Research Proposal Final Draft

NCM Research Proposal 1
Addressing Nutrition Related Health Disparities in Individuals Diagnosed

with HIV/AIDS in an Acute Care Setting
A Case Study
Colette E. Akhimien
Jordan T. Brown
Norine E. Fraval
Howard University, Department of Nutritional Sciences
Nutrition Care Management II – Fall 2021
Dr. Adeola, Ph.D., RD, LDN
December 1st , 2021
Table of Contents
INTRODUCTION
Background
Statement of Problem
Purpose of Study / Aims
Objectives
Significance of Study
LITERATURE REVIEW
METHODOLOGY
Patient selection
Procedures/Data collection
RESULTS
Data analysis
Case Report
Summary of Case One
Nutrition Assessment and Diagnosis
Nutrition Intervention, Monitoring and Evaluation of Outcomes
Summary of Case Two

Summary of Case Three

CONCLUSION
DISCUSSION
REFERENCES
APPENDICES
INTRODUCTION
Background - prevalence, and pathology of HIV/AIDS, Malnutrition and SDOH
In patients diagnosed with chronic diseases, changes in metabolic processes,
inflammatory status and immune response occur. HIV/AIDS is linked to immunosuppression,
the suppression of the body’s innate ability to defend against disease and infections. Although
there is limited evidence of the role of health disparities on nutritional status of people with
HIV/AIDS, this population is at increased risk of being malnourished if factors affecting
nutritional status are not addressed. The Centers for Disease Control and Prevention (CDC)
recommends that people with HIV/AIDS eat a healthy balance diet in conjunction with other
healthy lifestyle behaviors and continue their HAART treatment and to minimize the risk of
malnutrition. Immunonutrition, the potential to modulate the activity of the immune system by
supplying the body with specific nutrients, is used to improve the outcome in critically ill and
surgical patients. Individuals with HIV/AIDS can benefit from coupling HAART with
individualized nutrition plan and prescription, or immunonutrition.
HIV
HIV (human immunodeficiency virus) is a virus that attacks the body’s immune system
and can lead to AIDS (acquired immunodeficiency syndrome) if not treated. Currently there is
no cure for HIV and once infected, people are diagnosed with HIV for life. In 2018, 37,968
people in the United Stated were diagnosed with HIV. This was a 7% decrease from 2014. At the
end of 2018, there was an estimated 1.2 million people in the Unites States with HIV. About
14% or 1 in 7 individuals did not know they had HIV. Gay, bisexual, or men who have sex with
other men accounted for 69% of HIV diagnoses (Appendix A1). Blacks or African Americans
accounted for 42% of all new diagnoses of HIV and were most affected by HIV. Hispanics or
Latinos were also strongly affected as 29% of all new HIV diagnoses (Appendix A2). In 2018,
young people accounted for 21% of all new HIV diagnoses. Young gay and bisexual men
accounted for 83% of all new HIV diagnoses in people aged 13 to 24 years old. Young Black or
African American gay and bisexual men represented 42% of new HIV diagnoses among young
gay and bisexual men. In 2018, there were 15,820 health among adults and adolescents
diagnosed with HIV. HIV is also a highly urban disease with most cases occurring in
metropolitan areas with 500,000 or more people. In the United States, the South has the highest
number of people living with HIV, but the Northeast has the highest rate of people living with
HIV (Rate is the number of cases per 100,000 people) (Appendix A3). Around the world, there
were about 1.7 million new cases of HIV in 2018 and about 37.9 million people living with HIV
around the world. About 24.5 million of them were receiving antiretroviral medicine to treat HIV
(HAART). Sub-Saharan Africa is the region most affected by the disease and accounts for 61%
of all new HIV infections worldwide.
HIV is categorized into three stages: Stage 1 (Acute HIV Infection), Stage 2 (Chronic
HIV Infection), and Stage 3 (acquired immunodeficiency syndrome – AIDS) (Appendix B1).
Stage 1 includes individuals who have a high HIV RNA count in their blood and are very
contagious. Some people have flu-like symptoms or no symptoms at all. This stage can be
diagnosed by an antigen/antibody test or from nucleic acid tests. Stage 1 is defined by CD4 count
equal to or greater than 500 cells/mm 3 or percentage equal to or greater than 26% without the
presence of an AIDS-defining clinical condition. Stage 2 or Chronic HIV infection is also called
asymptomatic HIV infection or clinical latency. People may not have symptoms or get sick
during this stage, but the disease is still active, can be transmitted, and is reproduced at very low
levels. This phase may last a decade or longer without medicine, but some people may progress
faster. At the end of this phase, the viral load increases and the CD4 count decreases. Stage 2 is
defined by a CD4 count equal to or greater than 200 cells/mm 3 and less than 500 cells/mm 3 or as
a percentage between 14% and 25%, without an AIDS-defining clinical condition. Symptoms
may develop as the virus multiplies in the body. Those who take antiretroviral medication or
HAART may never progress to stage 3. Stage 3, or acquired immunodeficiency syndrome
(AIDS), is the most severe phase of the infection. Risk for opportunistic infections increases,
severe illnesses in people who have compromised and damaged immune systems. People with
AIDS have a very high viral load and are very infectious and without treatment typically survive
for about three years. Stage 3 is defined by a CD4 count less than 200 cells/mm3, a percentage
less than 14%, and the presence of an AIDS-defining clinical condition (CDC, 2021).
In the absence of CD4 count or percentage, research has shown that alternative methods
could be used to predict CD4 count such as the use of absolute lymphocyte count (ALC) or white
blood cell count and percent lymphocyte count. ALC can be determined using the following
calculation: WBC count (cells/mcL) x 1,000 x percent lymphocyte count (expressed as a
decimal) (Calculating Absolute Cell Counts, 2021). One study has shown a correlation between
ALC and CD4 cell counts with a cut-off of <1,643 cells/mcL indicating a cost-effective
surrogate marker for CD4 cell counts <200 cells/mcL in settings with limited resources
(Agrawal, 2016). This decreased CD4 cell count is a possible indicator of decreased immune
function in patients with HIV and the progression of HIV/AIDS in combination with other
HIV/AIDS defining characteristics. Another study correlates a CD4 count of <200 cells/mcL
with an ALC of 1,450 cells/mcL and a CD4 count of <350 cells/mcL with an ALC of 1650
cells/mcL (Khanna, 2018). These studies indicate the use of ALC in the absence of CD4 count in
settings where resources are limited or the CD4 count is unknown. Further research is needed to
confirm this correlation and validate the accuracy of ALC as a marker for CD4 cell count.
The following are risk factors that can increase the chance of contracting or transmitting
HIV: viral load, other sexually transmitted diseases, and alcohol and drug use. An individual is
more likely to transmit HIV when their viral load, or amount of HIV in the blood of someone
who has HIV, is higher. The viral load is highest during the acute phase of HIV and when HIV is
untreated. The viral load can decrease with HAART and can even become so low that it is
undetectable. If an individual has another sexually transmitted disease, they are more at risk of
contracting or transmitting HIV. Frequent testing is crucial to lower one’s chances of getting or
transmitting the disease.
Alcohol and drug use are also factors that can increase one’s risk of getting or
transmitting HIV. When one is drunk or has a drug-induced altered mental status, they are more
likely to engage in risky behaviors that put them at risk of contracting the disease. Being infected
with HIV also does not mean that you cannot get infected again. An individual who is already
infected with HIV can contract a different strain. This is called HIV superinfection. The new
strain of HV can replace the original strain or remain alongside the original strain. Superinfection
can progress faster because the new strain may be resistant to HAART. Taking HAART can help
protect someone from getting a superinfection.
Once one is diagnosed with HIV, it is important to take the necessary steps to treat and
manage your symptoms (Appendix B5). Individuals who should be on one’s health care team
should include, a primary care HIV health care provider (medical doctor, nurse practitioner, or
physician assistant), allied health care professionals (nurses, mental health providers,
pharmacists, nutritionists, dietitians, and dentists), and social service providers (social workers,
case managers, substance use specialists, and patient navigators). It is also vital that individuals
with HIV take their HIV medicine as prescribed, keep their medical appointments and follow-
ups, and talk honestly with their health care providers to continue being consistent with their
HIV care and treatment. A healthcare provider may ask a patient with HIV to take a blood
sample to check their viral load, ask questions about their health history, look for other kinds of
infections or health problems, give immunizations, discuss, prescribe, and monitor HIV
medications, discuss ways to help an individual follow their HIV treatment plan, help identify
other support as needed, and ask about sexual or injection partners and discuss ways to protect
them from HIV. Different tests may be used to help monitor an HIV infection. These tests
include CD4 count and a viral load test.
HIV treatment involves taking medicine to reduce the viral load in your body. This
medicine is called highly active antiretroviral therapy (HAART) and can help control HIV.
Taking HAART does not prevent the transmission of other sexually transmitted diseases.
Treatment should be started immediately after diagnosis and is recommended for all people with
HIV regardless of how long they have had the virus, their CD4 levels, or how healthy they feel.
If an individual diagnosed with HIV delays treatment, HIV would continue to impair their
immune system and put them at risk for developing AIDS and contracting opportunistic
infections. It will also put one at higher risk for transmitting HIV to sexual partners and injection
partners. The benefits of taking HIV medicine every day as prescribed include reducing the risk
of drug resistance. HAART can greatly reduce the viral load. It is defined as having less than 200
copies of HIV per mL of blood. It is essential that HAART is taken as prescribed as skipping
medications can give lead to increased HIV RNA synthesis and weaken the immune system and
lead to severe illness. Keeping an undetectable viral load effectively ensures that there is no risk
of transmitting HIV to an HIV-negative partner through sexual contact. Some data may show
that the risk of transmission from injection drug use also decreases, but not enough data is
available to say by how much. An undetectable viral load also helps prevent transmission from
mother to baby. It can also reduce the risk of transmitting HIV to the baby though breastfeeding
but does not eliminate the risk. In addition, taking HAART as prescribed can help prevent drug
resistance. Drug resistance can occur when individuals decide not to take their HIV medication
as prescribed and the virus changes or mutates and is no longer responsive to certain HIV
medication. Drug-resistant strains of HIV can also be transmitted to others.
HIV medication can cause side effects in some people. The most common side effects
include nausea and vomiting, diarrhea, difficulty sleeping, dry mouth, headache, rash, dizziness,
fatigue, and pain. It is important to speak with the health care provider to manage side effects or
possibly change your treatment plan. There are also no known drug interactions between HIV
medication and hormone therapy. If the current treatment is not working, the healthcare provider
may change the individual’s prescription. Changes in treatment plans are not unusual as the same
treatment affects everyone in different ways. Some difficulties may arise when an individual tries
to stick with their treatment plan. Problems that could arise include problems taking pills, side
effects from medicine, treatment fatigue, a busy schedule, being sick or depressed, and alcohol or
drug use. It is important to consult with a doctor if a dose or multiple doses are missed. Joining a
support group or asking family and friends for support can also help an individual stick to their
treatment plan.
Once an individual’s CD4 count drops below 200 cells per mL of blood, they are in the
most severe stage of HIV, AIDS. People with AIDS have greatly impaired immune systems and
an increased chance of developing or having other severe illnesses, called opportunistic

infections. Opportunistic infections (OI) are illnesses that occur more frequently and are more
severe in people with HIV. OI is less frequent today because of effective HIV treatment. Some
people may still develop an OI because they may not know they have HIV, they may not be on
HIV treatment or consistent with it, or their treatment may not be working properly. OIs can be
prevented by taking HAART to keep one’s immune system strong and healthy. Other ways to
prevent OIs include talking to a healthcare provider about medicines and vaccinations,
preventing exposure to other sexually transmitted diseases, not sharing needles, syringes, or
other drug injection equipment, limiting exposure to germs, not consuming certain foods such as
undercooked eggs, raw milk and cheeses, unpasteurized fruit juices, or raw seed sprouts, not
drinking untreated water, and speaking to healthcare providers about other potential ways to be
exposed to OIs at work, at home, and on vacation. Common opportunistic infections include
candidiasis, invasive cervical cancer, coccidioidomycosis, cryptococcosis, cryptosporidiosis,
cystoisosporiasis, cytomegalovirus, encephalopathy (HIV-related), herpes simplex virus,
histoplasmosis, Kaposi's sarcoma, lymphoma, tuberculosis, mycobacterium avium complex,
pneumocystis pneumonia, pneumonia, progressive multifocal leukoencephalopathy, salmonella
septicemia, toxoplasmosis, and wasting syndrome due to HIV.
People with HIV often face issues that affect their nutrition such as changes in the body's
metabolism, medicines that can upset the stomach, opportunistic infections that can cause issues
with eating and swallowing, and foods that can affect HIV treatment (like raw meats and fish).
These issues can affect the body’s ability to absorb the nutrient needed for good health. In order
to maintain good health, it is essential to eat healthily. A healthy diet can offer several benefits,
such as providing the energy and nutrients needed to fight HIV and other infections, maintaining
a healthy weight, managing HIV symptoms and complications, and improving absorption of
medicines and manage potential side effects. Health care providers with as a nutritionist or
dietitian can help people with HIV with their nutrition needs (CDC, 2021).
Maintaining a well-nourished state is important for people living with HIV to help
manage their health status. Other challenges can arise and compromise the nutritional status of
patients with HIV/AIDS. A chronic infection may lead to nutritional impairment over time and
some patients may experience malnutrition at baseline. Some patients may also already have pre-
existing comorbidities that require nutrition intervention regardless of their HIV status. Drug use
problems may also affect a patient’s adherence to medication and could lead to advancing
disease states, weight issues, food insecurity, and more. Wasting and malnutrition may also be
seen in settings where HAART may not be readily accessible. People with HIV/AIDS who are
obese may still be malnourished due to the availability of low cost high-calorie, low-nutrient-
dense foods. Research has shown that although few cases of AIDS have been reported in
countries with access to combination therapy, weight loss, wasting, and other forms of
malnutrition continue to occur. Weight loss and wasting have remained common in HIV-infected
patients with 33% of patients meeting a definition on wasting in a HAART analysis spanning
from the introduction of HARRT. Weight loss and wasting are independent predictors of
mortality in patients with HIV infection with as little as 5% weight loss being associated with
increased risk of mortality. Weight gain and potential progression to overweightness and obesity
are seen in individuals taking HAART. Compared to malnourished HIV/AIDS patients,
overweight and obese HIV/AIDS patients have improved survival. HIV can disrupt or destroy
many other cells in the body such as the gastrointestinal tract, liver, kidney, lung, and pancreas
that can then affect nutritional status. Alterations in nutrient metabolism are also common and
can lead to nutrient deficiencies and toxicities like chronic inflammatory conditions. Hormone
balances can also be altered which can lead to changes in nutritional status. There is no standard
meal plan recommendation for an individual with HIV/AIDS. Food modifications are based on
the disease and tolerance of treatment as well as the symptoms associated and other
comorbidities.
It is also important to exercise regularly to maintain good physical and mental health.
Exercising regularly helps increase strength, endurance, and fitness, reduces the risk of
depression, and helps the immune system work better to fight off infections. People living with
HIV/AIDS can do the same types of exercise as people who are HIV-negative.
Smoking has many negative health effects and people who have HIV/AIDS and smoke
are more likely than people who do not have HIV and smoke to develop lung cancer, head and
neck cancers, cervical and anal cancers, and other cancers, develop bacterial pneumonia,
pneumocystis, jiroveciipneumonia, chronic obstructive pulmonary disease, and heart disease,
develop conditions that affect the mouth, such as oral candidiasis (thrush) and oral hairy
leukoplakia, have a poorer response to HIV treatment, develop a life-threatening illness that
leads to an AIDS diagnosis, and have a shorter lifespan (CDC). (NCM, 2021)
Malnutrition
It is important to research and identify the nutritional status of people diagnosed with
HIV/AIDS, and design tailored nutrition interventions with the goal of increasing the probability
of better outcomes in HIV patients.
“Registered Dietitian Nutritionists (RDNs) are the food and nutrition experts who can
translate the science of nutrition into practical solutions” (EatRight, 2021). RDNs use Medical
Nutrition Therapy (MNT) to provide a nutrition assessment, diagnosis and a consequent nutrition
intervention to patients with altered nutritional status.
Over the years, the impact of nutritional status on health and disease outcomes has gained
interest and now represents a vast field of opportunity for research. Data and their analysis are
still scarce and additional research needs to be conducted to help registered dietitian nutritionists
(RDN) reach consensuses on evidence-based nutrition interventions tailored to the disease state
and individual being treated. Furthermore, knowing the rate of patients diagnosed with the same
disease who also have an altered nutritional status and researching similarities in nutritional
statuses may increase the RDN’s efficiency when screening for patients at risk for altered
nutritional status.
Malnutrition is a subset of nutritional status, and the term has no universally accepted
definition. For instance, the European Society for Clinical Nutrition and Metabolism (ESPEN)
defines malnutrition when one of the following criteria is met:
1. a body mass index (BMI) < 18.5 kg/m2
2. an unintentional weight loss and a reduced aged dependent BMI, or
3. an unintentional weight loss and reduced gender dependent fat free mass index
The Academy of Nutrition and Dietetics (AND) and the World Health Organization
(WHO) define malnutrition as a physical state of unbalanced nutrition (AND, 2017). In their
definition, the term refers to both overnutrition and undernutrition. Undernutrition is a lack of
calory and/or nutrient intake (macro- and/or micronutrients). On the other hand, overnutrition is
an excess intake of calories and/or nutrients. The WHO includes wasting, stunting, underweight,
inadequate vitamins or minerals, overweight, obesity, and nutrition-related non-communicable
disease in its definition of malnutrition (WHO, 2021).
Malnutrition can be caused by several factors. The stage in the life cycle at which an
individual is, along with gender may influence nutritional status as nutrient requirements vary
according to those criteria. Metabolic shifts due to age, growth and development will affect how
much of each nutrient the body needs. For instance, women who can become pregnant require
higher intake of iron (18 mcg/day) whereas men and older women require a lesser amount
(8mcg/day).
Clinical factors that may alter nutritional status and lead to malnutrition include chronic
illnesses. For instance, Crohn's disease, an inflammatory disease that affects parts of the
gastrointestinal (GI tract), can affect nutrient absorption and lead to malnutrition. A drug-nutrient
interaction may also impair optimum nutrient utilization while treating malnutrition with
medication.
Malnutrition is of high prevalence in hospitals, affects between 30% to 50% of patients,
and is associated with greater morbidity, mortality, and length of hospital stays. Malnutrition also
increases the risk of hospital readmission and consequently raises healthcare costs.
Studies encourage malnutrition screening (defined as the identification of malnutritional
risk) and nutritional assessments and agree on their efficiency and effectiveness in the prevention
and treatment of malnutrition. Challenges in conducting screenings and assessments for
nutritional status arise because there is no consensus on a clinical diagnosis for malnutrition and
no anthropometric or analytical value can be used alone to carry out a diagnosis. Screenings are
only performed in about 10% to 20% of hospitalized patients and only 50% of patients in
hospitals undergo laboratory tests or physical examinations to evaluate nutritional status.
Tools to identify individuals who are at risk for malnutrition have been developed and
validated with the objective of identifying individuals at risk for malnutrition. Many clinics and
healthcare settings give care to patients of different ages sometimes diagnosed with more than
one chronic illness, which limits tailoring malnutrition screening tools for one disease state.
The Malnutrition Universal Screening Tool (MUST) was developed for application in
community and hospital settings. The tool uses a BMI score, an unintentional weight loss score,
and acute disease effect score to evaluate the risk for malnutrition. A score of two or more
places the patient at high risk for malnutrition and referral to a RDN is recommended. One
limitation of this screening tool is the focus on underweight and low BMI in defining
malnutrition.
The Mini Nutritional Assessment (MNA) has been designed to provide a one-time, rapid
assessment of nutritional status in elderly patients. Elderly is defined from a chronological
standpoint and represents individuals from the age of 65 years and older, although other factors
may be considered to define elderly patients. The test is composed of measurements and
questions that can be answered in ten minutes. The test used to comprise of 18 questions which
were reduced to six. Anthropometric measurements include weight, height, and weight loss and
the questions assess lifestyle, medication, mobility (autonomy), and dietary habits (food and
fluids intake). The score distinguishes between elderly patients with normal nutritional status
(score between 12 and 14 points), elderly patients at risk of malnutrition (score between 8 and 11
points), and elderly patients who are malnourished (score between 0 and 7 points). The MNA is
used in free-living and log-term care environments.
The Short Nutritional Assessment Questionnaire (SNAQ) is used regardless of age in
hospitals, nursing homes and out-patient settings. Studies have shown that the SNAQ could
assess moderate to severe undernourishment in patients diagnosed with cancer undergoing
chemotherapy in outpatient setting. This assessment tool is validated for use in hospitals and
studies consider that it can identify complex malnourished patients.
The Nutritional Risk Screening 2002 (NRS-2002) is a risk score for malnutrition-
associated mortality and adverse outcomes over a period of 180 days. This assessment can
predict the risk of malnutrition in critically ill patients. The guidelines for the Provision and
Assessment of Nutrition Support Therapy in the Critically Ill Patient: Society of Critical Care
Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) were
used in designing this tool. The screening has four criteria, a BMI inferior to 20.5 kg/m², a
weight loss within the last three months, a reduced dietary intake within the week, and the
presence of severe illness. If one of the criteria is present, then a second screening is performed.
A score between 0 and 3 places a patient at low risk for malnutrition, a score of 4, at risk for
malnutrition, and a score between 5 and 7, at high risk for malnutrition.
The Subjective Global Assessment tool was developed to remove the need for precise
body composition analysis for diagnosis of malnutrition. The SGA is used in different population
groups including surgical and oncology patients.

The Nutrition Screening Initiative (NSI) was developed to assess prevalence of
malnutrition among older adults. DETERMINE your nutrition health checklist focuses on the
following signs for inadequate nutrition:
1. Disease
2. Eating poorly
3. Tooth Loss/Mouth Pain
4. Economic Hardship
5. Reduced social contact
6. Multiple medicines
7. Involuntary weight loss/gain
8. Needs assistance in self-care
9. Elder Years above the age of 80
The Malnutrition Screening Tool (MST) is the tool recommended by the Academy of
Nutrition and Dietetics. The (MST) was developed by Ferguson and colleagues who conducted a
systematic review of validation studies for malnutrition screening tools that were published in
the peer-reviewed literature from January 1997 through July 2017. Criteria for inclusion included
quick and easy screening tools, defined as taking less than ten minutes to complete. The tools
researched also had to be supported with adequate evidence defined as more than four validation
studies. In at least nine countries, the MST has been validated for use in acute, long-term,
rehabilitation, and ambulatory care and oncology clinics.
The MUST, MST, SNAQ, and NRS-2002 were positively associated with very long
hospital stays. MUST, DETERMINE, and the Subjective Global Assessment-HIV have been
validated for adults diagnosed with HIV although studies point out their limits in defining actual
body fat composition. Some studies recommend the use of waist-to-hip ratio and mid-arm
circumference in addition to weight loss and BMI classification in evaluating risk of malnutrition
in patients diagnosed with HIV.
The Global Leadership Initiative on Malnutrition criteria (GLIM) is a global consensus
on core diagnostic criteria for malnutrition in adults in a clinical setting. Diagnosis for
malnutrition is a 2-step process and the first step involves screening to identify risk status.
Screening can be done using any of the validated tools discussed above. Three phenotypic
criteria (low BMI, reduced muscle mass, and non-volitional weight loss) and two etiologic
criteria (reduced food intake or assimilation, and inflammation or diagnosis of illness) are used
for diagnosis. An individual who presents with one phenotypic criterion along with one etiologic
criterion is diagnosed with malnutrition.
The etiologic criteria can help tailor interventions to patients. In a clinical setting for
instance, causes for reduced food intake may be clinical such as an inability to swallow or
consume foods and interventions may include individualized formulas for nutritional support
designed by an RDN. In an outpatient setting, reduced food intake may be due to limited access
to nutritious foods for financial and/or physical reasons.
Physical reasons for limited intake of food include reduced motility and living in a food
desert. Food deserts are defined by the U.S.D.A. as “low levels of access to retail outlets selling
healthy and affordable foods”. Low access may be due to a low-income defined as a poverty rate
of 20% or greater, or a median family income at or less than 80% of the statewide or
metropolitan area median family income. It can also result from living more than a mile away
from a supermarket or large grocery store (ten miles in rural areas), and the absence of
transportation to reach them.

The Census Household Pulse Survey (CHHPS) records data on food sufficiency and was
used in a study to determine food security on account of the relationship between the two
concepts. The results of this study show that Black and Hispanic households with children
experience food insecurity the most when compared to White households with children with
41.1% of Black respondent’s households and 36.9% of Hispanic respondents’ households
experiencing food insecurity between April 23 and June 23, 2020, against 23.2% of White
respondent’s households for the same period. Food security is a crucial social determinant of
health. Living in a food desert is a risk factor for malnutrition and can both reduce overall intake
or modify households' diet by increasing fat consumption when choices for food purchase are
limited to fast-foods and convenience and corner stores that do not offer affordable nutritious
food. This high consumption of fat and sugar resulting from food insecurity may lead to
unintentional weight gain along with nutrient deficiency.
It is within the scope of practice of the RDN to execute proper coordination of care for
patients who are eligible to register for government-funded assistance programs such as the
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the Senior
farmer’s market nutrition program, or privately owned associations and charities who aim at
closing the gap in health disparities by providing resources to underprivileged communities. In
this context, social determinants of health and factors contributing to health disparities should
also be taken into account when assessing for malnutrition otherwise, opportunities for
improvement of nutritional status in all patients diagnosed with HIV regardless of weight status
may be missed.
Social determinants of health (SDOH) include where people live, learn, work and play,
and influence health outcomes and quality of life. Healthy People 2030 outlines five key areas of
SDOH. The first area is healthcare access and quality, the connection between people access to
healthcare, their understanding of healthcare services, and their own health. Other challenges
include access to healthcare, primary care, health insurance coverage, and health literacy. Access
to quality education refers to graduating from high school, college, education attainment,
literacy, and early childhood education. The social and community context englobes cohesion,
civic participation, discrimination, conditions in the workplace and incarceration. Economic
stability is another area that focuses on poverty, employment, food security, and housing
stability. Neighborhood and built-in environment analyses housing, access to transportation,
availability of healthy foods, water and air quality, and neighborhood crime and violence. All
aspects of social determinants of life have the potential to influence dietary habits and intake and
overall health and wellness.
Black/African American, Hispanic or Latino, and American Indian or Alaska Native,
have the highest prevalence of HIV compared to non-Hispanic Whites (Appendix C).
Concurrently, these populations are more affected by food insecurity as they tend to have limited
access to nutritious food because of financial or physical barriers and therefore may be at
increased risk for malnutrition. Incidence of high BMI (>30 kg/m2) is also greater for
Black/African American adults (44.8%) and Hispanic or Latino adults (42.2%) compared to
17.4% for non-Hispanic white adults (CDC: Overweight and Obesity, 2021).
Statement of Problem
Studies show the negative impact that HIV/AIDS may have on nutritional status which
increases the likelihood of malnutrition and screening, should be a routine process with a
diagnosis. However, data on the relationship between HIV/AIDS and nutritional status is still
scarce and a review of the literature needs to be conducted to identify the extent to which the
disease impacts nutritional status and may increase the prevalence of malnutrition in hospitalized
patients. Once patients have been assessed to be at risk for malnutrition, further action to identify
the cause and provide a nutritional intervention can be taken.
A RDN uses the nutrition care process to assess malnutrition and prescribe medical
nutrition therapy. Techniques for assessment include interviewing, and performing a nutrition
focused physical examinations (NFPE). It is within the scope of the RDN to coordinate care with
a physician to obtain and analyze biochemical data to assess nutrition related health issues. When
the etiology for malnutrition has been identified, the RDN can devise a plan to improve a
patient’s nutritional status through counseling, and individualized nutrition support. Systematic
and accurate assessment of malnutrition can go a long way in improving health outcomes in HIV
diagnosis.
Nutrient deficiency and unintentional weight loss are associated with longer hospital
stays, recovery periods, and increased healthcare costs however, using loss of appetite, nutrient
deficiency and unintentional weight loss as sole criteria for malnutrition may not correspond to
patients at risk for malnutrition who are overweight or diagnosed with obesity. Studies show that
obesity and chronic diseases are associated with increased inflammation, which in turn can have
an adverse effect on the immune system already mobilized to fight HIV/AIDS and associated
opportunistic infections. Inflammation is the normal response of the body to injuries,

environmental chemicals, pathogens, and radiation. However, disease is the main cause for
chronic inflammation. Low levels of micronutrients such as vitamin A and zinc have also been
associated with inflammation. When chronic and prolonged inflammation is present, having
adequate stores of vitamin C, vitamin E and phytochemicals (carotenoids and polyphenols) for
utilization as anti-inflammatory substances may be beneficial. Fermentation of dietary fiber by
the gut microbiome and synthesis of short-chain fatty acids is also shown to have an anti-
inflammatory effect. Inflammation and oxidative stress (imbalance between free radicals and
antioxidants) caused by diseases such as HIV/AIDS may place a patient at increased needs for
some nutrients such as protein (crucial for antibody production), to support the immune system
and increase the chance for a positive outcome in clinical settings. In oxidative stress, reactive
oxygen species (ROS), reach a level that cannot be neutralized by antioxidants, they can damage
biological molecules, and alter their functions. Infection with HIV triggers massive ROS
production and changes in levels of ascorbic acid (vitamin C), tocopherols, carotenoids,
selenium, superoxide, dismutase, and glutathione. Oxidative stress in HIV/AIDS contributes to
viral replication, inflammatory response, decrease in immune cell proliferation, loss of immune
function, chronic weight loss, and apoptosis (programmed cell death). Studies show the
efficiency of antioxidant therapy in managing oxidative stress.
Incidence of HIV vary according to ethnic groups and illustrates health disparities in the
U.S. All the factors mentioned so far make it primordial that data be collected and analyzed to
identify the risk factors associated with malnutrition in patients with HIV/AIDS. Without
accurate identification of those risk factors, RDNs will lack the evidence on which to base their
interventions.
We conducted a narrative review to answer the following questions:

1. What is the impact of HIV/AIDS on the body’s capacity for absorption, storage
and utilization of macronutrients and micronutrients?
2. What are the factors influencing nutritional status in adults diagnosed with
HIV/AIDS?
3. Are there identifiable social determinants of health which increase the impact of
HIV/AIDS on nutritional status?
Research has shown that HIV/AIDS may influence nutritional status. After conducting a
narrative review, we will identify the extent to which this diagnosis impacts nutritional status and
increases the prevalence of malnutrition. Yet, data on the association between HIV/AIDS and
malnutrition in populations where health disparities exist is scarce. In 2020, 12,408 residents of
D.C. were living with HIV (DC Health, 2021). In order to prevent and treat malnutrition, it is
essential to first identify the confounding factors that affect individuals living with HIV’s
nutritional status to design interventions with the goal of improving individual’s outcomes.
Purpose of Study – Aim of the Study.
Malnutrition is prevalent in individuals living with HIV/AIDS and can be caused directly
or indirectly (opportunistic infections). Malnutrition reduces the body’s immune function and the
ability to fight off infection. Health disparities can further increase the prevalence of malnutrition
seen through under or overnutrition. A narrative review revealed the correlation between health
disparities as important factors influencing nutritional status in patients living with HIV/AIDS.
This study examines participant profiles and compiles a case report of participants admitted to an
acute care setting living with HIV/AIDS who experience health disparities to determine the
incidence of malnutrition in this population.
Aims
Primary aims
1. To identify the incidence of malnutrition in a population of individuals living with
HIV/AIDS who experience health disparities in an acute care setting.
2. To assess information on the impact HIV/AIDS infection on nutritional status based on
current literature.
Secondary aims
1. To apply the nutrition care process to improve the outcome of participants with
HIV/AIDS.
2. To address social determinants of health and nutrition related disparities in individuals
with HIV/AIDS.
Objectives
1. To assess risk factors associated with an HIV/AIDS diagnosis that affect nutritional
status.
2. To determine effectiveness of nutrition intervention in improving nutritional status in
participants diagnosed with HIV/AIDS and who are impacted by health disparities.
3. To utilize effective malnutrition screening tools for individuals with HIV/AIDS based on
current literature.
4. To provide individuals living with HIV/AIDS with resources and treatment to treat or
prevent malnutrition.
Hypothesis
The incidence of malnutrition in those with an HIV/AIDS infection will likely be
influenced by factors such as age, sex, biochemical data, compliance to HIV treatment
regiments, comorbidities, opportunistic infections, and social determinants of health.
Significance of Study
The limited amount of evidence on the impact of HIV infection on the incidence of
malnutrition in patients affected by health disparities requires more research to validate the
associate. HIV/AIDS negatively affects the nutritional status of patients through both wasting
and weight loss and weight gain into the progression of obesity or overweightness (CDC, 2021).
Black/African American, Hispanic or Latino, and American Indian or Alaska Native, have the
highest prevalence of HIV and obesity compared to non-Hispanic Whites (CDC, 2021). These
populations are also at a higher risk of malnutrition due to food insecurity. They often have
limited resources and other financial or physical barriers that prevent them from gaining access
to healthy food, therefore, SDOH plays a key factor in assessing nutritional status. They
determine factors that influence the outcome of health and the quality of life. Healthcare access
and quality, education access and quality, social and community context, economic stability, and
neighborhood and built environment all determine a patient’s wellbeing. These SDOH vary with
different racial or ethnic groups. To find solutions to problems within these communities, it is
first important to accurately assess certain factors affected by the SDOH such as nutritional
status. An accurate review of the status of people living with HIV/AIDS will give an insight into
how to properly provide intervention for this group.

HIV/AIDS has affected the black and African American community at disproportionate
rates. It is essential to identify how these factors affect nutritional status within this group. Black
or African American people account for 13% of the US population but 42% of the new HIV
diagnoses in the United States in 2018. Men are among the largest group of Black or African
Americans diagnosed with the disease. When compared to other groups, Black or African
American gay and bisexual men had the highest number of new HIV diagnoses. It is important
for black or African American people to know their HIV status to receive the proper treatment.
Blacks or African Americans are also disproportionately affected by food insecurity which
affects access to healthy food and can contribute to malnutrition. Nearly one-quarter or 22.5%
were found to be food insecure in 2016, which is nearly double the national average of 12.3%.
Nutrition assistance programs have been used to help mitigate hunger and food insecurity. These
factors put the Black and African American communities at risk for HIV and malnutrition. It is
important to examine how the two interact as they affect this community more than others.
Washington, D.C. has a population of 705,749 people as of 2019. 46% of its population is
Black or African American. Washington, D.C. has a total of 17,781 cases of HIV in the past 5
years. 12,408 of those individuals with HIV are DC residents. 28% of those living with HIV are
black men who have sex with men or men who use injection drugs. In addition, 1 in 10 residents
of the metropolitan Washington region is food insecure. Washington D.C. needs evidenced-
based interventions to treat HIV and the risk of malnutrition in residents diagnosed with
HIV/AIDS. Future research can help the District and other regions to increase their overall
health.
Malnutrition is prevalent in individuals living with HIVAIDS. Those with opportunistic
infections, social barriers to health, and non-compliance to medication among other factors have
a higher risk for mortality. Limited research has been done relating individuals who have
HIV/AIDS and are experiencing these phenomena and their nutritional status. Black and African
American people and individuals affected by health disparities are at a greater risk for
contracting HIV and often suffer from barriers to receiving adequate healthcare and maintaining
optimal health status. It is important to examine how multifactorial causes possibly affect the
nutritional status of those with these diagnoses and the incidence of malnutrition in this
population. There is very little research done on the role of health-related disparities in
nutritional status in patients with HIV/AIDS. This offers a great area for future research to help
decrease the incidence of nutrition related diseases in patients with HIV/AIDS who are affected
by health disparities. The consequences of HIV/AIDS and health disparities on nutritional status
are still understudied, and in order to design future intervention for prevention of malnutrition,
more research is necessary.

LITERATURE REVIEW
This narrative review was conducted using PubMed by the National Center of
Biotechnology Information (NCBI) as our primary database. When using this database, key
words for research included: nutritional status, malnutrition, HIV, and AIDS. Articles were
excluded from the narrative review if they were not written in English or if participants were
under the age of 18, over the age of 65, or pregnant. Additionally, studies were excluded if they
were systematic reviews or meta-analysis, unless it was for secondhand research. Inclusion
criteria comprised of relevancy which we defined as published within the last five years. Because
the focus is on nutritional status, pregnancy was also an exclusion criterion as it influences
nutritional status. Lastly, studies that used research on animals were excluded from the narrative
review. After all these exclusion criteria, we were able to compile nine different studies
encompassing nutritional status in people diagnosed with HIV/AIDS. Studies included different
methodologies. Of the compiled studies, methodologies included cross-sectional analyses and
cohort studies, however there was also a meta-analysis used for secondhand research, as well as
a randomized controlled trial.
A review of all current literature on the topic of HIV/AIDS and nutritional status was
conducted. These studies were then placed into categories based on interest themes
corresponding with the topic of this case study report. To the best of our knowledge, the
following narrative review includes all related studies, however it is continuously being updated.
Additionally, to be more comprehensive and precise some studies are grouped into multiple
themes to which they qualify. Major themes include food insecurity, social determinants of
health, health disparities, dietary intake, malnutrition screening tools, biochemical data,
anthropometric data, and medication usage.

Food insecurity is a significant factor in malnourished patients. “89.5 percent (116.7
million) of U.S. households were food secure throughout 2020” (Appendix C). According to the
USDA, food insecurity is defined as limited or uncertain adequate food access due to economic
and social conditions at the household level. From our literature review, two studies fell into this
category. The first study was conducted in Bahir Dar, Ethiopia (Hassen, 2018). This cross-
sectional study aimed to determine whether household food insecurity and dietary diversity in
patients with HIV were good indicators of dietary intake within a diverse population. A total of
423 HIV infected individuals who are members of HART clinics in Northern Ethiopia were
studied. To determine the level of food insecurity, the Household Food Insecurity Access Scale
(HFIAS) was used. Data collected during the study was then entered and analyzed utilizing
Epidata version 3.1 and SPSS version 20. In addition, reliability, sensitivity, sensitivity analyses
were conducted. Following its conduction, it was found that 87.9% of participants we are food
insecure based on the HFIAS tool. It was also found that food insecurity along with other
measures are good indicators of nutritional status in patients living with HIV. However, to be
more concise this study could have included more data regarding the patients including past
medical history, biochemical data and current comorbidities which may impact educational
status. In another cross-sectional study conducted in Ethiopia, the HFIAS tool was used to
determine his nutritional status and determinants of malnutrition in HIV/AIDS patients (Hussen,
2016). 512 patients attending HART in public health facilities located in West Shewa Zone,
Central Ethiopia were interviewed by trained professional to determine their level of food
insecurity using the HFIAS. Data gathered was reviewed for accuracy and completeness before
beginning coded and analyzed using Epi-Info 3.5.1 and SPSS Version 22 for windows.
Following the conduction of the study, it was found that of the 505 participants who responded
to the survey, 35.2% were food insecure and 23.6% were found to be undernourished. (Appendix
D1). Additionally, of all factors tested within the study, household food insecurity was
determined to be the strongest indicator of nutritional status, with those insecure were being 5.3
times more likely to be undernourished. Although this study considered multiple factors which
could affect nutritional status, there were some limitations. Primarily, generalizability is not
possible due to all patients being on regular HART. Therefore, this study cannot be applied to
patients or populations that are not actively seeking medical attention and on regular HART. In
addition, because multiple variables were tested in a cross-sectional study design cause-effect
relationships of variables and undernutrition over time cannot be measured and explored.
Our next theme is social determinants of health (SDOH). Social determinants of health
pertain to the physical and social environments which impact health. Dismantling of SDOH has
led to improvements in nutritional status and health outcomes in patients with HIV. SDOH can
be divided into five distinct categories (Appendix C3). These categories include economic
stability, education, health and healthcare access, neighborhood and built environment, social
and community context. Economic stability is a primary determinant of health as it affects
individual and household ability to afford healthy foods, health care and housing. The
consumption of healthy foods and access to health care directly impacts the nutritional status of
individuals. Community policies which stimulate programs such as employment programs and
training, affordable child-care access. Reduced quality of education is also known to lead to a
decreased likelihood and higher-paying job employment. This has generational implications by
creating a cycle of inability to afford adequate healthcare access. Those with lower education
levels are also more likely to suffer from conditions such as cardiovascular disease, depression
and diabetes. Healthcare quality and access is also a determinant of nutritional status. Access to
health is significantly decreased in communities where individuals do not have adequate
transportation systems and increased rates of violence. These conditions not only obstruct
individuals from receiving necessary treatment, but preventative care as well. These outcomes
also relate to circumstances of the built physical environment and social and community context.
Improved education and housing opportunities are all methods to decrease the gap created by
SDOH. In addition, the creation of policies which support implementation of programs which
reduce the impact of SDOH are necessary. A total of two studies were included within the theme
of SODH. The first study conducted a cross-sectional study concerning nutritional status and
associated factors in a hospital-based HAART site in Kathmandu, Nepal. Along with
anthropometric and biochemical data the study was able to conclude that overweightness and
obesity in HIV was an emerging issue in HIV patients (Appendix D2). The study also suggests
that it is vital HIV patients be screened for overweightness and obesity. In addition, the study
gave evidence which supports the idea that nutritional programs should be an integral part of
HIV/AIDS continuum of care. In the second study, a systematic review was conducted to review
and analyze the relationship between nutritional status and immune response ranging from
malnourished to obese HIV patients. After a multitude of research was reviewed to form a
concise understanding of the topic, it was found that those with obesity suffer from heightened
inflammatory markers. It was also found that immune activation is implicated by the presence of
multiple comorbidities in HIV patients. In resolution to these findings, the study suggested
interventions such as food assistance programs, micronutrient supplementation, and expanded
HIV testing could navigate the adverse effects of malnutrition and obesity on immune activation,
thereby improving the HIV patient outcomes. In terms of obesity, interventions such as weight
loss and exercise programs can be used to reduce the prevalence of obesity and overweightness
in HIV patients. Interventions such as these would have to consider social determinants of health
for certain communities and populations to be effective within that population. For instance, with
the addition of food assistance and weight-loss/exercise programs, transportability, cost, literacy-
level and community acceptance of such programs need to be considered. In terms of
micronutrient supplementation and expanded HIV testing, policies and implementation methods
that account for individuals and households without adequate access to healthcare will also need
to be addressed.
The fourth major theme found in our review of the current literature includes socio-
demographic data. Socio-demographics include key characteristics of a population such as age,
gender, ethnicity, education level, geographic location, and marital status. A total of three studies
fell into this category. In the first study, “Nutritional status and the associated factors among
people living with HIV: evidence from cross-sectional survey in hospital based antiretroviral
therapy site in Kathmandu, Nepal”, as previously mentioned within the SDOH theme, socio-
demographic data was collected using retested structured questionnaires implemented through
interview techniques. It was found that, along with anthropometric and biochemical data, socio-
demographic including age, gender, marital status, and occupation were strongly associated with
body mass index (BMI). For instance, HIV patients that were male, married, in a business
occupation or in middle-age ranges, tended to have higher BMIs. In the second study, “The
Nutritional Status of Adult Antiretroviral Therapy Recipients with a Recent HIV Diagnosis; A
Cross-Sectional Study in Primary Health Facilities in Gauteng, South Africa”, the relationship
between duration of HAART and nutritional status was determined. A researcher-designed,
standardized, pretested questionnaire was used to collect sociodemographic data including age,
gender, marital status, educational status, employment status, household income, and household
size. In result, it was found that females with HIV had higher weights and BMIs than their male
counterparts (Appendix D4). In addition, household income was associated with underweight,
with those with lower incomes having a higher prevalence of underweight. Overweightness on
the other hand was associated with age and lower household sizes. Lastly, obesity was associated
with gender, employment, and income. The last study included under this theme is, “Nutritional
status and its effect on treatment outcome among HIV infected clients receiving HAART in
Ethiopia: a cohort study.” The main aim of this study was to determine the effects of nutritional
status on highly active antiretroviral treatment (HAART) and its impact on survival, CD4
recovery, occurrence of opportunistic infections of malnutrition, and overall patient outcomes.
CD4 levels are noted that indicate nutritional status. After isolating and grouping 340 patient
medical charts into malnourished and nourished groups and following patients for up two years
or death occurrence, it was found that sociodemographic factors played a key role in
immunological recovery. At 6, 12 and 24 months (about 2 years) of HAART duration, age and
sex were major predictors of immunological recovery. At 6 months age was the only
independent predictor of immunological recovery with CD4 count of malnourished group
decreasing by 12.40 cells/mm3 (p = 0.500) compared to well-nourished group. Additionally, at
12 months, age and CD4 count were major predictors while at 24 months (about 2 years) age,
sex, marital status, and baseline HARRT were all major predictors (Appendix D5). For every 1
year of age, there was an increase in CD4 count of 2 cells/mm3. In terms of gender and marital
status females and married individuals had higher CD4 counts than their counterparts.
Our next theme of interest is dietary intake of patients with HIV. Dietary intake, or daily
individual eating patterns, is a major indicator of under- and over-nutrition in both healthy and
immunocompromised individuals. Dietary intake does not only include intake of certain food
items and kilo calories, but also frequency of meals, intake of micronutrients, supplementation,
and others. Four studies were included under this theme. The first study, “Household food
insecurity access scale and dietary diversity score as a proxy indicator of nutritional status
among people living with HIV/AIDS, Bahir Dar, Ethiopia” used a cross-sectional design to
establish whether both household food insecurity and household dietary diversity (HDDS) can be
used as reliable indicators of the dietary intake of a population. Dietary diversity was measured
using a tool adopted from Food and Nutrition Technical Assistance Project (Appendix D3). It
was found that HDDS was also proven to be a good indicator of nutritional status of PLHIV. The
results indicate that both food insecurity access scale and household dietary diversity score were
found valid and reliable proxy indicators for measuring nutritional status. In the following study,
“The Nutritional Status of HIV-Infected US Adults”, NHANES was used to determine the
nutritional status of people living with HIV. Adults ages 19 to 49 participated in the study
(Appendix D6). In conducting the NHANES, two 24-hour dietary recalls were conducted. In
conclusion, in contrast with non-HIV women, women with HIV had lower intake of key
nutrients including fiber, vitamin E, vitamin K, magnesium, and potassium. However, they also
had a higher intake of protein and niacin (Appendix D7). This suggested that HIV infected
patients had poorer markers of some nutritional status. Finally, the last study, “Effectiveness of
Macronutrient Supplementation on Nutritional Status and HIV/AIDS Progression: A Systematic
Review and Meta-Analysis”, aimed to determine if introduction of protein-energy-fortified
macronutrient supplements at ART initiation improved HIV treatment outcomes (Appendix D8).
After conduction of the current literature on the subject, it was found that protein-energy-
fortified macronutrient supplementation when starting ART may positively influence nutritional
status and immunologic response in person living with HIV (PLWH) in Sub-Saharan Africa.
Biochemical data can indicate levels of nutritional status in patients with HIV. This data
can include levels from tests including serum protein, serum micronutrient levels, serum lipids,
and immunological agents such as CD4 levels, WBC, H/H, HIV antibody test, and T Cell tests.
Data was collected from Medicare records or through in person testing at HIV clinics or primary
care facilities. CD4 count indicates the progression of HIV and can be used among other tests to
assess immunological health. Nutritional status can be determined by monitoring and evaluating
the biochemical data, in conjunction with other tests, of patients in different stages of HIV. A
study included a data analysis from NHANES 2003-2014 to determine the nutritional status of
people living with HIV in the US. HIV antibodies were ascertained initially by immunoassay and
confirmed with Western blot. The study showed that individuals with HIV had higher serum
protein, lower serum albumin, and lower serum folate than individuals without HIV. HIV
positive women also had lower serum 25-hydroxyvitamin D concentrations than HIV negative
women. It was also found that women with HIV had a lower intake of fiber, vitamin E, vitamin
K, magnesium, and potassium and a higher intake of protein and niacin than those who were
HIV negative. HIV is associated with poorer markers of nutritional status. Another study
measured the CD4 levels as an indicator of nutritional status and disease progression. It was
found that there was no difference in CD4 count of those who were on HAART and
malnourished and those that were on HAART and well nourished. A narrative review was also
conducted that measured CD4 levels and T cell count. This study found that those with higher
BMIs tended to have better CD4 recovery and higher T-cell counts regardless of HAART
initiation of HIV treatment.
Anthropometric data, such as height, weight, and BMI were used to assess nutritional
status and often used to diagnose malnutrition. Five studies conducted on-site anthropometric
data measurements and then calculated BMI (Appendix D2,D4,D5,D6,D7). BMI is used as a
validated measure of nutritional status. If your BMI is less than 18.5, it falls within the
underweight range. If your BMI is 18.5 to <25, it falls within the normal. If your BMI is 25.0 to
<30, it falls within the overweight range. If your BMI is 30.0 or higher, it falls within the obesity
range. It can be taken from medical records or measured on site. These following studies used
height and weight and measures anthropometric data to determine their BMIs: Nutritional status
and the associated factors among people living with HIV: an evidence from cross-sectional
survey in hospital based antiretroviral therapy site in Kathmandu, Nepal; Implementation of the
nutrition assessment, counseling, and support program is not associated with body mass index
among people living with HIV in Accra, Ghana; The Nutritional Status of Adult Antiretroviral
Therapy Recipients with a Recent HIV Diagnosis; A Cross-Sectional Study in Primary Health
Facilities in Gauteng, South Africa; and, The Nutritional Status of HIV-Infected US. BMI
classification was then assessed in relation to the participants' nutritional status. The results of
these studies varied from majority of participants were found to be overweight or obese, to
majority of participants with HIV had a BMI classified as underweight. BMI also varied from
male to female as one study showed that more females than males are classified overweight or
obese.
The nutrition focused physical exam is a validated tool used to determine nutritional
status. It can be used to assess malnutrition in patients with HIV in both acute and outpatient
settings. The studies we have found utilize physical or medical exams done by healthcare
professionals. These exams, in addition to other tests, can be used to determine nutritional status.
The Nutrition Focused Physical Exam, or NFPE, is a physical exam that RDNs perform to assess
nutritional status or evaluate malnutrition. This exam may be part of your nutrition assessment
when you meet with an RDN. None of the studies reviewed utilized a dietitian. This is a great
area of improvement for future research. The study “The Nutritional Status of HIV-Infected US
Adults” includes a medical examination, but not a nutrition focused physical exam. The physical
examination provided more information on the nutritional status of the patient.
Medication use and adherence can be a determining factor in the progression of both
HIV/AIDS and can affect the nutritional status of a patient. Antiretroviral medication also known
as HAART (Highly Active Antiretroviral Therapy) can be used to slow the progression of HIV
by slowing the decrease of CD4 levels. One study aims to determine the effects of nutritional
status on highly active antiretroviral treatment also known as HAART and found that there were
no significant differences in CD4 recovery after HAART between those that were malnourished
and those that were well nourished. “The Nutritional Status of Adult Antiretroviral Therapy
Recipients with a Recent HIV Diagnosis; A Cross-Sectional Study in Primary Health Facilities
in Gauteng, South Africa” study collected data on the duration of HAART. It was shown that the
prevalence of overweightness increases with those who take HAART for more than two years
(Appendix D9). Examining the duration and possible types of HAART can affect the nutritional
status of individuals with HIV.
CONCLUSION!!! RESULTS OF NARRATIVE REVIEW

METHODOLOGY
Case studies will be used to demonstrate how components of the nutrition care process
(NCP) are used to provide nutrition care. In addition, available guidelines are used to supplement
and support the use of interventions. By utilizing the NCP, proper assessment and interventions
can be used to address nutrition related disparities in patients with HIV/AIDS in an acute care
setting. The NCP consists of nutrition assessment, diagnosis, intervention and monitoring and
evaluation. It is important to note that the terminology of participants and patients was used
interchangeably.
The following data will be obtained: body mass index (BMI), height, weight and weight
changes, age, nutrition related biochemical data, and scoring on nutrition screening and
assessment tools must be collected. Biochemical data that is highlighted for collection includes
CD4+ cells, markers of inflammation such as C-reactive protein and indications of macro and
micronutrient deficiencies. In the absence of CD4+ count, absolute lymphocytes count (>1643 or
>1450) or white blood cell count and lymphocyte percentage is possibly predictive of the CD4+
cell count below 200. Qualitative data is also important to identify factors which influence health
disparities which affect the nutritional status of a patient with HIV. This qualitative data includes
the collection of patient social history, family history, past medical history, procedures and
diagnoses, lifestyle, education, social life support system, environmental conditions, diet history,
nutrition focused physical findings, employment, education level, and socioeconomic status are
also collected.
Primary data will be collected via an interview with the patient and a nutrition focused
physical exam will be conducted. Weight changes and qualitative data such as patient history,
social life and results from nutrition questionnaires are also included. Results from screening and
assessment tools conducted during a food and nutrition related interview may also be included.
This may include MST, SGA, and utilization of the GLIM criteria to diagnose malnutrition.
Secondary data will also be obtained from the medical record as well as data described by other
members of the interdisciplinary team such as nurses and physicians. Secondary data will include
biochemical data, medications, past medical history and medical diagnoses.
Patient Selection
Eligible patients will be adults admitted to the selected acute care facility with a prior
diagnosis of HIV/AIDS. Patients must live in either wards 5, 7, or 8 in Washington D.C. and will
excluded if they are diagnosed late-stage AIDS, are intubated, on ventilation, pregnant, are above
65 years of age, or have a code status of do not resuscitate and have been placed on comfort care
or hospice.
To collect this information, it is also important to have inclusion and exclusion criteria.
Participants are non-pregnant, adult patients (men and women from 18 years old to 65 years old)
admitted to Howard University hospital who have been diagnosed with HIV/AIDS, who live in
ward 5,7, and 8 in Washington D.C. Four participants will be assessed, which removes the need
for approval from the Institutional Review Boards (IRBs) for conducting our research. Patients
who meet the criteria will then be assessed and interviewed using methods described in the
Nutrition Care Process.
Procedures/Data Collection
Patient demographic information will be collected from the medical record. This
information would include age, sex, race/ethnicity, occupation, education, and language. Patient
past medical and family history will also be collected. Additionally, social history such as
alcohol and tobacco use, socioeconomic factors and living/housing situation would be collected.
All of this data must be validated during the interview with the patient
Malnutrition screening was performed using the SGA while malnutrition diagnosis was
determined using the GLIM criteria. The SGA tool is comprised of six main categories
(Appendix E1). These allow for the assessment of weight status/weight change, dietary intake,
functional capacity, disease states/comorbidities causing possible metabolic stress, as well as
edema, and muscle and fat loss via a physical examination. Each category is ranked on a scale
from 1-7. An overall rating between 3-5 is indicative of mild to moderate malnutrition while a
rating of 1-2 indicates severe malnutrition. The GLIM criteria outlines that an individual must
present with one phenotypic and one etiologic criteria to be diagnosed with malnutrition
(Appendix E2). Phenotypic criteria may include weight loss, low body mass index and reduced
muscle mass while etiologic criteria would include reduced food intake or presence of
inflammation. The severity of malnutrition is then determined by the severity of the phenotypic
criteria met.
Factors of social determinants of health which may be affecting the patients’ health
outcome were identified utilizing the Accountable Health Communities Health-Related Social
Needs Screening Tool (AHC-HRSN) developed by the Centers for Medicare and Medicaid
Services (CMS). This tool identifies 5 core domains such as housing instability, food insecurity,
transportation problems, interpersonal safety and utility help needs. Eight supplemental domains
highlight employment, education, financial strain, physical activity, family and community
support, mental status, substance abuse and disabilities. Data required for this tool was collected
during a patient interview.

To maintain standards of the NCP and to track intervention efficacy on outcomes, a
nutrition care plan was developed using the ADIME (Assessment, Diagnosis, Intervention,
Monitoring/Evaluation) format.
Assessment for risk of malnutrition in patients with HIV will be done via an interview
and a nutrition focused physical examination (NFPE) which is documented utilizing standardized
terminology per the eNCPT. We will use the GLIM criteria for diagnosing malnutrition. Three
phenotypic criteria (low BMI, reduced muscle mass, and non-volitional weight loss) and two
etiologic criteria (reduced food intake or assimilation, and inflammation or diagnosis of illness)
are used for diagnosis. The presence of one etiologic criterion and one phenotypic criterion is the
basis for diagnosis of malnutrition. We chose the GLIM criteria as tool for identifying patients at
risk for malnutrition because there is now a global consensus on the use of this validated tool in
acute care settings.
The nutrition care process (NCP) is the method chosen to assess nutritional status, give a
nutrition diagnosis, design an intervention, and select indicators and criteria for monitoring and
evaluation of progress. NCP is designed to better the substance and quality of individualized care
for patients.
The Subjective Global Assessment (SGA) was also used to assess areas leading to
malnutritional risk within a patient. This assessment tool utilizes a rating system which is
partially completed by the patient and partially by the dietitian. The PG-SGA considers weight
loss, metabolic demand, symptoms, function and physical findings to determine nutritional risk
and recommended next steps for intervening.

Once the patient is assessed and possible problems leading to increased nutritional risk
are prioritized, an intervention is planned. Intervention methods include adjusting nutrient and
food delivery, providing education and counseling services, and coordinating care with other
members of the interdisciplinary team to meet objectives. Lastly, monitoring and evaluation of
outcomes is necessary to determine whether interventions produced positive patient outcomes
and reduced the impact of health disparities in decreased nutritional status of patients with
HIV/AIDS.
RESULTS
Data Analysis
Analysis of quantitative data is done by measurement against evidence-based
comparative standards. To assess nutrient intake, comparative standards can be derived from the
Dietary Guidelines for Americans (DGA), recommended dietary intakes (RDAs), and dietary
recommended intakes (DRI). To analyze biochemical and anthropometric data it will be
compared against standard reference ranges according to weight, height, age and stage of disease
process.
In order to analyze data, we decided to use the content analysis method. This method was
chosen due to its flexibility to be used with either quantitative or qualitative data since both types
of data are presented within our narrative review. Content analysis is used to analyze contextual
and visual data, which is collected from surveys, literature reviews, as well as other sources. In
addition, because hypotheses were used in conjunction with the intention of further exploring
upon current literature, a methodological method which considered both qualitative and
quantitative data was required. This gives us the flexibility to further expand on current
literature.
Discourse analysis can also be used in order to discuss the results of analysis in
comparison to their social implications, especially when discussing health disparities such as
food insecurity and accessibility to nutrition programs to reduce nutritional risk. This
methodology of analysis is able to exemplify the context of nutrition research in an acute care
setting that utilizes the nutrition care process to support findings. Utilizing the NCP, evidence-
based comparative standards and validated tools will aid in the broadening knowledge base of
the NCP to impact and influence health disparities.
Case Report
The participants for this case report were admitted into an acute care facility which
provides high quality care for a diverse population including populations affected by health
disparities. Our case reports depict the relationship between health disparities, disease state and
nutritional status.
In this case study report, patients were selected based on their positive diagnosis of HIV
(CD4>200/mm3), age (18-65years), and comorbidities. Patients without a confirmed diagnosis
of HIV were excluded in concordance with the focus of this study. Furthermore, candidates with
a CD4+ cell count below 200 (diagnosis of AIDS) were excluded to account for the increased
risk of developing opportunistic infections which may alter nutrient needs and nutritional status.
In patients with an unreported CD4+ cell count, ALC or WBC and lymphocyte percentage may
be used to predict CD4+ cell count.

Age was limited between 18 to 65 years old, and pregnant patients were excluded.
Growth and development, pregnancy, and aging may increase the needs for some nutrients
according to increased or decreased metabolic rates. Thus, aging, growth and development and
pregnancy become independent variables that can further affect nutritional status. For instance,
individuals before the age of 18 years old have an increased need in calcium (Male between the
age of 14 and 18 years old and older than 70 years have an increased need in calcium. Inadequate
calcium utilization is then influenced by 25-hydroxyvitamin D plasma concentration (vitamin D).
In these populations, a single nutrient deficiency can provoke subsequent impaired nutrient
utilization.
Furthermore, candidates with a diagnosis of cancer or in critical care were excluded.
Individuals with a diagnosis of cancer have an increased need in protein (1-1.5/Kg of body
weight) and inadequate protein intake may lead to loss in lean body mass, hence affecting criteria
for diagnosis of malnutrition according to the Glim criteria for diagnosing malnutrition.
Markers of compliance with medical and nutrition-related recommendations were
identified for monitoring and evaluation. Daily adequate energy intake was monitored and
compared to the calculated estimated daily requirements, and recommendations were provided
when the current diet order was inadequate to current or future needs.
The MST questionnaire was used as a tool to evaluate for risk of malnutrition, and the
GLIM criteria to diagnose malnutrition.
The Accountable Health Communities Health-related Social Needs Screening Tool
(AHC-HRSN) was used to identify needs that can be addressed by coordination of care with
community services.
Summary of Case One
The first participant of this case report is a 49-year-old white female with a medical
history of liver cirrhosis, cholelithiasis and Bipolar affective disorder. The patient was diagnosed
with HIV a year prior to this occasion. This first patient also has a family history of chronic
obstructive pulmonary disease (COPD) and cancer. The patient presented to the hospital with
bilateral flank pain, fever, nausea, vomiting 2-3 per day for 5 days and anorexia. Upon admission
the patient was diagnosed with sepsis secondary to acute complicated cystitis, related to
pyelonephritis. The patient was administered IV ceftriaxone in addition to Percocet and
morphine for pain management. The patient had a weight of 75.353kg and BMI of 26.02 kg/m 2.
After transfer from the ED, a urinalysis showed a positive test for cocaine. She also admitted to
having brought whiskey with her to the hospital to avoid symptoms of withdrawals.
Additionally, the patient felt weak and fatigued but was able to perform ADLs and IADLs
independently.
The patient was on a regular diet (2,200kcal/day) with 2g sodium for the duration of her
hospital stay. She reported her appetite increasing and denied symptoms of nausea, vomiting,
diarrhea or constipation. The patient had an estimated intake of 50% to 75% of her plate,
indicating adequate nutrient intake. The patient reported no recent weight loss but showed
significant temporal, triceps and interosseous muscle loss. In addition, there was significant
buccal, orbital, and clavicle fat loss.
Assessment and Diagnosis

The first assessment interview was conducted in-person in an acute-care setting. The
patient still showed weakness and fatigue and was slightly agitated. The patient admitted not
seeing a doctor regarding HIV for an extended period of time but reported taking her medication
(Biktarvy) daily. She also stated that she walks frequently (60min/7days a week) but recently
has been having trouble moving around. After evaluating her usual dietary intake, she revealed a
diet high in protein, fat, sodium and added sugars. The patient denied having barriers to adequate
food and medical services. The patient also reported drinking ½ quart of distilled alcohol per day
and has a current alcohol and drug abuse disorder. According to her responses on the CMS
survey, the patient is depressed and has a lack of social support.
In terms of her biochemical data, the patient laboratory data showed elevated levels of aspartate
amino transferase (AST) and low red blood cells (RBC), hemoglobin, hematocrit, mean
corpuscle volume and mean corpuscle hemoglobin. Her abnormal hematological panel is likely
due to complications associated with liver cirrhosis rather than HIV, however HIV can further
exacerbate and prevent recovery of these levels. Since the patient’s recent CD4 panel was unable
to be collected, absolute lymphocyte count (ALC) was used in its absence. Her white blood cell
count is elevated at 15,480 cells/mcL, lymphocyte percentage at 20.7%, and an ALC of 3,200
cells/mcL. This is indicative of a CD4 cell count above 200 cells/mcL however a proper
assessment, including laboratory data for CD4+ cell count, is needed to more accurately
determine her HIV status.
Relevant medications taken by the patient include Biktarvy, Spironolactone, Lasix,
Triazodone and folic acid supplements. The patient’s energy requirements were estimated to be
1,800kcal/day (Mifflin St.Jeor) and 90g of protein per day (1 – 1.5g/kg) due to liver cirrhosis.
The Subjective Global Assessment (SGA) was used to assess the patients' risk of malnutrition.
The patient had an SGA rating of 5, indicating mild to moderate risk of malnutrition. The GLIM
criteria were used to diagnose the patient with moderate malnutrition based on her moderate
muscle loss, symptoms affecting nutrient intake and presence of inflammation secondary to liver
cirrhosis. The patient’s nutrition diagnosis was documented as moderate chronic disease or
condition related malnutrition related to liver cirrhosis exacerbated by excessive alcohol use as
evidence by reduced energy intake ( </= 75%), elevated AST of 63 IU/mL and mild wasting of
the triceps, temporalis, pectoralis, deltoids, and interosseous muscles.
Goals for participant 1 include (1) increasing vitamin C, potassium, thiamine and magnesium to
recommended intake per MD within 24 hours and (2) referral to alcohol abuse program and
mental counseling program or counselor before discharge.
The patient requires at least 1,800kcal/day to maintain weight during HIV especially
considering illicit drug and excessive alcohol usage. Using the Acceptable Macronutrient
Distribution Recommendation (AMDR) the patient should consume upwards to 60g fat with less
than 7% of total kcal from saturated fat to avoid hyperlipidemia. According to the Dietary
Guidelines for Americans, the patient requires 90g of protein and at least 25g fiber per day with
adequate fluid (2,700mL) to avoid constipation. It is recommended that the patient also increase
intake of vitamin C due to smoking (110g/day) as well as thiamine, magnesium and potassium
according physician recommendation.
The patient was given education related content regarding reducing alcohol intake due to
health risks and the exacerbation of cirrhosis. Motivational interviewing provided by the RD will
also be vital to encourage the participant to initiate alcohol and substance abuse counseling.
Coordination of care with other professionals such as a social worker and a physician.
Coordination with social work is vital to ensure the patient receives counseling and assistance
regarding alcohol and substance abuse. Coordination with a physician is also needed to ensure
that the patient receives correct dosages of key vitamins and minerals including vitamin C,
potassium, thiamine and magnesium due to substance abuse. Indicators that need to be measured
to evaluate outcomes include presence of inflammation secondary to chronic disease (AST and
CRP), weight status, muscle and fat loss as well as alcohol and energy intake.
Summary of Case two
The second participant is a 52-year-old African American female admitted with altered
mental status secondary to severe hypothermia. The participant is currently homeless has limited
access to food due to lack of transportation and financial means to obtain food. The participant
had previously been on SNAP benefits but reported needing assistance to renew it. When
obtaining a dietary recall, she reported consumption of highly processed, high-fat, high-sodium
food items coming primarily from fast-food restaurants. She also has a history of polysubstance
abuse (cocaine and phencyclidine) and reported that due to her drug use she has been
noncompliant with her HIV medication (Biktarvy). Non-compliance has been ongoing for at
least the past year per her previous hospital admission. At the time of visitation, the patient was
being managed by wound care for several full thickness, stage 3 pressure injuries. In addition to
polysubstance abuse disorder, the patient has a past medical history of hyperlipidemia, asthma,
seizures, bipolar disorder, schizophrenia, GERD and DVTs. She has no known allergies and
family medical history was non-contributory to the patient’s condition.
Assessment and diagnosis
The participant is 57.3kg with a BMI of 23.1 kg/m2 and a weight loss of 37% in the 7
months which is classified as severe weight loss. Relevant medications that the participant takes
include apixaban, atorvastatin, Biktarvy, cetirizine, famtodine, lithium carbonate, quetiapine,
ceftriaxone, lovenox, vancomycin, Tylenol and lorazepam although the level of compliance to
each of these medications is not known. The participant’s estimated energy needs were
calculated to be 2,400kcal/d using Mifflin St. Jeor. Her estimated protein needs were 80g/day
(1.25-1.5g/kg) and fluid at 2,000mL/day to promote healing of pressure injuries.

Though the patient reported having generally low appetite, the daughter reported that the
meal eaten during the interview (lunch) was the most she has ever seen her eat (about 30-40% of
plate at time). The participant reported symptoms of nausea, vomiting and diarrhea 4 – 5 times
per day and was observed to have poor oral health. She expressed interest in getting dentures due
to difficulty eating harder foods and its associated pain. The participant was observed trying to
eat bread and was unable. According to the CMS tool completed by the participant, she is
experiencing significant mental health and severe substance abuse issues. She also reported a
lack of community and family support. In terms of malnutrition, the patient has and SGA rating
of 2, indicating severe malnutrition.
A nutrition focused physical exam revealed moderate fat loss (buccal fat, triceps, legs)
with prominent clavicula and moderate muscle loss (temples). Participant is also missing teeth
and as a result, has difficulty chewing her food.
When assessing the patient’s biochemical data, she was hypoglycemic with low casual
glucose, low RBC and low hemoglobin and hematocrit. The patient also had a reported CD4+
count of 494 with a diagnosed C. difficile infection which is categorized as an opportunistic
infection.
Utilizing the GLIM criteria, the patient was diagnosed with severe chronic disease or
condition related malnutrition related to diminished intake secondary to polysubstance abuse as
evidence by severe weight loss of 37% in 7 months, consumption of meals limited to <50% of
plate, moderate fat loss (buccal fat, triceps, legs) with prominent clavicula, moderate muscle loss
(temples) and reports of prioritization of illicit substance intake over medication compliance.
Another nutrition problem found was biting/chewing difficulty related to inappropriate texture of
foods as evidence by poor oral health and missing/damaged teeth, patient reporting
difficulty/pain chewing hard foods and expressing interest in getting dentures and patient
observed having difficulty eating hard food items on plate (bread and salad). The last nutrition
diagnosis was undesirable food choices related to limited access to foods as evidence by patient
reporting limited access to transportation and discontinuation of food stamps as well as diet
recall composed primarily of high fat, high sodium food items.
A mechanically altered, ground diet nutrition prescription providing 2,400 kcal, 80g pro
and 2,000 ml fluid per day is recommended. Adherence to mineral and vitamin
recommendations per the DGA is recommended. Goals of nutrition intervention for this
participant included (1) increasing consumption to 50 – 75% of plate within next 48 hours, (2)
meeting 70% of estimated energy and protein needs in 24 hours and (3) establishing
understanding of education materials concerning community resources for food supply before
discharge.
Provision of a mechanically altered diet with ProSource protein supplement once per day
PO is recommended to meet estimated needs as well as provide adequate texture of the diet
based on the chewing ability of the patient. The diet should be advanced as tolerated to regular
diet once seen by dentist for proper fitting of dentures.
The participant will be educated on the importance of maintaining a general healthful diet
with an HIV diagnosis. She will also be educated on a neutropenic diet, promoting food safety
due to immunosuppression, for discharge. The participant will also be educated on the
importance of discontinuing substance usage and prioritizing nutrition and medication

compliance. Community food assistance programs provided by the D.C. department of health
services should also be provided to the patient.
Nutrition counseling based on the Transtheoretical Model (TTM) Stages of Change
approach should be used. Barriers to healthier eating such as transportation and lack of financial
assistance should be discussed. The participant acknowledged barriers to taking HIV medication
which included drug use. Further counseling will be beneficial to support the participant in
making healthier dietary and lifestyle choices.
Lastly, collaboration by a nutrition professional with other providers should be
conducted. It is vital to discuss with the physician the need for patient referral to a dentist to
assess her teeth and get fitted for dentures. It is also integral to discuss with the social worker the
possibility of housing, transportation, and substance abuse support options in the community for
the participant. Finally, it is important to discuss with the physician the need for an SLP consult
to assess swallowing ability due to reported and observed dysphagia.
Important indicators that should be monitored and evaluated include energy and protein
intake, weight, enrollment in community and/or government nutrition programs, food and
nutrition knowledge and tooth erosion. Criteria to evaluate these indicators include consumption
of at least 70% of estimated energy and protein needs in 48 hours, no further weight loss,
enrollment in SNAP or other nutrition program, ability to summarize components of a general
healthful diet and appointment with an otolaryngologist with referral to a dentist, respectively.
DISCUSSION
Both participants experienced malnutrition at baseline due to the presence of comorbidities,
social determinants of health, nonadherence to HIV/AIDS treatment, and alcohol and/or drug
use. Participant 1 suffered from alcohol and drug use disorder that affected her health status
through the presence of comorbidities such as liver cirrhosis. Her diagnoses resulted in a
decreased intake due to her pain levels. Her uncontrolled alcohol and substance use disorder
further progressed her state of moderate malnutrition (based on her Glim score). She also
experienced social uncertainty with the feeling of alienation and by exhibiting signs of
depression which could have also contributed to her state of malnutrition through a decreased
intake. Participant 2 experienced malnutrition also because of her alcohol and substance abuse
disorder that prevented her adherence to HIV treatment and led to a decreased oral intake. Both
patients also had nutrition focused physical exam findings that indicated muscle loss or for
patient 2, fat loss. Malnutrition was prevalent in the two case study participants who experienced
health disparities.
Based on the narrative review of current literature on the prevalence of malnutrition and the
assessment of nutritional status in patients with HIV/AIDS, it was concluded that HIV/AIDS
affects an individual with HIV/AIDS’ nutritional status is diverse ways. The screening tools used
were also adapted for this study and were used on participants including GLIM, SGA, and a
screening tool for determining SDOH, the Accountable Health Communities Health-Related
Social Needs (AHCH-RSN) (not included in any of the articles of the literature review). These
screening tools were used to evaluate the participant’s risk of malnutrition, as a criterion for
malnutrition, or to determine the individual’s health related SDOH. The narrative review also
revealed the relevant biochemical data that should be integrated into the evaluation of nutritional
status including CD4+ numbers as well as the information pertaining to diseases that affected the
nutritional status of individuals with HIV/AIDS. The narrative review also indicated the use of
over- and undernutrition to define malnutrition in individuals with HIV/AIDS. Patients with both
underweight or overweight/obesity were included in the study to encompass all aspects of
malnutrition.
The nutrition care process was used to provide medical nutrition therapy to participants to help
treat and prevent exacerbation of malnutrition. Interventions were given that included food and
nutrient delivery of the appropriate diet according to comorbidities and the progression of
HIV/AIDS, nutrition education that included educating participants how to prevent exacerbation
of signs and symptoms of malnutrition and HIV/AIDS mainly through nutrition education
handouts, nutrition counseling through the use of motivational interviewing and the
transtheoretical model (stages of change), and coordination of care with various nutrition health
care professionals.
Social determinants of health played a role in the nutritional status of individuals with HIV/AIDS
and the incidence of malnutrition. Among the two participants, access to food and mental
wellbeing affected their nutritional status through a decreased intake of food. Their alcohol and
substance use disorders also progressed their status of HIV/AIDS and malnutrition through
medication nonadherence and comorbidities that were as a result of the use disorder. Other
SDOH included a lack of access to transportation to access food. Participant 1 stated that she
often relied on others to obtain access to transportation for her food needs. Participant 2 stated
that she had trouble utilizing public transportation to access food. In wards 5, 7, and 8, food
swamps exist and in order to access healthy food options, some residents need to travel to get to
a grocery store.
Risk factors associated with a diagnosis of HIV/AIDS that affect nutritional status include the
presence of comorbidities, medication interactions and side effects, and a decreased appetite with
the progression of the disease. Nutrition intervention was used to improve nutritional status, yet
in the acute care setting, follow up with participants on their nutritional status is difficult due to
the length of the process of improving nutritional status. Malnutrition tools were identified
through the narrative review that assessed the patient’s malnutrition status and health related
SDOH. During the nutrition care process, resources were allocated to participants that were
individualized to the participant’s needs. Coordination of care was also arranged, and care was
continued outside of the acute care facility.

CONCLUSION
Both participants shared similar causes for decreased health partly due to poor nutritional
status. First, all participants were diagnosed with several comorbidities including hypertension
and kidney disease which renders compliance to nutrition recommendations all the more crucial
when non-compliance is synonym to compromised health status. Two of the participants
reported difficulties accessing food. All participants reported experiencing stress at one point or
another under the form of financial uncertainty or conflicts in their rapport with others (family
and friends) as a social determinant of health. One common cause of health status stemmed from
the non-compliance with medical therapy for HIV. In other instances, inadequate micronutrient
intake, coupled with alcohol and illicit drug abuse had a greater impact on nutritional status.
Most participants received a high score when screened for social determinant of health using the
CMS “accountable health communities health-related social needs screening tool”.
Common nutrition problems include food and nutrition related knowledge deficit,
undesirable food choices, limited access to food, inadequate energy intake, excessive alcohol
intake, not ready for diet/lifestyle change, malnutrition, unintended weight loss, and chronic
disease related malnutrition. The validated tools used during assessment allowed for diagnosis of
malnutrition in some participants as well as identification of health disparities directly impacting
food intake and lifestyle.
After nutrition related problems are resolved during admission, all participants would
benefit from medical nutrition therapy in the form of nutrition counseling to increase health
beliefs to promote adherence to nutrition therapy and pharmacological therapy, and coordination
of care to increase access to food and promote alcohol and illicit drug use cessation. It is
important that patients with a diagnosis of HIV are followed by a multidisciplinary team to lower
the risk of non-adherence to recommendation and improve health outcome. Adequate nutrition
promotes an efficient immune response to infections and in the case of HIV/AIDS can help fight
opportunistic infections common in this population. Risks of contracting opportunistic infections
increase as individuals advance in stages of HIV and CD4 counts decrease. Although for some of
the participants CD4 counts were not available, white blood cells and lymphocyte counts could
give an estimation of HIV status. Individuals who are not compliant with prescribed
pharmacological therapy can further benefit from adequate nutrition to support their immune
system. For instance, practicing food safety can help avoid bacterial infection from unsafe
sources of food. However, without compliance to HIV medical therapy, a decline in CD4 levels
and risk of developing associated health risk factors are inevitable.
As social determinants of health have an impact on nutrition status, coordination of care
goes beyond collaborating with healthcare providers and encompasses community resources
especially for access to food and improving lifestyle through counseling for healthy behavioral
changes.
The study encountered a few limitations including the limited sample size and the limited
availability of biochemical data for an HIV panel. The acute care facility houses had a limited
number of patients who met the criteria for this study. Of those who were eligible to participate
in the study, many of the participants had comorbidities that affected their nutritional status and
led to their status of malnutrition, such as a cancer diagnosis. In addition to comorbidities
affecting the eligibility of participants, a smaller sample size could have prevented data from
being extrapolated. The results from a smaller sample size are hard to generalize to larger
groups. The acute care facility also did not provide biochemical data pertaining to the patient’s
HIV status or viral load status. This limited the results of the study as the progression of HIV
indicated through laboratory data was only able to be predicted through ALC for two of the
participants. Both studies used to predict CD4 cell count gave conflicting ALC values. For the
purposes of this study, ALC values that met the criteria for both studies were used to indicate the
possible CD4 cell count. Often, physicians ordered CD4 counts in their plans of care, but a
simple CBC was done instead without a CD4 count. Participants also admitted rarely seeing a
physician about their HIV status. For participants 1, blood tests for immune system function
including CD4 cell count tests were not done within the last 3 months prior to admission or the
participant did not remember the results of their tests. Thus, ALC was used to predict their CD4
cell count and stage of HIV/AIDS progression was not identified by the physician.
Future areas of research include involving a larger sample size, using randomized
controlled trials on intervention methods for HIV patients, utilizing alcohol and substance abuse
interventions for these patients, and including biochemical data from a blood test that evaluated
immune system status (CD4 count) and monitors viral load (HIV viral load). As mentioned
earlier, the larger sample size allows for more accurate data interpretation. Larger sample sizes
more closely reflect the population and allow for a margin of error that is not available in a
smaller sample size. Randomized controlled trials can be used to test which interventions should
be used to achieve and maintain a healthy nutritional status and prevent or treat malnutrition in
patients with HIV who experience health disparities. This can also be used to help establish the
association with HIV, the prevalence of malnutrition, and health disparities. The randomization
reduces bias, and the control of the trial allows for a cause-and-effect relationship to be
established for patients with HIV in an acute care setting. As majority of the participants in this
study had drug and alcohol use, it would be negligent to not address the prevalence of alcohol
and substance abuse in patients with HIV/AIDS. Future research should also include the use of
alcohol or substance abuse intervention for willing participants from a trained professional.
Requiring the use of biochemical data that evaluates immune system function such as CD4
should also be a requirement of the study. It allows for the staging and classification of
HIV/AIDS and allows for the correlation between the prevalence of malnutrition and the
progression of the disease.

REFERENCES
Adults Benefit Most From A Standardized Malnutrition Screening Tool: Position of the
Academy. (2020, February 11). Eatright. https://www.eatrightpro.org/media/press-
releases/positions-and-issues/malnutrition-screening-tool-position
Agrawal, P. B. (2016). Absolute lymphocyte count as a surrogate marker of CD4 count in
monitoring HIV infected individuals: A prospective study. JOURNAL OF CLINICAL
AND DIAGNOSTIC RESEARCH. https://doi.org/10.7860/jcdr/2016/19263.7765
Annual Epidemiology & Surveillance Report. (2020, August 20). DC Health.
https://dchealth.dc.gov/sites/default/files/dc/sites/doh/publication/attachments/2020-
HAHSTA-Annual-Surveillance-Report.pdf
The Benefits of Nutrition Assistance for African American Maternal and Infant Health. (2018,
December 5). Center for American Progress.
https://www.americanprogress.org/issues/women/news/2018/05/01/450209/benefits-
nutrition-assistance-african-american-maternal-infant-health/#:%7E:text=African
%20American%20households%20are%20disproportionately,percent%20rate%20for
%20white%20households.
Bruno Vellas, Yves Guigoz, Philip J Garry, Fati Nourhashemi, David Bennahum, Sylvie Lauque,
Jean-Louis Albarede,
Calculating Absolute Cell Counts. Calculating Absolute Cell Counts - LabCE.com, Laboratory
Continuing Education. (n.d.). Retrieved November 11, 2021, from
https://www.labce.com/spg398915_calculating_absolute_cell_counts.aspx.
Cederholm, T., Jensen, G., Correia, M., Gonzalez, M., Fukushima, R., Higashiguchi, T.,
Baptista, G., Barazzoni, R., Blaauw, R., Coats, A., Crivelli, A., Evans, D., Gramlich, L.,
Fuchs‐Tarlovsky, V., Keller, H., Llido, L., Malone, A., Mogensen, K., Morley, J., . . .
Compher, C. (2019). GLIM criteria for the diagnosis of malnutrition – A consensus
report from the global clinical nutrition community. Journal of Cachexia, Sarcopenia and
Muscle, 10(1), 207–217.
Centers for Disease Control and Prevention. (2021, June 7). Adult obesity facts. Centers for
Disease Control and Prevention. Retrieved September 11, 2021, from
https://www.cdc.gov/obesity/data/adult.html.
Cevik, M., Kuppalli, K., Kindrachuk, J., & Peiris, M. (2020). Virology, transmission, and
pathogenesis of SARS-CoV-2. BMJ, m3862. https://doi.org/10.1136/bmj.m3862
Cortes, Regina RNa; Bennasar-Veny, Miquel PhDb,c,∗; Castro-Sanchez, Enrique PhDd; Fresneda,
Sergio MSa,b; de Pedro-Gomez, Joan PhDb,c; Yañez, Aina PhDb,c Nutrition screening tools
for risk of malnutrition among hospitalized patients, Medicine: October 23, 2020 -
Volume 99 - Issue 43 - p e22601 doi: 10.1097/MD.0000000000022601
Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, Jeejeebhoy KN.
What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr.
1987 Jan-Feb;11(1):8-13. doi: 10.1177/014860718701100108. PMID: 3820522.
https://pubmed.ncbi.nlm.nih.gov/3820522/
Food insecurity in the United States, 2019 vs 2020. Food Research & Action Center. (2021,
September 10). Retrieved September 11, 2021, from https://frac.org/hunger-poverty-
america/foodinsecurityvisuals.
Gebremichael, D. Y., Hadush, K. T., Kebede, E. M., & Zegeye, R. T. (2018). Food insecurity,
nutritional status, and factors associated with MALNUTRITION among people living
with hiv/aids Attending antiretroviral therapy at public health facilities in West Shewa
Zone, Central ethiopia. BioMed Research International, 2018, 1-9.
Healthcare Workers 2020, English, Centers for Disease Control and Prevention;
https://www.cdc.gov/coronavirus/2019-ncov/hcp/therapeutic-options.html
HIV, Accessed April 2021 HIV | CDC. (2021). CDC. https://www.cdc.gov/hiv/default.html
HIV/AIDS - Nutrition Care Manual. (2021). Nutrition Care Manual.
https://www.nutritioncaremanual.org/auth.cfm?err=NLI&path=%2Ftopic%2Ecfm
%3Flv1%3D20149%26ncm%5Fheading%3DNutrition%2520Care%26ncm%5Fcategory
%5Fid%3D1%26ncm%5Ftoc%5Fid%3D20149
Hong, H., Budhathoki, C., & Farley, J. E. (2018). Effectiveness of macronutrient
supplementation on nutritional status and hiv/aids progression: A systematic review and
meta-analysis. Clinical Nutrition ESPEN, 27, 66-74. doi:10.1016/j.clnesp.2018.06.007
Hussein, F. M., Ahmed, A. Y., & Muhammed, O. S. (2018). Household food INSECURITY
Access scale and Dietary diversity score as a proxy indicator of nutritional status among
people living with HIV/AIDS, Bahir DAR, Ethiopia, 2017. PLOS
ONE, 13(6). doi:10.1371/journal.pone.0199511
Hussen, S., Belachew, T., & Hussien, N. (2016). Nutritional status and its effect on treatment
outcome among HIV infected clients receiving HAART in ETHIOPIA: A cohort
study. AIDS Research and Therapy, 13(1). doi:10.1186/s12981-016-0116-9

Household Dietary Diversity Score (HDDS) for Measurement of Household Food Access:
Indicator Guide | Food and Nutrition Technical Assistance III Project (FANTA). (2021).
FANTA. https://www.fantaproject.org/monitoring-and-evaluation/household-dietary-
diversity-score
“Key Statistics & Graphics.” USDA ERS - Key Statistics & Graphics,
www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/key-statistics-
graphics.aspx.
Khanna, R. (2018). Absolute lymphocyte count: A probable substitute marker for CD4 count in
HIV-infected patients in economically restrained countries. Indian Journal of Forensic
Medicine and Pathology, 11(4), 237–244.
https://doi.org/10.21088/ijfmp.0974.3383.11418.3
Khatri, S., Amatya, A., & Shrestha, B. (2020). Nutritional status and the associated factors
among people living with HIV: An evidence from cross-sectional survey in hospital based
antiretroviral THERAPY site in Kathmandu, Nepal. BMC Nutrition, 6(1).
doi:10.1186/s40795-020-00346-7
Koethe, J. R., Heimburger, D. C., PrayGod, G., & Filteau, S. (2016). From wasting to obesity:
The contribution of nutritional status to immune activation in hiv infection. Journal of
Infectious Diseases, 214(Suppl 2). doi:10.1093/infdis/jiw286
Kruizenga HM, de Jonge P, Seidell JC, Neelemaat F, van Bodegraven AA, Wierdsma NJ, van
Bokhorst-de van der Schueren MA. Are malnourished patients' complex patients? Health
status and care complexity of malnourished patients detected by the Short Nutritional
Assessment Questionnaire (SNAQ). Eur J Intern Med. 2006 May;17(3):189-94. doi:

10.1016/j.ejim.2005.11.019. PMID: 16618452.
New HIV Diagnoses - Epidemiology of HIV - Screening and Diagnosis - National HIV
Curriculum; https://www.hiv.uw.edu/custom/screening-diagnosis/epidemiology/3;
English, Accessed April 2021
Nutrition Care Process. (2021). ENCPT. https://www.ncpro.org/nutrition-care-process
Understanding Motivational Interviewing | Motivational Interviewing Network of Trainers
(MINT). (2021). MINT. https://motivationalinterviewing.org/understanding-motivational-
interviewing
Nutrition screening tools for risk of malnutrition among hospitalized patients A protocol for
systematic review and meta-analysis. (2020, October 23). Medical Journals.
https://journals.lww.com/md-
journal/Fulltext/2020/10230/Nutrition_screening_tools_for_risk_of_malnutrition.23.asp
Mahlangu, K., Modjadji, P., & Madiba, S. (2020). The nutritional status of ADULT antiretroviral
Therapy recipients with a Recent HIV Diagnosis; a cross-sectional study in primary health
facilities in Gauteng, South Africa. Healthcare, 8(3), 290. doi:10.3390/healthcare8030290
Quick Facts DC. (2019, July 1). United States Census. https://www.census.gov/quickfacts/DC
Rabito EI, Marcadenti A, da Silva Fink J, Figueira L, Silva FM. Nutritional Risk Screening
2002, Short Nutritional Assessment Questionnaire, Malnutrition Screening Tool, and
Malnutrition Universal Screening Tool Are Good Predictors of Nutrition Risk in an
Emergency Service. Nutr Clin Pract. 2017 Aug;32(4):526-532. doi:

10.1177/0884533617692527. Epub 2017 Feb 15. PMID: 28199797.
Racial Disparities in Food Insecurity Persist: Institute for Policy Research - Northwestern
University. (2020, July 9). Northwestern Institute for Policy Research.
https://www.ipr.northwestern.edu/news/2020/food-insecurity-by-race-ethnicity.html
Sackey, J., Zhang, F. F., Rogers, B., Aryeetey, R., & Wanke, C. (2017). Implementation of a
NUTRITION assessment, counseling and support program and its association with body
mass index among people living with HIV in Accra, Ghana. AIDS Care, 30(5), 586-590.
doi:10.1080/09540121.2017.1420137
SAGE Journals: Your gateway to world-class research journals. (2010, December 6). SAGE
Journals. https://journals.sagepub.com/action/cookieAbsent
Sieber CC. Der ältere Patient--wer ist das? [The elderly patient--who is that?]. Internist (Berl).
2007 Nov;48(11):1190, 1192-4. German. doi: 10.1007/s00108-007-1945-3. PMID:
17934704. https://pubmed.ncbi.nlm.nih.gov/17934704/
Makhija S, Baker J. The Subjective Global Assessment: a review of its use in clinical practice.
Nutr Clin Pract. 2008 Aug-Sep;23(4):405-9. doi: 10.1177/0884533608321214. PMID:
18682592. https://pubmed.ncbi.nlm.nih.gov/18682592/
The mini nutritional assessment (MNA) and its use in grading the nutritional state of elderly
patients, Nutrition, Volume 15, Issue 2, 1999, Pages 116-122, ISSN 0899-9007,
https://doi.org/10.1016/S0899-9007(98)00171-3.
Thuppal, S. V., Jun, S., Cowan, A., & Bailey, R. L. (2017). The nutritional status of hiv-infected
us adults. Current Developments in Nutrition, 1(10). doi:10.3945/cdn.117.001636
USDA ERS - Access to Affordable, Nutritious Food Is Limited in “Food Deserts.” (2020, March
1). U.S. Department of Agriculture. https://www.ers.usda.gov/amber-
waves/2010/march/access-to-affordable-nutritious-food-is-limited-in-food-deserts/
USDA ERS - Documentation. (n.d.). U.S Department of Agriculture. Retrieved May 5, 2021,
from https://www.ers.usda.gov/data-products/food-access-research-
atlas/documentation#comparisons
USDA ERS - Key Statistics & Graphics. (n.d.). U.S. Department of Agriculture. Retrieved May
1, 2021, from https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-
the-us/key-statistics-graphics.aspx/
U.S. Department of Health and Human Services. (2021). Social Determinants of Health -
Healthy People 2030 | health.gov. Healthy People 2030.
https://health.gov/healthypeople/objectives-and-data/social-determinants-health
Young AM, Kidston S, Banks MD, Mudge AM, Isenring EA. Malnutrition screening tools:
comparison against two validated nutrition assessment methods in older medical
inpatients. Nutrition. 2013 Jan;29(1):101-6. doi: 10.1016/j.nut.2012.04.007. Epub 2012
Aug 2. PMID: 22858197.

APPENDICES
Appendix A
HIV Statistics
(CDC, HIV Statistics)


Appendix B
HIV Basics
When people with HIV don’t get treatment, they typically progress through three stages. But
HIV medicine can slow or prevent progression of the disease. With the advancements in
treatment, progression to Stage 3 is less common today than in the early days of HIV. (CDC,
HIV Basics)
Most people who get HIV get it through anal or vaginal sex, or sharing needles, syringes,
or other drug injection equipment (for example, cookers). But there are powerful tools that can
help prevent HIV transmission. (CDC, HIV Transmission)
Today, more tools than ever are available to prevent HIV. You can use strategies such as
abstinence (not having sex), never sharing needles, and using condoms the right way every time
you have sex. You may also be able to take advantage of HIV prevention medicines such as pre-
exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). If you have HIV, there are
many actions you can take to prevent transmitting HIV to others. (CDC, HIV Prevention)
The only way to know your HIV status is to get tested. Knowing your status gives you
powerful information to keep you and your partner healthy. (CDC, HIV Testing)
If you have HIV, it’s important to make choices that keep you healthy and protect others.
This section answers some of the most common questions about HIV treatment, stigma, family
planning, and more. You can also download materials about living well with HIV. (CDC, HIV
Living with HIV)

Appendix C
Social Determinants of Health
(USDA, 2020)
(FRAC, Food Insecurity)

(U.S. Department of Human and Health Services, 2020)

Appendix D
Assessing the Nutritional Status of Patients with HIV
Kaplan–Meier plots of nutritional status in HIV infected individuals in cohort of patients at

Jimma University specialized hospital, January 2006 to December 2011 (Hussen, 2016)
(Khatri, 2020)
(Khatri, 2020)
(Mahlangu, 2020)
(Hussen, 2018)
(Thuppal, 2017)
(Thuppal, 2017)
(Hong, 2018)
(Mahlangu, 2020)
Appendix E
Screening tools for Malnutrition and SDOH
(Centers for Medicaid and Medicare Services, 2021)

(Canadian Malnutrition Task Force, 2017)

(Cederholm, 2019)
Appendix F
Nutrition Education given to participants from the Nutrition Care Manual.
(Nutrition Care Manual, 2021)




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NCM Research Proposal 1

Addressing Nutrition Related Health Disparities in Individuals Diagnosed

Summary of Case Two

Summary of Case Three

Background - prevalence, and pathology of HIV/AIDS, Malnutrition and SDOH

In patients diagnosed with chronic diseases, changes in metabolic processes,

inflammatory status and immune response occur. HIV/AIDS is linked to immunosuppression,

HIV/AIDS, this population is at increased risk of being malnourished if factors affecting

individualized nutrition plan and prescription, or immunonutrition.

of all new HIV infections worldwide.

HAART may never progress to stage 3. Stage 3, or acquired immunodeficiency syndrome

calculation: WBC count (cells/mcL) x 1,000 x percent lymphocyte count (expressed as a

transmitting the disease.

protect someone from getting a superinfection.

include CD4 count and a viral load test.

medication. Drug-resistant strains of HIV can also be transmitted to others.

an increased chance of developing or having other severe illnesses, called opportunistic

candidiasis, invasive cervical cancer, coccidioidomycosis, cryptococcosis, cryptosporidiosis,

cystoisosporiasis, cytomegalovirus, encephalopathy (HIV-related), herpes simplex virus,

histoplasmosis, Kaposi's sarcoma, lymphoma, tuberculosis, mycobacterium avium complex,

pneumocystis pneumonia, pneumonia, progressive multifocal leukoencephalopathy, salmonella

septicemia, toxoplasmosis, and wasting syndrome due to HIV.

are seen in individuals taking HAART. Compared to malnourished HIV/AIDS patients,

pneumocystis, jiroveciipneumonia, chronic obstructive pulmonary disease, and heart disease,

of better outcomes in HIV patients.

intervention to patients with altered nutritional status.

defines malnutrition when one of the following criteria is met:

1. a body mass index (BMI) < 18.5 kg/m2

2. an unintentional weight loss and a reduced aged dependent BMI, or

inadequate vitamins or minerals, overweight, obesity, and nutrition-related non-communicable

disease in its definition of malnutrition (WHO, 2021).

Malnutrition is of high prevalence in hospitals, affects between 30% to 50% of patients,

Studies encourage malnutrition screening (defined as the identification of malnutritional

and treatment of malnutrition. Challenges in conducting screenings and assessments for

hospitals undergo laboratory tests or physical examinations to evaluate nutritional status.

assessment of nutritional status in elderly patients. Elderly is defined from a chronological

used in free-living and log-term care environments.

The Short Nutritional Assessment Questionnaire (SNAQ) is used regardless of age in

assess moderate to severe undernourishment in patients diagnosed with cancer undergoing

studies consider that it can identify complex malnourished patients.

malnutrition, and a score between 5 and 7, at high risk for malnutrition.

groups including surgical and oncology patients.

The Nutrition Screening Initiative (NSI) was developed to assess prevalence of

following signs for inadequate nutrition:

3. Tooth Loss/Mouth Pain

5. Reduced social contact

7. Involuntary weight loss/gain

8. Needs assistance in self-care

9. Elder Years above the age of 80

rehabilitation, and ambulatory care and oncology clinics.

in patients diagnosed with HIV.

The Global Leadership Initiative on Malnutrition criteria (GLIM) is a global consensus

criterion is diagnosed with malnutrition.

to nutritious foods for financial and/or physical reasons.

transportation to reach them.

41.1% of Black respondent’s households and 36.9% of Hispanic respondents’ households

unintentional weight gain along with nutrient deficiency.