseling    25 Key Food & Nutrition Activities  Micronutrient intake & supplementation  Single RDA as in general population, but recognizes greater vulnerability of PLWHAs  Limited, targeted supplements where diet inadequate & deficiencies prevalent Emphasis on routine VA & Zn tx of diarrhea in infected children/OVCs WHO entrance/exit criteria Pre-ART & ART, OVCs Facility- and community-based 26   Therapeutic & supplementary feeding    Key Food & Nutrition Activities  PMTCT & infant feeding  WHO/UNICEF/UNAIDS guidance    individual, informed choice HIV+ mothers avoid all BF if/when AFASS If not AFASS, EBF in first months of life   Balance risks of BF/MTCT vs RF/mortality Procurement of formula & other RFs permissible, but responsibility to support AFASS, HIV-free survival & comply w/ “The Code” Counseling & program support from antenatal period through at least first year of life   Emphasis on testing mothers to enable informed 27 choice Key Food & Nutrition Activities  Link EP programs to food security/assistance programs  Primary source of food for supplementary & therapeutic feeding EP pays “freight” (program costs) for targeting, distribution, M&E Entry point for prevention, care and treatment 28  