NUTRITION SUPPORT IN HIVAIDS

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• NUTRITION SUPPORT IN HIV/AIDS
• BY
• DR. CHARLES MUGISHA (PHD)
• CONSULTANT NUTRITIONIST
• MINISTRY OF HEALTH /MULAGO HOSPITAL COMPLEX
• TEL [phone]

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• Objectives for the training
• At the end of the sessional training ,the
  trainees should be able to
• Describe the effects of HIV infection and
  nutrition on each other
• Discuss special nutritional needs related to HIV
  infection AIDS , pregnancy , women and children.
• Discuss HIV infection and breast feeding /breast
  milk substitutes
• Describe the effects of anti retroviral drugs
  /therapy (ARVs/ART) and nutrition on each other
  (briefly)

3

• Preamble
• The immune system
• Most powerful natural healing machinery in the
  body .
• Has the inordinate ability to heal the body from
  all diseases.
• Provided it is adequately supplied with all the
  nutrients it requires.
• Our best defence against disease and illness is a
  healthy immune system.
• Boost immune system through adequate nutrition

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• A properly working immune system is a function of
  good nutrition .
• For example
• If Yours body has a strong enough immune system
• You can be infected with a flu virus and not get
  flu
• You can be infected with the TB germ and not
  develop tuberculosis
• You can even be infected with HIV and not
  develop AIDS.

5

• Importance of nutrition to human health and
  disease management
• Nutrition is a basic scientific discipline
• It studies the relationship between food and
  human health
• Nutrients and biologically active ingredients in
  the food are used for
• Normal growth and development ,especially in
  children
• Mental development is a function of a adequate
  nutrition
• Used in the maintenance of tissues in a normal,
  healthy state.

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• Used in tissue repairs
• Used as part of integrative medicine in the
  better management of disease .
• Nutrients / bioactive agents help the
  conventional drugs to work better
• Used for normal reproductive performance
• Used for maintenance of the immune system
• Co-factors for several metabolic processes in
  the body.
• Good nutrition maintains optimal health status
  ,prevents many diseases from occurring or the
  old ones emerging.

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• Nutrition intervention in HIV/AIDS
• Nutrition intervention in HIV/AIDS is a neglected
  area , generally
• Yet its beneficial effect in HIV/AIDS prevention,
  ,care and mitigation is well known This
  treatment aspect of HIV/AIDS is lacking in
  sub-Saharan Africa (SSA)

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• Beneficial effects of nutrition intervention in
  HIV/AIDS Evidence that nutrition intervention
  can reduce mother-to child HIV infection
  transmission .
• Nutrition intervention delays HIV disease
  progression to full blown AIDS.
• Nutrition intervention improves the quality of
  life of people living with HIV/AIDS.

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• Objectives of nutrition intervention
• Optimize and maintain proper nutrition
• Improve quality of life of the infected people
• Prevent or reverse micronutrient deficiencies
• Reverse the biochemical and immunological changes
  associated with HIV/AIDS .
• Prevent or stabilize weight loss
• Preserve muscle mass.
• Optimize and maintain the immune system.

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• Prevent enteric infections (2/3 of the
• immune system is in the GIT)
• Promote recovery from infections
• Promote response to medical treatment (both
  conventional drugs to treat opportunistic
  infections and ARVs to treat HIV infection)
• Unfortunately , there is limited capacity for
  intensive nutrition support in resource
  constrained settings , such as occur in
  sub-Saharan (SSA)
• Reversal of abnormalities in immunity and
  nutrition is possible in early HIV infection.

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• Nutritional support in HIV/AIDS
• Great variation of nutritional requirements in
  HIV/AIDS patients
• Different modes of feeding in HIV/AIDS patients
• Dietary regime to provide RDA (all nutrients)
  except vitamins and minerals (3-4X)
• Recommended diet for HIV patients is not
  different from that required for healthy
  individuals

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• Deficiencies of several micronutrients have been
  documented in HIV- infected people
• In severe AIDS , incremental factors for some of
  the nutrients are
• Selenium (3-8X), Zinc (7-15X), magnesium (1-2x),
  vitamins A (6X), vitamin B1 (25-50x) vitamin B2
  (25-50X) , Vitamin B6 (25-50x) , vitamin B9
  (2-3x) vitamin B12(5-10x)
• Nutrient concentrates such as nutritional
  supplements meet the enormous nutrient
  requirements for HIV/AIDS.

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• HIV/AIDS is a highly stressful , wasting syndrome
  
• Ordinary diets for healthy individuals may not
  meet the nutrient requirements in HIV/AIDS
• Ordinary diets are sufficient in early stage of
  the disease.
• Consumption of naturally grown organic foods may
  meet the nutrient requirements of the disease
  process.

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• HIV plate
• An HIV plate has been contemplated for the
• AIDS patients
• It Constitutes
• Protein 40 (20-40) Carbohydrates
  50 (50-70)
• Fat 10 (5-10)
• Vitamins minerals 3-4x RDA
• Water 2-4L/24hrs
• Hence a combination of carbohydrates (55)
  proteins(40) fat (5) may correct the
  nutritional wasting in HIV/AIDS

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• The effects of HIV infection and nutrition on
  each other and malnutrition and HIV disease
  progression

NUTRITION
HIV
AFFECTS
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• Source Designed by C. Mugisha 2006
• Key notes
• Malnutrition is defined as involuntary weight
  loss gt10, weight lt 90 of ideal, lt 90 of body
  cell mass , lt 20 of body mass index (See WHO
  definition )
• Malnutrition (macro and micro nutrient
  deficiencies) is common in HIV/AIDS disease.
• Malnutrition in HIV/AIDS is associated with
  oxidative stress which depresses the immune
  system .
• Malnutrition weakens the immune system and
  increases susceptibility to opportunistic
  infections.

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Similarity of the effects of malnutrition and HIV
disease on immune system (Immunological changes

• Malnutrition Immune system HIV-disease
• CD4 T-lymphocyte number
• CD8- (cytotoxic) T-lymphocyte number
• Delayed cutaneous hypersensitivity
• CD4/CD8 ratio
• Serologic response after immunization
• Bacterial killing capacity of phagocytes/
• Polymorphs.

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• Source Designed by C. Mugisha , 2006
• Key notes
• The diagram shows similar immunological changes
  in primary malnutrition and HIV/AIDS.

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• Source Designed by defined as involuntary
  weight lossgt 10 weight lt 90 of ideal lt 90 of
  body all mass, 20 of body mass index (see WHO
  definition)
• Malnutrition in HIV/IDs is associated with
  oxidative in HIV/IDS is associated with oxidative
  stress which depresses the immune system
• Malnutrition weakens the immune system and
  increases susceptibility to opportunistic
  infections.

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• The vicious cycle of HIV pathogenesis

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• Source Designed by C. Mugisha , 2006
• Key notes
• The gastro intestinal tract (GIT) is one of the
  organs affected by HIV infection
• GIT dysfunction is set in motion (diarrhoea,
  malabsorption , malnutrition)
• Opportunistic infections proliferate
• HIV disease progresses to full-blown AIDS
• HIV infection is associated with enhanced
  oxidative stress (excess free radical production)

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• There is relative depletion of the bodys
  anti-oxidant forces.
• Reduced food intake and poor nutrient
  absorption lead to weight loss, weakened immune
  system
• The above processes hasten HIV disease
  progression to full blown AIDS.

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• The vicious cycle of malnutrition and HIV/AIDS

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• Source Adapted from the regional centre for
  quality of Health care and FANTA 2003
• FANTA- Food and nutrition technical assistance
• Key notes
• The diagram shows the interacting factors in the
  vicious cycle of HIV infection, immune system
  suppression and nutritional status.

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• Effects of HIV/AIDS on nutrition
• Loss of appetite
• Decrease in the amount of food consumed
• Impaired nutrient absorption (GIT enteropathy)
• Alterations in body metabolism (cytokine
  mediation)
• Defective enzyme system.

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• Changes in body metabolism (nutritional) in
  respect of HIV disease
• HIV infection increases energy (10-15) and
  protein (50) requirements .
• In severe AIDS, energy demands go up to 55 and
  protein requirements go up to 60, while fat
  requirements are about 5 (limit fat intake,
  because of fat malabsorption syndrome).
• Infection increases demand for and the
  utilization of anti-oxidant vitamins (A,C,E, Beta
  carotene) and anti-oxidant micro- minerals
  (Zinc, selenium, copper , manganese, iron,
  magnesium )(3-4x)

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• Increased cytokine activity(IL-1, IL-6, TNF).
• The net result is insufficient anti-oxidant
  status, leading to oxidative stress which
  depresses the immune system.
• Increased HIV replication and rapid progression
  to full blown AIDS.

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• Mechanisms of weight loss and wasting in HIV/AIDS
• Wasting is almost universal and a recognized sign
  in HIV/AIDS, both in adults and children
  (CDCWHO).
• The wasting may be of slow or rapid progression
• Several factors are responsible for wasting in
  HIV/AIDS
• Reduced food in take (reduced appetite, nausea,
  vomiting).
• Malabsorption (HIV gastroenteropathy).

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• increased nutrient loss (chronic diarrhea ).
• Increased nutrient demands (highly stressful
  wasting syndrome)
• Increased nutrient utilization (HIV is a wasting
  and stressful condition).
• Increased nutrient utilization (HIV is a wasting
  and stressful condition).
• Metabolic changes inflammatory, unbalanced
  cytokine response to HIV infection (IL-1, 1L-6,
  TNF, etc).

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• Pathogenesis of wasting in HIV infection
• Alterations in oral intake weight loss
• Loss of appetite /Nausea / vomiting
• Decreased food intake
• Food drug interactions (indirect-effect)
• Elevated metabolic rate (e.g increased
• cytokine activity (indirect effect)

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• Causes for altered food intake are
  multi-factorial
• Oropharyngeal lesions
• Oesophageal lesions
• Psychosocial factors
• Economic factors
• Fatigue
• Focal or diffuse neurological diseases
• Anorexia due to medications (lt 500kcal intake
  /day)
• Malabsorption/defective enzyme systems.
• Systemic infection

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• Stool incontinence
• Chronic diarrhoea
• Conscious effort to avoid eating (anal
  incontinence )
• The anorexia is thought to be medicated by
  inflammatory cytokines (IL-1, IL-6, TNF , etc)

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• Metabolic alterations
• Marked cachexia in HIV/AIDS
• Opportunistic infections, lymphomas /cancers
  compound the wasting state.
• Weight loss may be rapid (7-11kg/week or 5 of
  body weight per month).
• Metabolic rate is very high
• Food intake is markedly diminished.
• Extreme lethargy and weakness.
• Rapid wasting is seen in the quadriceps and
  gluteus maximus muscles (skinny legs and flat
  butt) among other areas.

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• Hypertriglyceridemia (increased lipids in blood
  stream)
• Adipose tissue atrophy
• Decreased serum cholesterol concentrations.

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• Endocrine alterations in HIV infection include
• Increased serum cortisol concentration
• Loss of the cortisol normal diurnal periodicity
• Low serum testosterone
• Low dihydroepiandrosterone (DHEA)
• Deficient endogenous anabolic activity, which may
  promote protein breakdown and hence weight loss.

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• Malabsorption / Chronic diarrhea
• Diarrhoea is very common in HIV infection
• It affects about 60 of HIV infected individuals
  in the United States of America at some point in
  the disease process and up to
• A greater percentage of HIV infected individuals
  in the developing countries
• Many opportunistic infections, depending on the
  geographical region, are responsible for some
  gastro intestinal pathologies.

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• The small intestinal epithelial cell damage leads
  to malabsorbption (The brush border with
  digestive enzymes is damaged).
• Malabsorption of fats and bile acids / salts
  because of ileal dysfunction has been associated
  with chronic bacterial enteropathy caused by
  adherence of pathogenic strains of E. Coli to the
  brush border.
• A role for HIV infection as a causative agent in
  malabsorption is uncertain.

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• Alterations in energy expenditure
• Weight loss is a consequence of negative caloric
  balance
• Normal nutritional status (NS) implies total
  energy intake (TEI) equals total energy
  expenditure (TEE). (NS TEI TEE)
• TEE resting energy expenditure (REE) energy
  expenditure in activity (EEA) energy
  expenditure in digestion (EED).
• EED is also known as thermal dynamic action of
  food (TDAF)

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• Effect of disease stage
• The course of HIV infection can be subdivided
  into 3 stages Early, middle and late.
• Early stage (Asymptomatic stage).
• Early stage includes seropositivity without
  clinical or immunological evidence of deficiency.
• Little evidence of HIV- associated nutritional
  problems at this time.
• Give nutrition education (promotive, harmful)
• Maintain normal body composition

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• The middle stage
• Laboratory evidence of immune deficiency, but
  little clinical evidence of the disease.
• Weight loss may occur may not be progressive
• Variable fatigue
• Oral (or vaginal) candidiasis may be present.
• Herpetic lesions or aphthous ulcers in the mouth
  may become frequent.
• Reduced body cell mass
• Elevated basal metabolic rate is related to
  viraemia.
• Weight loss is detectable due to productive HIV
  infection

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• Late stage
• Clinical and laboratory evidence of immune
  deficiency.
• Patients have frank AID or are undergoing active
  progression to AIDS.
• Malnutrition occurs ,and may be severe and
  progressive.
• Severe malnutrition may lead to death by
  inanition.
• The pathogenesis of malnutrition in HIV/AIDS is
  multi- factorial e.g.

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• Defective nutrient intake
• Defective nutrient absorption
• Defective intermediary metabolism
• Treat infections
• Use therapeutic diets

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• Clinical consequences of malnutrition on HIV/AIDS
  
• Malnutrition per se has adverse clinical
  consequences on any given condition for a
  patient.
• Malnutrition in HIV infection is associated with
  increased morbidity and mortality.
• Malnutrition in HIV / AIDS leads to weight loss
  which in turn predicts shortened survival.
• The effect of weight loss upon mortality was
  independent of CD4 lymphocyte counts.

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• Weight loss was also associated with high risks
  of requiring hospitalization and being diagnosed
  with opportunistic infections. These effects were
  also independent of CD4 lymphocyte counts.
• The timing of death from wasting in HIV/AIDS in
  related to the degree of body cell mass depletion
  rather than the specific cause of the wasting
  process.

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• HIV/AIDS AND FOOD SECURITY
• Even if we could provide a plow and seeds to
  harvest every bit of land , there are not enough
  able bodied people to do the work (UNICEF
  senior programme officer Kimberly Gambie
  payne).
• Food security has three (3) components
• i) Supply side
• - Food availability and stability
• ii) Demand side
• - Food accessibility and affordability
• iii) Health side
• - Food safety/ hygiene.

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• Food security
• People at all times have physical , social
  economic access to
• Sufficient , safe and nutrition food .
• Meets dietary needs and food preferences
• For an active and healthy life .

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• In Uganda, 0.9 of the GDP annually is lost due
  to HIV/AIDS pandemic.
• The agricultural labour force loss is about
  14Uganda, in Tanzania, it is about 13, while
  in Kenya, it is about 12.
• Deaths due to HIV/AIDS increase annually (UN
  estimates)
• Excess deaths in females out number those in
  males.

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• Assessment of HOV/AIDS patients Welcome
  classification (WL/A)
• Gomez Classification (WL/A)
• Water low classification (WL/A) (WL/A. W/H , 2-5
  core)
• Mid-upper aim circumference
• Body mass index

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• The food pyramid

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• Source US department of agriculture and
• health and social services.
• Key notes
• The food pyramid was provided by the education
  department of the national livestock and meat
  board.
• The food guide is commonly used to evaluate the
  dietary status of individuals and to educate
  patients about food choices.

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• The principles of diet design
• These are
• Nutrient adequacy and safety
• Nutrient balance
• Nutrient density
• Energy/ kilocalorie control
• Nutrient moderation
• Nutrient variety
• 13, Identification of available ,accessible ,
• healthy foods.

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• Dietary management of HIV/AIDS
• Malnutrition in HIV/AIDS is a multifaceted
  problem requiring multiple interventions.
• The multiple interventions may be short- term
  (1-2 years), medium term (2-5 years), and
  long-term (gt5 years), applied simultaneously to
  break the vicious cycle of malnutrition.
• The major components of the vicious cycle that
  need to be addressed are
• i) Depressed immunity
• ii) Infections and infestations (opportunistic)

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• Malnutrition
• In this presentation, emphasis will be put on the
  prevention and management of malnutrition in
  HIV/AIDS.
• HIV/AIDS patients should be assessed and
  classified for malnutrition, the same way as
  other malnourished patients (See previous
  anthropometric measurements).
• If found severely malnourished, they should be
  admitted to the therapeutic feeding centre (TFC)
  and managed for nutritional, medical and
  psychosocial complications, as well as daily care.

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• Referral for continuous follow-up and medical
  care in health facilities or specialized
  infectious disease centres (IDC), as well as
  supplementary feeding centres (SFC) should be
  observed.
• Referral to agencies that may offer assistance
  and continued care, such as TASO, should be made.
• The HIV/AIDS patients recovery takes longer than
  the matched non- HIV infected malnourished
  patient.

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• The therapeutic feeding centre (TFC) should not
  be involved in the chronic care of HIV /AIDS
  patients.
• Clinical status rather than official discharge
  protocol should be used for discharge.
• Physical and emotional stimulation for cases
  resulting from prolonged state of illness is
  important .
• Recommended micronutrients in normal and HIV
  positive child- bearing age women (15-49 years)

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• Recommended micronutrients in normal and HIV
  Positive child bearing age women (15-49 years)

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• Source Compiled by C. Mugisha, 2006
• Key Notes
• The table shows the recommended micronutrients in
  normal and HIV positive child being age women
  (15-49 years) in SSA and USA.
• It also shows the requirements of micronutrients
  in HIV infection and the incremental factors of
  the quoted nutrients for sub- Saharan Africa

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• Reference nutrient intakes for protein
• Age Reference Nutrient Intake a(g/day)
• Children
• 0-3 months 12.5b
• 4-6 months 12.7
• 7-9 months 13.7
• 10-12 months 14.9
• Years 14.5
• Years 28.3
• MALES
• 11-14 years 42.1
• 15-18 years 55.2
• 19-50 years 55.5
• 50 years 53.3
• FEMALES
• 11-14 years 41.2
• 15-18 years 45.0
• 19-50 years 45.0
• 50 years 46.5

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• Key
• Source Smith R. and W.P.T .James (eds). Oxford
  Text book of medicine (Nutrition). 3rd edition,
  vol.1,1996.
• a These figures, based on egg and milk protein,
  assume complete (100) protein digestibility.
• b No values for infants 0-3 months are given by
  WHO . The recommended nutrient intake (RNI) is
  calculated from the recommendations of COMA.
• c To be added to adult requirements through all
  stages of pregnancy and lactation.
• d- Based on protein providing 14.7 percent of
  estimated average requirements (EAR) for energy.

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• Reference nutrient intakes for vitamins.

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• Source Smith , R, and W.P.T. James (eds).
  Oxford textbook of medicine (nutrition ), 3rd
  edition, Vol, 1996.
• Key notes
• No increment
• After 65 years, the RNI is 10mg /day for men and
  women .
• For last trimester only.
• Based on protein providing 14.7 percent of
  estimated average requirements. (EAR) for energy.

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• Reference nutrient intakes for minerals

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• Source Smith R. and W.P.T .James (eds). Oxford
• Text book of medicine
• (Nutrition). 3rd edition, vol.1,1996
• Key notes
• a - No increment
• b - Phosphorus RNI is set equal to calcium in
  molar terms
• c - 1 immol sodium 23mg
• d - 1 mmol potassium 39 mg
• e - Corresponds to sodium 1 mmol 35.5mg
• f - Insufficient for women with high menstrual
  losses where the most practical way of meeting
  iron requirements is to take iron supplements or
  iron fortified foods.

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• Goals of nutrition actions
• Some approaches
• To prevent weight loss.
• Promote adequate energy , protein and
  micronutrients intake.
• Individualize the meal plan and modify to match
  the medication regime or health attentions .
• Advise on lifestyles that are promotive, harmful
  or neutral to health.
• To improve on the body composition
• Promote regular exercise to preserve, and build
  muscle mass.

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• To improve immunity and prevent infections
• Promote nutritional adequacy to meet the nutrient
  demands for optimal physiological functions.
• Promote food safety/ hygiene (safe kitchen
  behaviour)
• As this may be a source of opportunistic
  infections.
• Promote the use of ARVs and other conventional
  medications to reduce the viral load and treat
  opportunistic infections.

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• Increase micronutrient intake
• Promote strategies to increase vitamin and micro-
  mineral intake (Increased consumption of fruits
  and vegetables)
• Micronutrients serve as co- factors for the body
  metabolism and the promotion of the immune system.

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• Food based approaches
• Include local vegetables, fruits or vitamin /
  mineral enriched or fortified local products (e.g
  maize, cereals , wheat or soya flour).
• The foods should be affordable
• The food based approach has no major side
  effects.
• Use nutrient supplements (mainly body nourishes,
  detoxifiers/ cleansers, immune boosters )
• Multi-micronutrients supplements are better
  utilized than single nutrients .

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• Promote the use of ARVs and
• conventional drugs
• Reduce the viral load
• - Treat opportunistic infections
• - Promote immunity

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• Dietary management of symptoms in
• HIV/AIDS.
• Aims / Objectives
• To enable greater food intake
• Contribute to increased comfort
• Compensate for nutrient losses
• Prevent dehydration.
• Complement and strengthen medical treatment
• Reduce severity of symptoms

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• Examples of common symptoms in
• HIV/AIDS and their dietary management
• Anorexia / vomiting
• Eat small amounts of food frequently
• Eat energy dense food (High nutrient density
  foods).

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• Oral thrush / oral candidiasis.
• Eat soft, mashed food at room temperature or body
  temperature.
• Avoid spices
• Avoid cold foods
• Limit sugar / sucrose use.
• Constipation.
• Eat more high fibre diet / food
• Drink plenty of fluids /water (2-4L/ 24hrs ).

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• Heartburn / Dyspepsia / Bloating
• Eat small and frequent meals
• Take milk regularly
• Avoid gas forming foods, such as beans
• Eat dinner about 3 hours before going to bed
• Diarrhoea
• Drinking lots of fluids / water (2-4 L / 24 hrs)
• Eat energy and nutrient dense foods

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• Nausea
• Eat small frequent meals
• Avoid lying down immediately after food
• Rest between meals
• Fever
• Drink plenty of fluids (2-4L/ 24 hrs)
• Eat / drink a variety of soups
• Eat energy and nutrient dense foods

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• Anaemia (Iron deficiency)
• Eat iron fortified/ rich foods (e.g animal
  products) , green leafy vegetables
• Take nutritional supplements with iron to correct
  iron deficiency anaemia.
• Fatigue / lassitude lethargy.
• Moderate, regular physical activity increases
  energy expenditure, stimulates appetite,
  preserves and builds muscle / lean body mass).

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• Infections, infestations (opportunistic).
• Preventing food and water borne infections /
  infestations reduces the risk of diarrhea (a
  common contributing factor to weight loss),
  Malnutrition and HIV disease progression to full
  blown AIDS.
• Antiretroviral therapy (ART) can help improve the
  quality of life, and patients given comprehensive
  nutrition in addition to ARVs usually do better
  than those on either mode of management.

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Drug food interactions in HIV infected patients
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• Special nutrition needs related to HIV/AIDS and
  pregnancy and lactation.
• The goals of nutrition management include
• Prevention or mitigation of factors associated
  with the risk of malnutrition.
• Preserve body composition
• Use of balanced , locally available , natural ,
  organic foods
• Food pyramid should serve as a nutritional
  guide

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• Concurrent use of ARVs plus other conventional
  drugs
• To correct nutrition related metabolic changes
  caused by viral infection.
• HIV- infected pregnant and lactating women have
  poorer indices than non-infected women
• Malnutrition in HIV/AIDS in multifaceted ,
  requiring multiple interventions
• Cachexia (severe wasting) associated with
  HIV/AIDS responds well to ARV/ART

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• Use of ARVs, conventional drugs , nutrition,
  counseling, social support etc have changed the
  out look for many HIV-infected persons ,
  especially nutritional status
• Ensure adequate nutrient intake.

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• Special nutrition needs related to HIV/AIDS and
  children
• The management of HIV exposed and HIV
  infected children who are also malnourished
  include
• Prevention or mitigation of factors associated
  with the risk of malnutrition.
• Appropriate breast feeding practices.
• Nutrition supplementation
• Preserve body composition
• Use of breast milk (heated ) and breast milk
  substitutes.
• Malnutrition underlies 60 of all infectious
  diseases morbidity

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• Factors that increase the risk of under
• nutrition in childhood.
• Low birth weight (LBW)
• Inappropriate feeding practices
• Repeated infections
• Inadequate time set aside for infant and children
  and child feeding care
• Altered body metabolism
• Inadequate access to ARVs/ART (HAART)

84

• Infant feeding practices / guidelines
• Breast feeding is the primary guarantee for child
  survival in resource poor settings.
• Unfortunately , breast feeding by HIV- infected
  women significantly increases the incidence of
  HIV- infection amongst breast-fed infants,
• Lactating mothers with HIV infection pose an
  additional risk of transmitting the infection
  above the risk during pregnancy and delivery of
  about 15 for HIV exposed babies who are
  breast fed up to six months and about 20 for
  babies who breastfeed into the second years of
  life.

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• Women who are newly infected during pregnancy or
  lactation have a much higher likelihood of
  transmitting HIV infection to their infants.
• The risk of transmission through the breast milk
  among women with recent infection is about 25.
• Babies continue to be at risk of HIV infection as
  long as they are exposed to HIV- contaminated
  breast milk.
• Breast - feeding problems (Such as cracked and
  sore nipples, mastitis, and breast abscesses)
  significantly increase the risk of transmitting
  HIV by breast milk.
• Hence suitable replacements for breast milk.

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• Such breast milk substitutes include -
• Commercial infant formula
• Home prepared formula (eg soya milk )
• Modified animal milks.
• Mixed feeding may be more risky for HIV
  transmission than exclusive breast feeding,
  possibly because of the damage to the epithelial
  integrity of the intestine by food particles,
  which may facilitate the virus entry into the
  blood stream.

87

• Infant feeding during period 0 to 6 months.
• There is need to minimize the risk of HIV
  transmission to infants in the critical exclusive
  breast feeding period 0-4/6 months.
• One way is to boil the expressed breast- milk in
  water for about 20 minutes and then feed the baby.

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• There is also a necessity to avoid increasing
  their risk of morbidity and mortality from other
  causes. Therefore when replacement feeding is
  acceptable, feasible, affordable, sustainable and
  safe (FAASS), avoidance of all breast- feeding by
  HIV infected mothers is recommended.
• Otherwise, exclusive breast feeding is
  recommended during the first months of life, and
  then should be discontinued as soon as feasible
  (WHO/UNICEF/UNAIDS).

89

• Safe- breast feeding
• If adequate replacement feeding is not possible
• Two strategies to reduce the risk of breast milk
  transmission of HIV
• Exclusive breast feeding with early cessation
• Heat treatment of breast milk
• The strategies allow an infant to derive the
  benefits of breast feeding during the most
  critical period .

90

• Artificial feeding in environments with poor
  hygienic conditions in the first few months of
  life can be tragic.
• Reduces the risk of HIV transmission by reducing
  the length of time ,the infant is exposed to HIV
  through the breast milk.

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• Replacement feeding
• Stop breast-feeding as soon as mother is able
  to prepare and give her infant adequate and safe
  replacement feeding.
• Family conditions can determine when mother may
  stop breast feeding and start replacement
  feeding .
• Early cessation of breast-feeding is advisable
  if an HIV positive mother develops AIDS
• Socio-cultural reasons may bar woman from breast
  feeding.
• Replacement feeding includes feeding with a
  commercial or home prepared formula.
• 0-6 months give milk in some form.

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• Commercial infant formula (CIF).
• A baby who is not breastfed will need about
  150mls of milk per kg body weight per day.
• CIF is an option to breast feeding for an HIV
  positive woman
• Should be feasible and affordable by the family
  for at least 6 months (ie when the family has
  reliable access to sufficient formula for at
  least 6 months).
• Feeding an infant with the commercial formula for
  6 months requires 40x 500g tins (or 44 x 450 g
  tins ) of the formula .

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• The family should have the resources, water,
  fuel, utensils, skills and time.
• The time is to enable the mother prepare the
  formula correctly and hygienically.

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• Home prepared formula (HPF)
• (HPF) is a reasonable option for an HIV- positive
  lactating woman.
• May be used under following circumstances
• CIF is not available
• CIF is too expensive for family to buy and
  prepare
• Reliable supply of animal or other milk
• Family can make modifications accurately.

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• Attention paid to hygiene , correct mixing ,
  feeding methods.
• Replacement feeding is often a new way for a
  mother t feed her baby.
• It should not be assumed that the mother knows
  how to do it.

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• Infant feeding after 6 months
• Introduce complementary foods
• Breast fed and replacement fed, complementary
  foods introduced at 6 months.
• Duration of mixed feeding should be limited .
• Avoid undue traumatic effects, abrupt cessation
  of breastfeeding can have on baby .
• Milk should continue to be an important component
  of diet.
• It should provide 50 of nutritional
  requirements between 6-12months.

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• Milk may provide up to 33 of nutritional
  requirements between 12-24months.
• Family foods given 3 x per day for 6-9month
• Family foods given 4x per day for 9-12 month
• Family foods given 5 x per day for 12months
• I