Integrating Nutrition into ARV Treatment Programs

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Integrating Nutrition into ARV Treatment Programs
Evidence, Experience, and Suggested
Actions Presentation at the World Bank April 27,
2004 Ellen G. Piwoz, SARA Project
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Overview of the Presentation

• Overview of the Evidence 10 min
• Relationship between nutrition and HIV/AIDS
• Impact of nutrition interventions on HIV-outcomes
• Nutrition and ARVs
• Nutrition and HIV-treatment and care programs
  20 min
• Integrating nutrition into HIV treatment/care
  programs
• Available tools and experience
• New data on HIV and infant feeding 10 min
• Exclusive breastfeeding and transmission
• Impact of PH interventions on safer breastfeeding

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HIV/AIDS and nutrition are inextricably
inter-related, particularly in Africa

• Malnutrition and food insecurity are endemic in
  Africa, where more than 25 million people are
  living with HIV
• Nearly 40 of African children lt 5 are moderately
  or severely stunted (low height-for-age)
• gt 50 also suffer from micronutrient deficiency
  disorders
• Malnutrition is not limited to children.
• gt 50 of all pregnant women are anemic
• Much of population is at risk of IDD

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HIV and malnutrition work in tandem

• Both have similar effects on the immune system
• Nutritionally acquired immune deficiency
  syndrome
• HIV compromises nutritional status, increases
  susceptibility to secondary infections.
• Malnutrition exacerbates the effects of HIV by
  further weakening the immune system
• Several micronutrients, including Vitamins A,
  B-complex, C, E and iron, zinc, and selenium
  directly affect immune function
• Some MN, given in high doses, have adverse
  effects on the immune system

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Several nutritional indicators, including weight
loss, anemia, and micronutrient intakes/status
have been associated with shorter HIV survival
times
Anemia is an independent predictor of mortality
in HIV adults Mocroft et. al., AIDS, 1999
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HIV directly affects nutrition through multiple
mechanisms

• Increased energy requirements
• 10 increase during asymptomatic infection
• 20-30 increase during secondary infections
• 50-100 increase for children (WHO, 2003)
• Reductions in dietary intake
• Due to appetite loss, depression, oral sores
• Food insecurity/loss of livelihoods
• Nutrient malabsorption and loss
• HIV-infection of GI cells
• Diarrhea-related losses
• Metabolic changes
• Cytokine-related changes affect appetite
• Impaired transport, storage, utilization of some
  nutrients (e.g. protein)

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Summary of the impact of nutrition interventions
on HIV-related outcomes

• Food supplementation for HIV adults and children
  improves weight gain
• Most weight gained is fat, not lean body mass
• Improvements less likely in those with secondary
  infections
• Supplements frequently replace diet, not add to
  it counseling needed
• Recovery possible in severely malnourished HIV
  children
• Increased protein intake does not prevent or
  reverse muscle wasting
• No increased protein requirement in HIV (WHO,
  2003)
• MN supplementation studies have shown a wide
  range of benefits
• Reduced hospitalizations in adults (Selenium -
  Burbano)
• Increased survival in adults with advanced
  disease (Jiamton)
• Increased weight gain in pregnant women (Villamor
  et al)
• Reduced morbidity and mortality in children
  (Vitamin A - Coutsoudis)
• Improved birth outcomes and reduced MTCT (Fawzi
  et al)

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Daily MN supplementation reduced mortality in
HIV Thai adults, particularly those with low CD4
cell counts -Jiamton et al, AIDS, 2003
(P0.10)
(P0.05)
(P0.03)
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Vitamin A supplementation reduced morbidity in
HIV South African children Coutsoudis et al,
1995
Morbidity Rate ( episodes) in HIV children
(n28)
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Nutrition and ARV therapy
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Nutrition-related side effects, such as nausea
and vomiting affect adherence to HAART,
particularly early in treatment (USA)
Chen et al, CID, 2003
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Side effects were also a barrier to adherence to
ARV therapy in Botswana-Wieser et al, JAIDS, 2003
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Wasting is still a problem in patients on ARV
therapy
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Weight loss predicts risk of death in patients
receiving HAART Tang, AIDS Reader, 2003
N552. Models adjusted for CD4, BMI lt 20,
HAART use at baseline. A 3-5 weight loss was
associated with 3-fold increase risk of death.
NFHL study.
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Some ARV regimens increase the risk of metabolic
disorders, which require nutritional management

• Metabolic syndrome
• Subcutaneous fat depletion
• Visceral fat accumulation
• Disturbances in fat metabolism
• Causes unknown, may be varied
• type of drug (e.g. PI)
• genetic factors
• disease stage
• Result insulin resistance, Type 2 diabetes,
  increased cardiovascular risks, reduced adherence
  to therapy (stigma)

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Nutrition counseling and support are still
important in patients receiving ARV treatment

• Topics to cover
• Management of side effects affecting food intake
• Nausea and vomiting may affect adherence (slide)
• Management of wasting
• Food-drug interactions
• which drugs to take with food, which food/herbs
  to avoid
• Metabolic complications (depending on regimens)
• Body composition, insulin resistance
• Long-term health risks
• Prevent misinformation related to therapeutic
  benefits of food, herbs, and high dose MN
  supplements
• Iron, zinc, vitamin A in high doses may cause
  harm

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Conclusions

• There is a complex, synergistic relationship
  between malnutrition and HIV/AIDS
• HIV affects nutrition its impact begins early
  during asymptomatic infection and continues
  throughout
• Nutrition interventions have shown a wide range
  of benefits on HIV-related outcomes.
• The impact depends on the type of intervention,
  duration, and underlying vulnerability/nutrition
  status
• Nutrition counseling, care and support is an
  important component of comprehensive HIV-care,
  including ARV treatment
• Consider it from the outset when planning programs